In response to the need to increase staffing and to boost resilience in the NHS during the COVID-19 pandemic, the Nursing and Midwifery Council (NMC), Health and Care Professions Council (HCPC) and Approved Educational Institutions (AEIs) were tasked by Health Education England (HEE) with modifying their courses for final year students in nursing, midwifery and allied health professions (NMC, 2020). The students were given a choice of continuing with their studies and delaying their clinical practice until August 2020 or to be deployed and work in the NHS. The third-year student nurses and midwives who chose to be deployed were then accelerated into clinical placements that offered a band 4 salary and temporary registration, thereby boosting staffing throughout the NHS (HEE, 2020). These students were then placed in NHS trusts near their home and this was managed by HEE supporting the AEIs and the local NHS trusts (HEE, 2020). The expectation was that students would complete their academic work as well as working 30 hours a week as paid employees in the NHS. Deploying students into the workforce was the NMC’s response to the Coronavirus Bill published on 17 March 2020 (Department of Health and Social Care (DHSC), 2020), later passing into law as the Coronavirus Act 2020.
SARS-CoV-2, the virus that causes COVID-19, is a highly virulent pathogen, which is spread through respiratory droplets, saliva or nasal excretions from an infected patient. It is the seventh in the family of coronaviruses that includes the SARS and MERS viruses (Andersen et al, 2020). Most patients with COVID-19 are either asymptomatic or have mild-to-moderate flu-like symptoms. However, early reports on the novel virus highlighted a cohort of patients in which COVID-19 causes profoundly serious disease necessitating hospital admission and in some cases intensive care, with around 3% mortality (Wang et al, 2020). WHO declared the COVID-19 outbreak a global pandemic on 11 March 2020 due to its rapid spread around the world.
Background
The researchers were interested in the psychological impact of caring and how this linked to resilience and retention in the workforce. This concept of moral resilience and moral distress and the impact on nurses and other health professionals is now widely accepted in health care (Eaton, 2019; West et al, 2020). Epstein et al (2020) described it as the cost of caring and suggested that employers have a duty to mitigate this. The effect of moral distress can be deleterious to the mental wellbeing of the healthcare practitioner, but it can also impact on the quality of care given to patients (Henrich et al, 2017). For clarity, moral distress occurs when a healthcare provider is unable to give the care that they believe the patient should receive. This then causes an ethical dilemma, which leads to psychological distress (Eaton, 2019). It is variously described in literature as vicarious traumatisation, post-traumatic stress disorder (PTSD), secondary trauma, emotional exhaustion, compassion fatigue and burnout—all terms used to describe the distress caused by working in extreme conditions (Gökçen et al, 2013; Epstein et al, 2020) Moral distress is the result of a moral event combined with psychological distress (Morley et al, 2019). This description allies well with this research investigating the psychological impact on healthcare students. Moral distress is also linked to lack of resilience, described by Tubbert (2015) as the art of bouncing back from adversity—a description that is pertinent to this study. Resilience in health care is central to mental wellbeing of the health professional as it enables them to have greater moral courage and self-confidence in challenging ethically difficult situations (Lachman, 2016). This is key to the philosophical and conceptual framework of this research as educators prepare student nurses and midwives for the workforce.
There have been some reflective case studies published by students about their experiences of working during a pandemic (d’Aquin, 2020; Leigh et al, 2020), but few investigating the resilience or the emotional impact on the students. A study of 758 nurses and midwives in Turkey during April 2020 looked at the psychological impact of working during this pandemic and concluded that the staff suffered significant psychological distress (Aksoy and Kocak, 2020). Although this study was conducted early on in the pandemic, the results point to high levels of stress in healthcare workers. A further study in Wuhan, the epicentre of the pandemic, produced similar results and found that during the outbreak phase, the nurses suffered from higher levels of depression, anxiety and PTSD (Cai et al, 2020). Dos Santos (2020) conducted a study of 58 student nurses in South Korea and reported that most of the nursing students said they would leave the profession after graduation and the reason given was personal sacrifice—exposure to COVID-19. If all nursing students decided to leave straight after qualifying, it would have a devastating effect, not only on the nursing profession but also on patient care.
The long-term mental health of health professionals is a concern as it has implications for the individual and the organisation. Resilience and stoicism are common traits in nurses, however, long-term overexposure to high levels of stress, as experienced during the COVID-19 pandemic, is similar to the experiences of those in combat (Nelson and Kamisky, 2020).
There are a few studies looking at short-term extreme stresses in the working environment in the UK, but the researchers could find none looking at a prolonged time of stress in newly qualified staff. A small study conducted in Northern Ireland concluded that emotional exhaustion was linked to burnout and increased sickness rates (Gillespie and Melby, 2003). However, this was a study of nurses who had a wide variety of experience. We also know that health workers—both doctors and nurses—over the age of 40 are more likely to suffer burnout with prolonged stress in particular in acute settings (Gökçen, 2013). The concept of transformation from third-year student ‘apprentice’ to qualified nurse in these circumstances is unique to the COVID-19 pandemic. Research published before the pandemic indicated that nursing students had already suffered mild levels of moral distress in clinical practice (Gibson et al, 2020). This study is pertinent as it seeks to identify why student nurses and midwives report burnout and what those in education can do to mitigate this through academic support and teaching.
Research question
The research team were interested in the psychological impact on final-year student nurses and midwives working in the NHS in the midst of an international health crisis. The authors considered that the pandemic was a unique opportunity to understand the stresses placed on final-year students who were paid as part of the workforce and therefore no longer held supernumery status in the clinical workplace.
Method
Sample
A total of 53 third-year student adult, paediatric, mental health nurses and midwives were surveyed out of a cohort of 246. The team sent an electronic survey to 246 healthcare students with a response rate of 22%.
Data collection
The students who had chosen to be deployed were recruited via the university email system inviting them to participate in the research. There were also announcements regarding the research placed on the university virtual learning environment, encouraging participation. An information sheet about the research and consent form were provided and these required completion before they could access the online questionnaire. Data were collected over a period of 8 weeks during the pandemic, while the students were in clinical practice.
Ethics
The ethical approval for the study was granted by the university’s Institute of Healthcare Research. All data were collected through a Microsoft Forms questionnaire and no names or email addresses were recorded.
Methodology considerations
Measuring the psychological impact using only a quantitative approach would not do justice to the individuals’ narrative, therefore, qualitative questions were added to the questionnaire. Pauly et al (2012) argued that emotions such as distress cannot be quantitatively measured and adequately explained. The authors fully acknowledge that the statistical power of the quantitative data has no statistical validity outside the group of participants and has no wider validity; however, the qualitative narrative will add to a wider exploration in the second paper.
Study measures
Burnout was evaluated using the Maslach Burnout Inventory Human Services Survey (MBI-HSS), which has been validated for use in health professionals and students (Maslach et al, 2001; Dyrbye et al, 2010). The MBI-HSS is a 22-item questionnaire, with each item scored using a seven-point Likert scale from 0 (never) to 6 (every day) (Maslach et al, 2008). The 22 items on the MBI-HSS are divided into three domains, which are emotional exhaustion (EE: 9 items), depersonalisation (DP: 5 items) and a self-perceived lack of personal accomplishment (PA: 8 questions. Burnout on each of these domains can be identified when scores are more than 27 (EE), more than 13 (DP), and less than 31 (PA), which is reverse scored. A participant was classified as having burnout on a dichotomous scale if they had high EE and either high DP or low PA (Maslach et al, 2008).
Statistical analysis
Internal consistency of the three subscales of the MBI-HSS was estimated using Cronbach’s alpha, with an alpha level of 0.7 considered to be satisfactory (Cronbach, 1951). Descriptive statistics were used to characterise participants, including group comparisons for age and programme of study. Owing to the small sample size, all nursing specialties were grouped together and compared with midwives, while age groups were created based on tertiles of the ages in years and classified as ‘young’, ‘middle’, and ‘older’. Normality of the three subscale scores was evaluated using the Kolmogorov-Smirnov test. All subscales were non-normal, therefore non-parametric statistics were used for comparisons of scores between groups. The Kruskal-Wallis H test was used to compare groups for subscale scores, while the chi-squared test was used to compare groups for burnout. All statistical tests were carried out using SPSS version 26 (IBM, Armonk, NY, USA), with an alpha level of P<0.05 used for statistical significance.
Results
Of the potential 246 participants, a total of 54 completed the survey, which represents a response rate of 22%. The participants were 50 female and 4 male students aged on average 30.9 ± 8.7 years. With regard to the programme of study, there were 35 nursing (65%) and 19 midwifery (35%). The specialties of the nursing students were 21 adult (39%), 9 mental health (17%), and 5 child (9%).
The internal consistency of the three subscales using Cronbach’s alpha ranged from very good to excellent. The best consistency was for EE (0.91: 95% confidence interval 0.87-0.94), with similar scores for DP (0.81: 0.71-0.88) and PA (0.80: 0.71-0.87).
The scores of students for the three subscales are shown in Table 1. There were significant differences between nursing and midwifery students for both EE and DP subscales, with midwifery students having higher burnout levels for both subscales. There were no significant differences between age groups for any of the burnout subscales.
Table 1. Burnout scores in nursing and midwifery students
| Group | EE | PA | DP |
|---|---|---|---|
| All students | 22.4 ± 9.8 | 34.9 ± 5.6 | 6.2 ± 5.0 |
| Nursing | 20.4 ± 9.5 | 35.4 ± 5.8 | 5.4 ± 5.2 |
| Midwifery | 26.2 ± 9.3* | 33.9 ± 5.2 | 7.6 ± 4.4* |
| Young (≤24 years) | 21.4 ± 8.3 | 36.2 ± 6.1 | 5.4 ± 4.2 |
| Middle (25–33 years) | 20.7 ± 9.7 | 34.8 ± 4.9 | 5.4 ± 4.9 |
| Old (≥34 years) | 25.6 ± 11.0 | 34.2 ± 5.9 | 7.6 ± 5.9 |
Values are means ± SD
*Significantly different from nurses (P<0.05).
The percentages of students having burnout, according to the specified thresholds, are presented in Table 2. There were no significant differences between nursing and midwifery students or between age groups for the likelihood of burnout.
Table 2. Burnout levels in nursing and midwifery students
| Group | EE | PA | DP | Burnout |
|---|---|---|---|---|
| All students | 19 (35%) | 15 (28%) | 8 (15%) | 11 (20%) |
| Nurses | 10 (29%) | 7 (20%) | 5 (14%) | 5 (14%) |
| Midwives | 9 (47%) | 8 (42%) | 3 (16%) | 6 (32%) |
| Young (≤24 years) | 5 (29%) | 4 (24%) | 2 (12%) | 3 (18%) |
| Middle (25-33 years) | 6 (33%) | 4 (22%) | 2 (11%) | 3 (17%) |
| Old (≥34 years) | 8 (44%) | 6 (33%) | 4 (22%) | 5 (28%) |
Values are frequencies and percentages
Discussion
Throughout the pandemic, health professionals have been working in extreme conditions, working long shifts wearing personal protective equipment (PPE) and caring for patients with high levels of acuity and sudden deaths, likely more than they had ever seen. Some of the students who were deployed had the added stress of working in practice, studying and home-schooling children; some also lived away from home in order to protect their families. A high percentage of the student cohort were from black, Asian and minority ethnic (BAME) backgrounds and were caring for patients with COVID-19, knowing that they could be more at risk than their white peers of becoming seriously ill (Tonkin, 2020). In addition, they were coping with the reality of health professionals being infected with and dying of COVID-19 (Turale et al, 2020). There was no preparation for this for the students, other than an induction by the NHS trusts, and reports from the students indicated this support differed from trust to trust.
An interesting finding from the responses was that student midwives suffered from higher levels of emotional exhaustion and depersonalisation than student nurses. According to published research, this is a known phenomenon in midwifery. The results of a study of 150 student midwives indicated that high levels of stress or burnout combined with low levels of resilience resulted in high levels of attrition—students leaving university or leaving the profession within the first year of registration (Eaves and Payne, 2019). Research into moral distress in midwifery points to high levels of psychological distress as midwives are prevented from practising to the high ethical standards expected of them (Zolala et al, 2019). From point of registration, midwives practice autonomously and report higher levels of stress. This stress may have been replicated by the aspirant midwives as they were not supernumery in practice. However, long-standing organisational factors such as staff and bed shortages also contribute to the emotional exhaustion of the staff, as there is a constant balancing act between capacity and demand (Yelland et al, 2013).
West et al (2020) discussed the loss of autonomy where nurses and midwives feel that their integrity is compromised if they are prevented from giving compassionate care. This could be an underlying reason for the student midwives having higher instances of emotional exhaustion and depersonalisation than nurses, although there was not a significant difference in the rate of overall burnout for both nurses and midwives.
Moderate burnout was present in both cohorts of student nurses and midwives, a finding commensurate with a study by Hu et al (2020) who recently conducted a large scale cross-sectional study of 2014 qualified nurses in Wuhan, China and found that they reported moderate levels of burnout and high levels of fear. The study linked resilience to lower levels of burnout and self-efficacy.
Although there was not a significant difference in burnout with age in this study, the levels of emotional exhaustion and depersonalisation were higher in the older age range. This finding is common throughout the health professions and has been widely documented (de Souza et al, 2011; Schooley et al, 2016)
The qualitative questions asked in the questionnaire revealed a rich source of data building on the theme of burnout and moral distress and will be discussed in a further article.
Limitations
This study did not include a question about fear, which on reflection would have added deeper insight into the psychological impact of working in the NHS during a pandemic, on the healthcare students. The sample size was small (53 students out of a possible 246), despite the efforts of the researchers to recruit the students. Due to restrictions on visiting the NHS trusts, the researchers were unable to see the students and inform them of the study, relying on emails for contact, and this may have also had an impact on numbers of participants. Some students have since reported that they had not checked their emails as they were too busy working in practice and completing academic studies. The study could have also included allied health professionals, which may have boosted the sample size, but the researchers chose to focus on nursing and midwifery students.
Conclusion
Students need moral courage and resilience to work safely under stressful conditions. This research highlights the need for greater understanding of the psychological impact on student nurses and midwives working under extreme conditions. Although this research had a relatively small sample size, the students surveyed reported a moderate degree of burnout. The long-term impact of this is higher attrition rates before and after registration and staff leaving the profession early. The recommendations from this research are that moral distress, moral courage and resilience should have a higher profile within the nursing and midwifery curriculum in order to prepare and support the future workforce.
Part 2 of this research will focus on the results from the comparative analysis of the free text questions.
KEY POINTS
- Student nurses and midwives suffered similar levels of moderate burnout working in the NHS during the pandemic
- Student midwives reported higher levels of emotional exhaustion and depersonalisation than student nurses
- There is a need for deeper understanding of moral distress and burnout in healthcare
- More focus is needed on educating healthcare students on the importance of resilience and burnout
CPD reflective questions
- What do you understand by the terms moral distress and burnout?
- Can you recognise burnout in yourself and in your peers?
- What can you do to promote staff and students’ resilience in your workplace?