key: cord-0859755-pwva76fj authors: Heilferty, Catherine McGeehin; Phillips, Lorraine J.; Mathios, Rebecca title: Letters from the pandemic: Nursing student narratives of change, challenges and thriving at the outset of COVID‐19 date: 2021-04-19 journal: J Adv Nurs DOI: 10.1111/jan.14862 sha: 720a891acaccfaf0c00d14908641ec6c375d8be6 doc_id: 859755 cord_uid: pwva76fj AIM: The aim of this study is to explore the experience of third year baccalaureate nursing students during the outbreak of the COVID‐19 pandemic. DESIGN: Research design is a narrative analysis of archived letters written by nursing students in Spring 2020. METHODS: Letters and other media were written between 1 April and 20 May 2020. Fifty‐six letters, some with accompanying audio or visual media, were submitted in late May 2020. Approval from the University Institutional Review Board was obtained to explore the letters through narrative analysis (Riessman, 2008). As the letters were considered archival, consent from the students for the analysis was not indicated. Once thematic categories were identified independently, the authors discussed the findings until a list of narrative categories and narrative exemplars were agreed on. RESULTS: Three main thematic categories were found: stories of change, challenges and thriving. CONCLUSION: Findings were consistent with prior research and reveal new opportunities for understanding the perspectives and needs of undergraduate nursing students during times of crisis. Action by administrators and faculty are recommended. Disruptions in nursing education caused by the COVID-19 pandemic in the spring of 2020 were experienced around the world. Learning moved from the physical to the online classroom. E-learning has posed challenges to students with work and family responsibilities or who have limited electronic resources (Ramos-Morcillo et al., 2020) . In some countries, instructors were asked by hospitals to avoid clinical education onsite, so clinical experiences were substituted with hastily designed online virtual patient scenarios (Camelio, 2020) . The suddenness of the transition added uncertainty that has affected student academic success. Nursing students interviewed for campus newspapers described feeling worried and dissatisfied with what was perceived as inadequate learning during virtual patient interactions (Camelio, 2020; Mohammadi, 2020) . Third-and fourth-year students reported that they are now more fearful to be a nurse (Povitsky, 2020) . They reported feeling fearful and upset at having their clinical learning experiences cancelled, especially seniors, who feared not having enough clinical hours and experience to feel competent in practice (Al-Balas et al., 2020; Ramos-Morcillo et al., 2020) . Understanding nursing student life in college during the early months of the COVID-19 pandemic is significant to the degree that it honours students' experience under stress and that it can create a path for research on nursing education under conditions of rapid change. Ricoeur's (1979 Ricoeur's ( , 1980 theory of narrativity as the mode of expression of temporality emphasized the reciprocal nature of each. Ricoeur's understanding of daily life as constructed in narrative in the concept of time allowed a unique perspective on the students' writing about their experiences, positioned in the current crisis, while simultaneously envisioning a future in nursing. Acknowledging the life stress evident in student descriptions shared in class early in the pandemic, the present study was inspired by the fundamental tenets of Pennebaker (1997) , who made the case for writing about emotional experiences as therapeutic. Few research studies have been published on nursing student experiences during pandemics. One of the earliest studies examined graduate-level nursing students' narrative accounts of personal and professional experiences during the 2003 severe acute respiratory syndrome (SARS) crisis in Hong Kong (Holroyd & McNaught, 2008) . The narratives described concerns about the preparedness of the health system, the personal physical and psychological impact, and community and media responses. Later, against the backdrop of concern about the H5N1 strain of Avian influenza in 2007, Yonge et al. (2007) surveyed 456 undergraduate student nurses at a Canadian university about their level of knowledge and concern about the threat of pandemic influenza. Nursing students were aware of the potential for human-to-human transmission in the event of a flu pandemic; however, there was evidence of limited knowledge about the management of pandemic influenza, the process of influenza vaccine development, the role of antivirals and how the illness is transmitted. Nursing students' perception of personal risk of infection from pandemic influenza occurring in the next year was low (Yonge et al., 2010) . New literature is emerging in response to effects of the COVID-19 pandemic on nursing and medical education. A study examining the experiences of nursing and medical students in Spain at the time the Spanish government declared a state of emergency found that students, although many voluntarily agreed to join the health system in their final year of training, were troubled by lack of PPE and threat of infection for themselves and family members (Collado-Boira et al., 2020) . The students additionally expressed concerns about inadequate knowledge and skills for the situations they would face. A survey of US medical students, also at the start of the pandemic, echoed concerns about interrupted training, but their concerns were balanced by their desire to serve the sick (Gallagher & Schleyer, 2020) . Sentiments from medical and nursing students worldwide reflect a positive regard for their career choice (Leigh et al., 2020; Leong, & Sarohia, 2020) . College students in general experienced pandemic-related changes. Data from the Healthy Minds Study, during the early stages of the COVID-19 pandemic, revealed that more that 60% of college students experienced greater financial stress and 30% reported a change in their living situation (American College Health Association, 2020). In this national study of college students, depression increased, access to mental health care declined and academic performance suffered. Interestingly, some students reported higher levels of resiliency. An important element of the present study was the decision to analyse written narratives. Students were instructed to write a letter to a future nursing student about the experience of life as a nursing student during this pandemic. It was only after students' submissions were received and the results scored that the collective reflection inspired the research question. Constructed from experiences, narratives shape the writer's identity and perspective (Holroyd & McNaught, 2008) . The aim of the study was to identify themes present in student narratives about life as a third-year baccalaureate nursing student during the outbreak of the COVID-19 pandemic. those responsible for supporting nursing students will find suggestions for assisting novice nurses during times of crisis. An archival research design using narrative analysis was chosen to explore the experiences of nursing students as expressed in letters written to an imagined future nursing student ( Figure 1 ). To accommodate for the changes necessary as classes moved to an online environment due to social distancing requirements in spring 2020, adjustments in learning assessment methods occurred. One component of the nursing research class assignments asked students to write letters to future nursing students about their experiences as nursing students at the pandemic outbreak. After assessing the projects, that is, after all course grades were finalized, the authors were motivated by the richness and detail included in the letters to undertake this study. The letters, as artefacts, became the sample for this study. The sample consisted of 56 letters, 10 from men and 54 from women, submitted in late May 2020 as an optional element of a non-clinical course requirement. After submission for course credit occurred at the end of the semester, letters were deidentified, saved as numbered electronic documents and stored by the authors in password protected computers. University Institutional Review Board approval was obtained to explore the letters through narrative analysis in accord with the Helsinki Declaration and Belmont Report. All submissions were considered as found artefacts with identifying information removed before analysis. To prevent revealing students' identities, photos and other images were not included in the analysis. The letters were considered archival; therefore, consent from the students for the analysis was not indicated. The letters were analysed using the Riessman's method of narrative analysis. Once thematic categories were identified, the authors discussed the findings until narrative categories were agreed on Table 1 . Riessman (2008) outlined coherence, credibility and persuasion as criteria to be met when undertaking narrative analysis. Coherence of the narratives is confirmed when episodes in a life story 'hang together', when arguments are linked and consistent and when there are no major gaps or inconsistencies (Riessman, 2008, p. 189) . To enhance credibility, the authors maintained a detailed audit trail that included study design and analysis decisions. Rationale for the proposed research question and support for F I G U R E 1 Narrative analysis method IRB approval; Letters collected, deidentified, and photos removed Each letter read once by first 2 authors with notetaking Reread each letter; narratives identified in thematic categories First 2 authors discussed and organized narrative categories by impact and frequency of occurance Narratives organized by major themes the methodological approach are outlined. Documentation of decisions made and reflections on the research process has been recorded. The authors analysed the letters independently. Both authors have published reports of peer-reviewed qualitative research. Narrative research persuades readers through presentation of data in ways that demonstrate genuineness, plausibility of interpretation, and reasoned and convincing discussion of data. Positions taken in the reporting of study findings were supported by examples from the letters, with negative cases included and alternative interpretation considered. The final level of persuasion comes with critical peer-review of the work as presented (Riessman, 2008) . Nearly all letters began with a description of feelings of surprise at the first notification of a change to their semester calendar. Each writer narrated life after the change in plans chronologically, culminating with discussion of preparations for final exams. One letter included a narrated video illustration at several points in time. Two letters chronicled events in a series of entries written at multiple time points. Three main thematic categories of narrative were found: stories of change, challenges and thriving. Stories of change centred on three main phenomena: changes in students' school life, changes in their perceptions of nursing and changes in their academic progress. In mid-March and early April, as government limits on activities were generic and widespread, students' descriptions of their reaction to the change were comparable with those told when 'snow days' are declared, disruptive but festive. Although financial concerns were ever-present in media reports about the economy and employment conditions, almost none of the students in this group expressed this concern. Even in the letter below, the student described seeing a way forward financially. COVID-19 has also greatly impacted my family's fi- very day I am grateful that a college loan is my only concern. I know there are many other people in the world who are not as lucky as I am… (Letter 14) In contrast to the challenge of a lack of adequate information found during the spread of the H5N1 strain of Avian influenza in 2007 (Yonge et al., 2007) , early in the COVID-19 outbreak, students expressed knowledge and concern about transmission modes; management of the illness; viral testing and tracing; progress on vaccine development; and the role of personal protective equipment. Our findings align with those of studies in previous pandemics, wherein students felt troubled by the lack of PPE and the risk of infection for themselves and family members and feared they lacked essential knowledge and skills (Collado-Boira et al., 2020; Gallagher & Schleyer, 2020) . Many students in the present study expressed a positive regard for their career choice despite the hardship (Leigh et al., 2020; Leong, & Sarohia, 2020) . As the number and frequency of internationally communicable illnesses rise, it is imperative that serious consideration be given to the education of health professionals in advance of and during these crises (Saker et al., 2004) . Mental health challenges discussed in the letters are important to consider. Research prior to the COVID-19 the pandemic suggested that many nursing students experience mental health concerns. A systematic review and meta-analysis of cross-sectional studies found 27 studies of nursing students in Asia, Europe, Arab states, North America and Latin America with a pooled prevalence of mild to severe depressive symptoms in 34% students worldwide (Tung et al., 2018) . Descriptions of students' responses to the mental fatigue they experienced may suggest a role for educators to foster resilience in nursing students. The letters included references to the obvious challenges, but also the practical and often effective strategies that students used to cope. Resilience has been described as a set of characteristics or behaviours that includes the ability to respond effectively, to adapt positively and to be flexible in the face of adversity. The outcomes of these features can be a move toward positive functioning, though not necessarily a return to preadversity function, and eventually an adjustment to and accommodation of unpleasant feelings, thoughts, events or situations in the pursuit of a desired goal (Daly, 2020) . Although many students in the present study mentioned mental health challenges, expressions related to finding 'silver linings' showed evidence of resilience, similar to the results in the Healthy Minds Study (American College Health Association, 2020). Even those students that began their letter lamenting the loss of in-person classes and campus life, eventually ended on a positive note and expressed sentiments of appreciation that they really had nothing to complain about and had found a silver lining. This benefit finding behaviour has been connected to trauma experiences and is considered to play a role in posttraumatic growth (Cousins et al., 2014) . Resilience behaviours in nursing students have been associated with support and encouragement received from family, friends and faculty (Thomas & Revell, 2016) . Resilience-promoting effects of expressive writing in nursing, medical and educational research across diverse populations include reduced depressive and PTSD symptoms, improvements in blood pressure, improved quality of sleep, decreased anxiety and improved self-image. Nonhealthrelated benefits include improved grades and improvement in working memory (Mealer et al., 2014; Sexton et al., 2009) . Although speculative, we considered that resilience may have served as a stress modulator in students' lives and suggests questions that could guide future research: To what degree did students exhibit resilient behaviours before the pandemic? Is resilience related to the positive attitudes exhibited in the writing? and How can resilience foster adaptation to sudden unpleasant change in nursing education and/or college life? Evidence suggests that fostering resilience through targeted interventions should occur early in students' academic experience, especially during times of societal and personal stress (Tung et al., 2018) . The sample size and the interpretative nature of the analysis limit the transferability of the results to other settings or populations. The findings in the present analysis are consistent with prior research and reveal new opportunities for understanding the perspectives and needs of undergraduate nursing students. Letters included narratives that suggest the importance of understanding more about resilient behaviours as a response to mental fatigue, the impact of loss, family illness and uncertainty. In addition, evidence in the letters suggest that especially during times of sudden and pervasive disruption, administrators and faculty members should develop plans to assess and to help students manage the impact of such sudden change on their ability to function. Rapid assessment of student needs, including housing, food, technology, financial and social supports, is essential in the early days of a disruptive event. Frequent, personal, clear communication is indicated. Future consideration should focus on the effects on student life, clinical education and academic performance when a sudden event leads to prolonged uncertainty. Letter writing may serve not only to inform educators about students' experiences but also to promote positive physical and psychological health. Building research and support mechanisms that are ready to deploy quickly could mitigate the adverse effects of a pandemic such as the practicalities of temporality and the high degree of disruption to learning, teaching and research. 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