The year 2020 was set to be a great one for nurses, with many celebrations. It was named the Year of the Nurse and Midwife (International Council of Nurses, 2019) and it is also the 200th anniversary of the birth of Florence Nightingale. However, an announcement we did not expect was from the World Health Organization (WHO), which declared coronavirus a global pandemic in March. The WHO has also published a report highlighting the long-standing shortage of nurses globally, including in the UK (WHO, 2020).
Due to the pandemic and the assumption that an already stretched NHS might be overwhelmed, the Government had to consider alternatives, which included asking recently retired health professionals, including nurses, to rejoin the emergency register the regulator had created and also to co-opt nursing students to assist the workforce. Second- and third-year student nurses from all four UK countries were given a choice of two options (Nursing and Midwifery Council, 2020a; 2020b):
This must have been a challenging, anxious and worrying time given that the pandemic has caused the deaths of not only nurses but also student nurses, as highlighted by Mitchell (2020).
Countries, including Australia and the USA, cancelled significant numbers of clinical placements, meaning students did not have the choice offered to those in the UK (Carolan et al, 2020), which has caused several nursing leaders to question if this was the correct move here in the UK. The global pandemic has created an unknown territory for all health professionals, who have experienced a range of acute and chronic feelings and emotions. These feelings and emotions will last for several months, if not years, to come, and it is important to understand that these will affect student nurses as well as staff.
McCormack (2020) questioned why nursing leaders, including himself, allowed this situation to be pushed through, suggesting that not enough leaders protested against such a choice, which might significantly impact the theoretical element of the nursing curricula in the future.
It seems clear that the thought of a paid placement might have appeared enticing for the several thousands of nursing students who have entered the pandemic workforce. They may have done this for many reasons such as the chance of a temporary income, gaining a once-in-a-lifetime experience and an overwhelming desire to contribute. But we must not forget the students who chose to opt out.
Both Hayter and Jackson (2020) and McCormack (2020) highlighted the emotive narrative students might have experienced from their peers, social media and even universities, which might have put pressure on students to take the paid placement option. Given further time and much more detailed information, would as many have chosen as they did? However, it is clear time was not on their side, and this was not a decision that could be pondered over for weeks or months.
Social media has been full of this emotive narrative. Words and phrases being used include ‘hero’, ‘battle’, ‘stepping up’, ‘doing your duty’, ‘such a great work ethic’ and so on. I wanted to explore this further. As part of my Council of Deans of Health 150 Leaders Programme project, I decided to create and share a survey via my project website ThinkTheory19 (https://thinktheory19.wixsite.com/website). My project aims to support the students who could not or would not accept the offer of a paid placement in a non-biased and non-judgemental way. I chose to do this because of the negativity often shown towards them and the negative feelings they were experiencing such as guilt, shame, and the fear that they were being unprofessional.
On 7 May 2020, I posted the survey, which ran for 3 weeks; 198 students responded. It consisted of seven mandatory questions, with the eighth being free text and optional. The survey design ensured the respondents remained anonymous, with no option to reveal their identity, to maintain confidentiality and also to allow the students to express their feelings, particularly if answering the optional, free-text question. Students from all over the UK were able to respond; however, the survey was aimed at those who had chosen to opt out rather than to opt in.
People should not assume students are opting out for their own or a family member's health reasons. Their choice might be based on their values, beliefs and opinions on the matter. The survey shows that the majority of students who chose to opt out have had a negative experience.
Survey questions
Did you feel pressure from peers towards either of the choices?
Thirty-four per cent of respondents said they felt pressure from their peers towards one of the choices, although this question did not ask which of the two choices. Some 47% said they did not feel pressure and 19% felt some pressure from their peers. Two students stated the following in the optional, free text box (question 8) relating to question 1:
‘I felt there was a lot of pressure from some peers, not all, and pressure from [the] NHS board to take up placement, with them actually stating false truths to make placement more appealing.’
‘Choosing was quite difficult. Although I didn't feel pressure from the uni or my peers to opt in I felt like I put pressure on myself.’
Did you feel pressure from your university towards one of the choices?
Some 52% said they felt no pressure, 15% said the felt some pressure and 33% suggested they did feel pressure towards a choice from their university. This relates to points made in a paper by Swift et al (2020) on possible inappropriate pressure from institutions. Two students wrote the following in the free text box in relation to question 2:
‘Got no guidance from uni or rather no pressure either way but no communication at all from adviser of studies.’
‘The university are bad with communication and when you ask they simply say “this is the only information I am allowed to give students, the rest is just for staff”.’
Did either of these pressures end up influencing your choice?
Nearly three-quarters of participants responded no (72%); however over a quarter (28%) responded yes, they did end up making a choice based on pressure from peers and/or universities. One student's response relating to question 3 was:
‘I think it was a horrible choice to make us choose.’
Question 4 was aimed at gauging how students felt about their choice.
How were you feeling when you initially made your choice? (1 star is ‘Poor’ and 5 stars is ‘Great’)
The results suggest an average rating of 2.58 stars. By looking further into the individual responses, 51 students (26%) chose 1 star and 23 (12%) chose 5 stars. Here are some students’ points relating to this question:
‘I initially chose placement, had to change to theory. Now feel terribly guilty.’
‘The whole thing was a farce from start to finish. The communication and leadership from the university was abysmal.’
The next question would show whether there was evidence that a project such as ThinkTheory19 was needed.
If you were to select three of these feelings when making your choice, what would they be?
From a choice of feelings, the top three selections were ‘unsupported’, ‘anxious’ and ‘guilty’. The three least selected options were ‘unconcerned’, ‘guiltless’ and ‘appreciated’. Some student comments relevant to this question are as follows:
‘Felt very anxious about not knowing what to expect and like they wanted us to go into placement rather than choose theory.’
‘We were told we could continue as we were as one of our options. We chose this and then this option was taken away and we were forced to either defer or sign up. I feel we were almost railroaded into this.’
The next question aimed to gauge what influenced students' choice.
What factors influenced your choice?
‘Personal health’ was the most selected option, with ‘Didn't feel confident’ being the least selected. One student's commented:
‘Feel discriminated against due to long-term conditions—little correspondence from uni about placement or what our future holds. No low-risk placement option offered.’
The next question looked at how students were feeling about their education and programme moving forward, particularly regarding missing out on several months' worth of clinical experience via supernumerary placements.
How prepared do you feel to go into the next stage of your programme, having not had as many clinical hours as planned? (If 1 star is ‘Poor’ and 5 stars is ‘Great’)
The results suggest an average rating of 2.36 stars; 61 students (31%) chose 1 star and 11 (5%) chose 5 stars.
A free-text optional question
Students were able to input any additional comments and the full list of these can be found on the website (https://thinktheory19.wixsite.com/website/post/survey-results).
Conclusion
Although this survey was relatively small, it is an indication of how student nurses are feeling and their experiences of this situation. Universities and the higher education industry have a civic duty to respond to the pandemic efforts, as suggested by Hayter and Jackson (2020), but they also have a duty of care to their students. So it is imperative that we support students to transition out of the other end of this pandemic. I am positive universities and the sector are working to do this. I have seen amazing initiatives in universities across the UK, including my own, and the plans they have aim to ensure this is a period where students are supported more than ever. It will be so important for recruitment, as well as to prevent attrition, to ensure no students are disadvantaged by their choice. What is clear is that further work needs to be done to gauge the students' feelings relating to this situation on a much bigger scale than this small survey.