A career in nursing offers numerous and diverse opportunities. However, the nursing profession within the UK currently faces many challenges; the most pressing is the recruitment and retention of registered nurses (Beech et al, 2019). Given the existing and predicted shortages of registered nurses (Buchan et al, 2019), it seems constructive to ensure that student nurses are not only appropriately prepared for registration but they are also well supported and nurtured as they develop their nursing knowledge and skills. This study gave voice to the health and wellbeing experiences of 100 first-year student nurses through the use of their written narratives. These narratives captured their health and wellbeing experiences as they navigated through the first year of their undergraduate programme. The study findings identified student responses to programme and personal life stressors, revealing how students juggle the competing demands and attempt to seek equilibrium while managing their lives; all the time endeavouring to find ways of coping, continuing and succeeding on the programme. Finally, this article will discuss the impact of curricula that acknowledge and are guided by the experiences of students, as ways of addressing and ameliorating potential stressors.
Background
There is global recognition of the increasing levels of stress, anxiety and mental health problems experienced by young people attending college and university (Denovan and Macaskill, 2016; Bennion et al, 2018; Othman et al, 2019), with student nurses reporting higher levels of stress, anxiety and depression than other students (Edwards et al, 2010; Gurková and Zeleníková, 2018). Individuals view stress in terms of the demands it makes of them and their perceived ability to cope (Clancy and McVicar, 2009). Stress can be viewed as a continuum, with prolonged stress culminating in emotional suffering, burnout and mental distress (McVicar, 2003; Waddill-Goad, 2016).
It is widely documented that nursing is a stressful occupation (Waddill-Goad, 2016) and the preparation for such a career is equally stressful (Gurková and Zeleníková, 2018). Middleton (2018) argued that student nurses must work harder than many students on other university programmes, managing both theory and shift work practice against a backdrop of financial pressures. Considerable evidence documents that nursing students find the extensive academic element of their programmes stressful (Evans and Kelly, 2004; Moridi et al, 2014) and although clinical placements provide practical learning opportunities, they are often physically challenging, emotionally exhausting and mentally demanding (Pulido-Martos et al, 2012; Moridi et al, 2014; Health Education England (HEE), 2019). Placements frequently expose students to the extremes of human life, which, if not recognised and carefully managed, can impact on student wellbeing (HEE, 2019). Overall the high level of stress experienced by student nurses can have a negative impact on quality of life (Labrague et al, 2017) affect academic performance and holistic health (Edwards et al, 2010; Yıldırım et al, 2017), contribute to attrition and burnout (Lopez et al, 2018), and have long-term consequences for staff shortages within the profession (Wolf et al, 2015).
The complexity of modern health care demands highly skilled graduate registered nurses (Oliver, 2017). In recognition of this, nursing education for registered nurses became a minimum of a Bachelor of Science (BSc) degree in the UK in 2013. Aiken et al's (2018) study, which considered patient satisfaction in hospital care within the UK, highlighted the importance of sufficient numbers of graduate nursing staff for positive patient outcomes, while Aiken et al's (2017:560) work across European hospitals demonstrated the value of highly skilled nurses, and how reduction in nursing skill by the employment of ‘less-educated’ healthcare staff reduces patient safety, contributes to preventable mortality and adds to shortages of hospital nurses. These consequences are acknowledged by the Royal College of Nursing (RCN) (2017) in its policy on Safe and Effective Staffing.
In the UK, the nursing curriculum currently straddles the demands of an apprenticeship-style placement programme and undergraduate degree. Students typically undertake a 3-year BSc degree that combines the theory and practice of nursing within each 45-week academic year. Student nurses in England are required to complete 4600 hours of learning, which includes 2300 hours in NHS partner placements and 2300 hours of theory (Nursing and Midwifery Council (NMC), 2018). This necessitates a 45-week academic year, rather than the 30-week academic year enjoyed by many other undergraduate students. This has the impact of separating and isolating student nurses, limiting their opportunities to contribute and experience wider university life (Urwin et al, 2010), and prevents them accessing regular employment to boost personal finances (HEE, 2019). This extra 15 weeks for each academic year, which is unfunded by the maintenance loan, is 50% more per year than many other undergraduate programmes and can be seen as an additional major stressor for nursing students.
The current shortage of registered nurses has focused attention once more on student attrition, which has remained consistent for some time. Reports from the Health Foundation (2018) maintained that one in four student nurses do not complete their degree. The reasons for attrition are complex and rarely due to one reason—more often there is a combination of personal, organisational, course-related, and financial factors (Urwin et al, 2010). In addition, the introduction of student loans and the removal of the training bursary for student nurses has contributed to a reduction in applications, thereby further reducing the number of students working towards registered nurse status (RCN, 2018). In an attempt to address these issues the Government has announced that from September 2020, nursing students in England will receive a £5000-a-year maintenance grant, and further details of the payment have been promised (Prime Minister's Office, 2019).
Methodology
Participants
This study adopted a qualitative approach and was deeply rooted in the self-reported written narratives of 100 first-year student nurses in one university. The work gives voice to the students, their perceptions and experiences of the programme. All adult nursing students in year one are required to undertake a 20-credit (10 European Credit Transfer and Accumulation System) (level four) academic module entitled ‘My health and wellbeing’, which is taught towards the end of year one. The assessment for this module is a written case study in which students are required to recognise and explore the influences on their own health and wellbeing since starting the programme. These case studies formed the basis of this study.
Three academics from the teaching team completed this research. All members of the first-year cohort of students were invited to take part in the study. Voluntary participation was emphasised, with guarantees of confidentiality and anonymity. The research team informed the students that they were interested in analysing students' personal narratives of transition on to a nursing programme at university and not the quality of the written work. All of the assignments had previously been marked by nursing academics, bound by professional confidentially. Written consent was gained from all participants. One hundred students volunteered to take part in the study out of 184 in total. The research team were surprised at the number of students who wanted to take part; students stated that they saw the research as an opportunity to share their experiences with the wider nursing community.
Data analysis
Thematic analysis was employed to analyse the data contained within the narratives. For the purposes of this research, Braun and Clark's (2006:79) definition that ‘Thematic analysis is a method for identifying, analysing and reporting themes (patterns) within data’ was deemed to be the most applicable. When coding for patterns, the question of size and prevalence of the themes identified is relevant. However, as Braun and Clark (2006) stated, researcher judgement and flexibility in coding is needed as a theme may be given in many sentences or limited to one or two within the data. In addition, themes identified need to be relevant to the aim of the research.
Initially the three-person research team each analysed and coded the same 10 essays to cross check interpretations and ensure their approach to coding was consistent. The remaining essays were then sub-divided and thematically analysed with no major new themes being identified. Three dominant themes were selected as having the strongest supporting evidence and reflected all the participants' experiences.
Findings
From the thematic analysis, nursing students indicated that they were required to juggle multiple competing demands for their time, physical capacities, income and personal resources and were constantly trying to find balance and personal equilibrium. They also revealed the coping strategies they had developed to manage their emotional, mental and physical life and the programme demands.
Juggling
These student nurses reported the effects on their health and wellbeing of juggling and managing, not only their new roles as university students and going into clinical placements, but also in dealing with their existing roles.
The difficulties of juggling the nursing programme expectations with everyday life was expressed:
‘On a personal level, commencing a demanding degree programme has been challenging and several factors have challenged my health over the duration of the course. Managing my workload, adapting to a new routine and working long shifts alongside running a household, managing finances and carrying out daily tasks has impacted my physical and mental health.’
‘… having to build a new life in a new town whilst also keeping up with assignments and doing well on placements … never living on own, never done my own washing, never having to buy own food and never having to sort out budgets so I have enough money to pay my rent and run my [car].
Travelling to and being in clinical placement added to the juggling act with the consequential negative influence on health:
‘The experiences of being on placement in clinical practice also cause a great deal of stress and anxiety … I found my first placement incredibly stressful, especially with very long shifts and driving long distances. I am also a single parent and found managing our daily lives with study, placement and meeting the needs of my teenage son very challenging.’
Nursing students also had to deal with external factors and life events that were out of their control and had subsequent effects on their studies:
‘It [childcare] didn't always succeed and on two occasions I had to leave university early due to childcare failing. This was stressful as I felt like I lost valuable lesson time and was missing out on important information. I then felt guilty about leaving my daughter, I knew it would benefit both our futures, but the emotional stress that the guilt caused from spending longer away from home, the inconsistency of my routine and factoring in study time was hard.’
‘Prior to starting university my mother-in-law had been struggling with treatment for cancer. Sadly in November she lost this battle. As a family we were bereaved, my children needed supporting, and my husband especially needed more of my attention … Emotionally I faced dilemmas regularly, being torn between studying for our family future and wanting to be at home with them. This challenged my wellbeing as I was often tired, so again concentration took more effort …’
Finding balance
As a consequence of juggling competing issues, many students described the experience of their first year as ‘a balancing act’. They recognised that a key issue in their health and wellbeing was the influence of managing this balancing act.
‘Attempting to find the time to factor in home learning, family time, social life, rest, university, placement and parenting felt impossible and I rarely managed to keep a healthy balance.’
The balance between home and work life, or social and work life was difficult to manage, often leading to the neglect of important aspects of wellbeing. There was a perception that the academic workload alongside existing responsibilities had tipped the balance towards a lower level of wellbeing, with a consequent experience of being ‘overwhelmed’ or isolated.
‘I struggled with balancing my time between being at university, doing the essential pre-reading before lectures and keeping up my social life with friends and family. I believe this has had an impact on my health and wellbeing due to feeling overwhelmed with adapting to be a student, I have noticed a change within my physical health and mental health.’
‘… I was struggling financially on a student budget and had immense feelings of guilt placing my son in childcare all week. Maintaining a home and work life balance was becoming less achievable resulting in me not going out or socialising and spending the majority of the time at home studying.’
The pressures that tipped the balance most often came from the demands of their new course, with students feeling unable to ‘switch off ’, so that a constant state of alertness to course issues dominated daily life.
‘I also found it was difficult to switch off when I was with the family. I was carrying around the pressure on my shoulders, from the placement and my assignments.’
‘I was afraid to stop … for the fear I might let something slip.’
This constant state of alertness resonates with definitions of stress and the exhaustion experienced when the stress does not alleviate. Concurrently, mechanisms for reducing the level of stress, or buffering against stress, such as a social life and leisure pursuits, were losing out in the balancing act.
Additional pressures that tipped the balance came from family expectations, such as trying to please parents or justifying the feelings of guilt about children.
‘Parental pressure is also an important source of stress for me as a student; children do not want to disappoint their parents, so they overwork and do everything to reach the goals no matter how much stress it produces. I often place myself under this pressure, especially as I am the first in my family to go to university, despite my parents telling me they are proud of me no matter what.’
However, it was clear that learning to find the balance had also been a feature of the year. Making adjustments and finding a sense of equilibrium was an emerging outcome for a number of students.
Coping strategies
The term ‘stress’ was referred to by almost all the student participants, with their accounts demonstrating their recognition of how the effects of stress could permeate into all areas of their lives. Ways of coping and managing the symptoms and causes of stress varied, dependent on age, previous life experiences, responsibilities and learning gained from their experiences in the first year of the nursing programme. The earlier experiences on the programme provided them with insight and tools that subsequently helped them develop ways of managing and coping. There was also a recognition that it was important to be aware of their own feelings and wellbeing and to ensure that their own needs were respected, valued and considered in order to be effective on the programme.
‘Through experiencing stress throughout my first year, I have learned the importance of managing my stress effectively to maintain positive physical and mental health. Strategies I have developed include undertaking physical exercise where possible, resting when needed, ensuring … adequate sleep, being mindful and noticing early warning signs and participating in talking therapies if and when necessary.’
‘This new knowledge [on managing stress] is essential to me as a learner because it has helped me to make a difference to my own health, I now focus on how I am feeling instead of what I need to do, this has helped me to take a step back and take time for myself. For example, if I start to feel stressed while writing an assignment, I will take a break and go for a walk instead of playing on my phone or watching the television. This helps me to clear my mind and think clearly, I have also changed my diet, I now focus on eating fruit instead of chocolate during my most stressful times. I have noticed that changing small habits like these has increased my concentration levels, the way I organise myself around university and my social life. I feel like I have more energy and I feel healthier within myself.’
Mature students with caring responsibilities had the added workload and responsibility of learning to adapt and manage the demands of shift work within family life.
‘I am also self-aware that nothing is that bad when you break it down into small chunks and keep going … for example, I must work night shifts on my next placement, I have not experienced this and feel I will find it a challenge, as I have a family to look after. I will need to juggle everything and feel that working a few nights in a row will leave me feeling exhausted. But I will say to myself ‘What's the worst that can happen?’ I will be tired and out of routine and will have to make small changes to my home life, such as a change of bedtime routine and eating. I will put my children to bed earlier and have dinner ready slightly earlier, so I am organised.’
Many students highlighted the importance of social networks with people who shared a similar outlook and interests as a coping strategy and a way of enhancing personal health and wellbeing. Seeking out people with comparable interests was a high priority of many students.
‘I struggled to find a group of people to spend time with that had the same interests as me. The pressure to fit in and find a group of friends that I got on well with began to take its toll on my mental wellbeing. In the time it took me to find a group of people I could socialise with regularly, I had already begun to start doubting my ability to make it through the degree. I had made friends on the course early on, but these relationships were made out of necessity rather than the grounds of mutual interest, and therefore I was unable to form significant relationships.’
Discussion
This study demonstrates a number of important findings, namely that student nurses invest heavily in their nursing programme and work hard to manage the multiple competing demands of this intense 3-year programme. From their experiences over the first year, many students learn to develop the skill of juggling the numerous demands on their time and resources, constantly seeking to find equilibrium and strategies to help them cope. Transitioning into the programme throws students into a situation with competing demands, requiring the reframing of support mechanisms (McDonald et al, 2018). For some students, this involved the transition between school and university, home and living independently, and learning and acquiring major life skills. For other students, it often comprised transitioning from paid employment or parenthood to becoming a full-time student, managing family commitments, childcare, household chores, and grappling with academic writing, all on a reduced income. Transition for all students provides many opportunities and benefits, but is also a potential stressor and can negatively impact on academic achievement (Denovan and Macaskill, 2016). Ultimately all students must adjust to their programmes, to different ways of living and learning. However, obstacles, such as lack of support, or excessive programme demands, may affect mental health and wellbeing (Thorley, 2017).
Much of the literature on transitions for nursing students merely refers to their transition into clinical practice (McDonald et al, 2018) or to registered nurse status (Collard et al, 2019). In reality, student nurses manage multiple transitions within their 3-year undergraduate programme, from the initial move to university, to the many and various required placements and then to being a registered nurse. This study reveals that student nurses respond to the challenges by learning to juggle the competing demands of all aspects of their lives, including; academic learning, practice learning, peer social time, self-care and family time.
The importance of family and friends is evident within this research; the findings demonstrate that many students recognise the personal value of sustaining family relationships and developing like-minded friendships, but face numerous time constraints. The wider literature acknowledges the significance of good social connections for everyone (Aked et al, 2014) and the importance of supportive family and friends for healthcare staff (HEE, 2019). In the present study, the nursing students discussed the challenges of undertaking the programme as a parent, the cost of childcare, the guilt experienced when having to place small children into childcare facilities, and the stress when childcare is unavailable. It is well documented that the support of friends is linked to the promotion of student health and wellbeing (Friedlander et al, 2007). Although family support aids university integration even for stressed students (Friedlander et al, 2007), a lack of support can escalate stress and health problems (Yamaguchi, 2013).
A recurring theme within this research shows how students try to maintain a balance in their lives but, for many, the requirements of the programme were challenging, often forcing them into a state of ‘constant alertness’, which negatively influenced family time, and contributed to the adoption of health-diminishing behaviours and self-neglect. A large percentage of nursing students have cited the pressure of academic work, irregular shift work, lack of time and family commitments as contributing factors for poor personal health behaviours (Blake and Harrison, 2013). There is widespread recognition that academic, social and financial pressures are contributing to higher levels of mental distress and poor mental health outcomes among many young people at university, with rates higher than in previous generations (Thorley, 2017). Finding and using good support systems is essential, not only for success on the programme but also for students' personal health and wellbeing, and may contribute to reductions in student attrition. Initiatives to address and eradicate sources of stress require a good understanding of the stressors and their influence on students (McVicar, 2003; Waddill-Goad, 2016). Nursing programmes have an obligation to review the support systems available to students and move to develop mechanisms in conjunction with the students to ensure they address their needs.
Understanding the student experience of nursing programmes
Nursing programmes seek to prepare student nurses to become members of the professional nursing workforce, enabling them to work towards improving healthcare systems that meet population needs and protect the public (World Health Organization (WHO), 2009). In doing so, the nursing regulator and health education institution (HEI) providers have a responsibility to understand how students experience their programmes. WHO (1986) identified the impact on health of the settings in which people live and work. This is no different for student nurses, they study and work in multiple environments and work cultures, and these all influence and shape their health and wellbeing outcomes. Additionally, changes in the higher education landscape and to academic workloads have increased student-to-staff ratios, placed more demands on lecturers' time, and increased student group sizes, making it more problematic for some students to develop a sense of belonging and develop friendships, and reducing staff time for student support (Macaskill, 2013; Denovan and Macaskill, 2016).
Although nursing programmes across the globe combine academic work, practice simulation and practice placements, the move to higher education settings in many countries, including Australia, Canada and the USA, has changed the format and structure of the programmes. These countries currently require practice placement attendance of between 800 and 1000 hours over the duration of the programme, whereas the UK requires 2300 hours (NMC, 2018), which may also involve students travelling long distances, sometimes staying overnight in temporary accommodation and working long shift patterns, including night duty, weekends and bank holidays. HEE (2019) acknowledges that such shift patterns reduce student opportunities for financial remuneration with part-time work. The ensuing fatigue contributes to stress and impacts on multiple aspects of life, including compromising self-care (Waddill-Goad, 2016).
In contrast, undergraduate physiotherapy and occupational therapy degrees within England require students to successfully complete 1000 hours in practice in addition to academic work (Health and Care Professions Council, 2017), thereby providing a balanced educational experience and enabling these healthcare students the mental space to accommodate their learning and to enjoy and benefit from the wider experiences and opportunities offered by universities. Mitchell (2019) reported the academic Linda Aiken's challenge to the UK to reduce the number of hours UK student nurses are required to complete, arguing that the current apprentice-style model lacks relevance in an age of fast-changing knowledge, and adding that nurses in the USA are still great nurses while undertaking many fewer clinical hours.
This study has identified that student nurses work hard to manage, juggle and cope with the multiple requirements of their programme; these student experiences must be recognised and acknowledged by the NMC and the wider nursing profession. In order to address attrition and future nursing shortages it is now necessary to take decisive steps. The NMC must initiate an urgent debate within the profession to review the aim and key elements required within nurse education. Most importantly, the profession must be receptive and responsive to the student voice. Hearing the student voice can be achieved in many ways, including consultation, co-creation, participation and being genuinely receptive and responsive to student feedback (Hughes and Spanner, 2019). Additionally, nursing programmes in HEIs have a duty to reduce excessive academic and placement burdens: programmes should support student health and wellbeing, making it easier for undergraduate BSc Nursing students to be happy and healthy.
Limitations
The authors acknowledge the limitations of this study. The use of student assignments captured subjective self-reported health and wellbeing experiences. The study recruited participants from just one university setting. It is possible that some of the students may have presented a positive coping image in their work because they were aware that lecturers would be marking their work. Despite these limitations, the study identified the genuine and multiple programme stressors for students undertaking undergraduate BSc degrees in nursing.
Conclusion
This study has presented data that capture student narratives; how they strive to manage, juggle and seek to find strategies to help them continue on nursing programmes. The work has implications for nurse education and curriculum development. Understanding student experiences and the major stressors provides opportunities for the NMC in conjunction with HEIs to ensure that curricula avoid placing heavy unmanageable burdens on students. Nursing educational frameworks and requirements should encapsulate a realistic understanding of student experiences, thereby enabling the development of curricula that support and improve student health and wellbeing, while meeting professional requirements. BJN