Nursing associate students in practice during the Covid-19 pandemic

Introduction

When the first confirmed cases of Covid-19 in the UK started emerging in January 2020 (Flynn et al, 2020), the NHS was already experiencing shortages of both staff members and beds, and the outbreak added additional pressure. Pre-pandemic data demonstrates there were >41,000 vacant nursing and midwifery posts in England alone in 2018, which is more than one in ten (Buchan et al, 2019). Additionally, in July-September 2018, the average daily number of available beds in English hospitals was 127,378 (NHS, 2019); this is the lowest since records began in 1987/88. Over this 30-year period, the UK’s population and, consequently, the number of people seeking NHS treatment increased. This caused considerable and widely publicised resource pressures (Ewbank et al, 2021).

The nursing shortage was one of the reasons why Health Education England (HEE) introduced the new role of nursing associate (NA) in 2017; this was a direct response to its (2015) report Raising the Bar (HEE, 2019). Up until 2016, patient care in a hospital setting had been predominantly delivered by registered nurses and healthcare assistants. The new role of NA aimed to bridge the gap between the two (King et al, 2022), releasing nurses to perform tasks befitting their skills (Kessler et al, 2020). A Foundation Degree in Science (FdSC) NA programme was introduced following pilot programmes across 11 English universities, and the first NAs qualified and registered in 2019 (Kessler et al, 2020).

Many studies explored the impact of the Covid-19 pandemic, including obtaining personal experiences from nursing students, qualified nurses and other health professionals (HCPs) worldwide. However, as the role of NA was relatively new in England at the time of the pandemic, their views may not have been captured as comprehensively. This was one reason why we undertook this study into NAs’ positive experiences of practising during the pandemic.

“Students observed that, in difficult conditions, interprofessional teams pulled together”

Literature review

During the pandemic, HCPs had to deal with many stressful experiences that negatively affected their mental health and wellbeing. We conducted a comprehensive literature review of the pandemic’s effects on nursing-related professions. Its results mostly highlighted negative impacts; however, many accounts of positive experiences also emerged.

Numerous studies included statements from nurses who expressed pride in being able to help during an international crisis (Arcadi et al, 2021; LoGiudice and Bartos, 2021). HCPs viewed the pandemic as a historical event (Cengiz et al, 2021; Arcadi et al, 2021), although many downplayed the idea of being a ‘hero’, feeling they were simply doing their job (Aydin et al, 2022). There are numerous accounts of nurses seeing the pandemic as an opportunity to discover their potential (Cengiz et al, 2021; Sun et al, 2020). Many said they developed professionally by acquiring new skills (Aydin et al, 2022) and others, after reflecting on the situation, said they realised they had strengthened their willpower (Sun et al, 2020).

Nurses also recognised the pandemic’s positive influence in their workplace, particularly on teamwork. They appreciated the special bond that emerged due to sharing the same traumatic experiences (LoGiudice and Bartos, 2021; Robinson and Stinson, 2021) and valued the increased collaboration and team spirit (Chigwedere et al, 2021; Arcadi et al, 2021).

The pandemic disrupted student education substantially, and created a lot of anxiety among students (Green and Blunden, 2022). However, student nurses in the UK reported gratitude for being able to participate: many felt privileged to complete clinical nurse training during the pandemic (Green and Blunden, 2022; Townsend, 2020). Despite the many stressors, student nurses recognised that they were able to develop numerous skills – particularly reflection and the ability to work under pressure, which they saw as crucial for their future personal and professional development (Green and Blunden, 2022).

Aims

Much research has been conducted into the pandemic’s negative impacts on health professionals. Therefore, our study’s primary aim was to explore the positive experiences of student NAs in practice during the pandemic. The secondary aim was to use these findings to contribute to the knowledge base of how best to support student NAs and their wellbeing in clinical areas, particularly during stressful events.

“For many students, time spent in practice during the pandemic was a time of self-discovery”

Methods

The study explored seven participants’ lived experiences and, therefore, followed the qualitative paradigm that is considered appropriate when investigating human understanding of the world and personal perceptions (Critical Appraisal Skills Programme, nd; Silverman, 2020).

People recruited for the study were on the FdSC NA programme at Middlesex University London and belonged to a group of students whom the researcher taught or tutored at the time; this falls within the convenience sampling approach outlined by Liamputtong (2019). Participants were employed by various NHS trusts and worked in a range of hospital settings. The study was open to first- and second-year students of the NA programme.

Selection of study participants in phenomenological research is determined by specific criteria, the most important being that the individuals have experienced the phenomenon being examined (Creswell and Creswell, 2018). Students were, therefore, chosen using a purposive sampling method (CASP, nd). To be included in the study, students had to:

• Have cared for patients face to face on a practice placement during the first or second wave of the pandemic;
• Be an active student on the adult branch of the FdSC NA programme at the time of the study. Students were excluded if they:
• Were on prolonged leave during the pandemic;
• Quit the programme during the study;
• Were on the mental health or child and young adult branch of the FdSc;
• Did not return a consent form.

The study received full approval of the health and social care research ethics committee at Middlesex University London, which employs the researcher and delivers the participants’ FdSc NA programme.

Participants received an information sheet that included a short description of the study, its purpose, possible benefits and confidentiality principles. They were allowed to withdraw from the study at any time, and participation was voluntary. Students were reassured that their participation would not affect their academic performance. All information provided was treated confidentially and in accordance with the Data Protection Act 2018.

Individual, semi-structured, open-ended interviews were conducted between October and December 2021. To respect social-distancing measures in place at the time, Zoom was used to hold and record the interviews, which allowed us to capture both verbal and non-verbal expressions. The interview questions (Box 1) had been developed by the researcher after completing the literature review. Pilot interviews had been held with two volunteer students, and questions were modified based on their feedback.

The interviews lasted 20-40 minutes. During the discussion, the participants were asked questions verbally, and the questions were also displayed one at a time through Zoom’s screen-sharing function. Participants were reassured that they could pause or finish at any time if the discussion stirred too many emotions; additionally, if they showed any emotional distress during the interview, adequate support was provided. The discussion commenced with a review of the participant information sheet, and verbal consent was obtained.

The quantity of required participants was determined by interviewing students who met the inclusion criteria until no new topics were generated. Data saturation was achieved with seven students. Demographic information was collected before each interview and is shown in Table 1.

The interviews were analysed using Braun and Clarke’s (2006) six stages of thematic content analysis (Fig 1). The researcher read the transcripts repeatedly to achieve a sufficient understanding of NA students’ experiences of working during the pandemic. Noteworthy statements were highlighted and coded into themes; these are discussed below.

Results

The study’s findings included students’ negative experiences, positive experiences and coping strategies. Below, we explore the three positive themes that emerged.

Teamwork

Students were paired with qualified nurses during shifts. They all felt welcomed and appreciated, and recalled fond memories of working alongside dedicated team members:

“You came across great nurses and I absolutely loved working with them, because they were just ‘bang, bang, bang’[…] Things were done, there were clear instructions: [...] ‘Let’s work as a team and, if you will take care of that, I will take care of that,’ and it was actually a joint effort.” (P1)

“There are very hardworking nurses that I’ve seen […] Patients are the first priority.” (P2)

“It is just thanks to those nurses that patients were getting better, because [they received] good care.” (P1)

“I come across […] many, many great nurses, and it was a pleasure to work with them because I’ve seen the ethics.” (P4)

“It’s not very easy, but with communication and understanding, we try to make it to the end by working together […] We are in need, so we have to do our best to provide the best for the patient.” (P6)

Although patient care had to be delivered in extremely difficult circumstances, participants reported that nurses still provided student supervision. This was greatly appreciated:

“I had a great mentor, [because] she helped me a lot and I did learn quite a lot from her.” (P1)

“When there was time for, let’s say, medication and she was challenging me […] I was thinking: ‘Do we have time for that?’” (P1)

Students observed that, in difficult conditions, interprofessional teams pulled together:

“We had a great team of domestic staff. [They were] tremendous to help you as well, and I did notice that the relationship between nursing staff and […] domestic was great.” (P1)

“Ultimately, I think it made everyone a tighter unit.” (P4)

“It was smooth going. With all the staff, regardless if they are domestic staff or the kitchen staff or the cleaners – even the delivery men – they were trying their best.” (P1)

“I became a [trained] nurse [quickly], because I was allocated the patients immediately: 13 patients for the first day, with my manager being the second nurse and the matron being my healthcare support worker, because we have to work in collaboration to make sure that we provide the best.” (P6)

Some HCPs were forced to stay at home and shield due to their own underlying health conditions. Those who could work were affected by staff shortages, but the team spirit prevailed:

“The rest of us who were there, we were together. The teamwork was great.” (P7)

“One of my best, amazing impressions of the NHS is that we’re going to care for everyone exactly the same, no matter what. So I think […] the care was still really quite good.” (P4)

Learning

All student NAs reflected that their time spent in practice during the pandemic was highly valuable, mainly as a result of the many skills they acquired in a short period of time:

“The amount that I’ve learned was the most positive outcome […] If I was a nursing student, I wouldn’t have even been allowed into the hospital at that point.” (P4)

“It actually brought in a more mixed skill, without the actual need of going to […] a different department.” (P3)

“The amount that I learnt by just being thrown in was, like, amazing, and I probably will never have that experience again where […] people need you there, so they’re just going to show you the stuff that they need you to do.” (P4)

“[After being in practice in my first year,] I was able to be confident in the second year to really excel in it practically.” (P5)

Students were even able to thrive, due to the fact that staff were busy:

“That forced me to use my own initiative or my own brain.” (P1)

“You don’t have to be spoon-fed to do everything. There are some things you have to just [think]: ‘What do I need to do?’” (P5)

“It made me [...] know how to prioritise.” (P6)

Personal growth

For many students, time spent in practice during the pandemic was a time of self-discovery:

“I [thought,] ‘I’m just going to be a better person,’ [so] the biggest impact [was that it made me] be stronger.” (P1)

“Life is very short, so just work around and help as much as you can. I can’t give anything to anybody; it’s just my time, my dedication and how I look after somebody. My profession is what is most valued.” (P2)

“I’ve seen my other side of myself I didn’t know […] I realised that I have that care and compassion.” (P7)

“I was shielding as well for two months in the beginning […] Then I [stopped,] because I can’t be sitting at home. People are volunteering at the age of 90 and look at me – at the age of 35, I’m sitting at home. I said, ‘No, I will go and work.’” (P2)

All students recognised that they developed many transferrable skills, as well as personal traits:

“I could learn from it, [because…] the way [a nurse] was with a patient, it was great, and I want to be like that as well, so I can start developing those kinds of skills.” (P1)

“It changed me. Now, if [a] patient calls me, I […] present myself well […] I have to be polite to them, I have to put everything aside.” (P2)

“Even though you know the pandemic is bad – and everything it brought, it was bad for me – it’s just made me a bit stronger […] If that’s going to happen again, [I] know I can handle it.” (P1)

“We’ve always had to get on with things, you know, and Covid made us all a bit more flexible.” (P4)

“In the end, I became a lot more confident.” (P5)

“[I thought,] ‘How can I make them feel better to save them to go home and, if they cannot go, what can I do
to make their last minutes the best minutes of their life?’ It was a very good experience that really developed me morally, psychologically and professionally.” (P6)

In particular, resilience was the skill that students most appreciated developing:

“Apart from all that suffering and, obviously, negativity about the Covid [pandemic], it did teach me a lot of skills [and] resilience.” (P1)

“The biggest impact on me, it was that I gained a lot of knowledge, a lot of experience [and] resilience.” (P2)

“Now I am […] a little bit resilient, because […] I don’t let it bother me that much.” (P6)

“I’ve become more resilient to face difficult challenges.” (P7)

Discussion

All student NAs interviewed in this study agreed that time spent in practice during the pandemic was an invaluable learning opportunity. They appreciated the chance to learn new skills that underpin safe nursing practice, including:
Prioritising patient care;

• Critical thinking;
• Working under pressure;
• Confidence;
• Flexibility.

This is consistent with student HCPs’ experiences of working in healthcare during the Covid-19 pandemic worldwide (Green and Blunden, 2022; Roca et al, 2021).

Creating learning opportunities during a time of crisis can be particularly beneficial, especially when skills and knowledge can be gained from others through interprofessional learning. This has been shown to reduce anxiety and improve confidence among HCPs (Roca et al, 2021).

A large number of participants reflected on personal growth as one of the main benefits of their time spent in practice during the pandemic. For many, it was a time of a reflection, realisation and self-discovery. The idea of the pandemic resulting in HCPs “understanding the value of life” is consistent with a study by Aydin et al (2022), in which “almost half” of participants acknowledged a change in their perception of the value of life.

The interviews gave the student NAs an opportunity to reflect on their experiences in practice during the pandemic. In their responses, many focused on teamwork and learning opportunities, and some outlined the coping strategies they used to deal with difficulties. Understanding the impact of the pandemic on students in practice could result in the creation of a framework that could be beneficial if used in training sessions or as a basis for activities for clinical staff. These could not only focus on building resilience, but also promote reflection, which increases learning and self-awareness (Ardelt and Grunwald, 2018), and decreases stress while in practice (Badu et al, 2020).

Resilience-building activities have been shown to decrease self-reported stress and encourage a less-stressed workforce (Andersen et al, 2021). As such, the outcomes of our study could be shared with clinical practice leaders and managers so discussions can take place about how students can develop resilience.

During the Covid-19 pandemic, it was interesting to see how experienced HCPs could turn a challenging situation into a learning opportunity; collectively, we should explore how we can support them, as well as students, during such experiences in the future.

“Resilience-building activities have been shown to decrease self-reported stress”

Limitations

The study’s results could have been strengthened by the inclusion of focus groups, in which the participants could interact with each other to generate new data. However, due to the restrictions in place at the time, in-person group meetings could not take place and group meetings via Zoom would have been challenging due to individual availability and technical issues.

Study data was collected before the end of the pandemic. This was beneficial, as student NAs were more likely to be able to recall their experiences, but it would be worth exploring any long-term effects of those experiences.

Additionally, it could have been valuable to separate participants’ reflections on their experiences of the first and second waves of the pandemic. The study was initially scheduled to take place before the second wave in September 2020 but, due to unforeseen circumstances for the researcher, it was delayed until October 2021. We decided not to overcomplicate things for the participants, and felt that it could have been challenging for them to try to reflect on experiences from two separate occasions in the previous year.

Due to the nature of qualitative research, the sample size for this study was small, so the results are not generalisable to all student NAs. Additionally, the purposive sample of participants included only those already experienced in the healthcare environment; it would be beneficial for future studies to include students new to the healthcare system, as their perceptions and abilities to cope might differ. Research among students of other branches of the FdSc could also be beneficial.

Research into student NAs’ experiences is currently limited, so quantitative studies with a larger sample size are recommended to provide scientific evidence on the topic.

Conclusion

This study explored student NAs’ lived experiences of clinical practice during the Covid-19 pandemic, and provided an insight into some of the positive self-reported outcomes. These included improved teamwork, enhanced learning and personal growth. Understanding student NAs is particularly important because, in England, they form a relatively new occupational group. A comprehensive insight into their perceptions and experiences could enhance their clinical practice and development, as well as their success in the healthcare sector.