Impact of COVID-19 on nursing students: what does the evidence tell us?
=======================================================================

* David Barrett

*   COVID-19
*   nursing education research

A previous [EBN editorial](https://ebn.bmj.com/content/23/2/33.long) discussed the role of universities in supporting the mental health and well-being of nursing students.1 This editorial was published in February 2020, so was written with little or no idea of the extraordinary challenges that were soon to confront society and healthcare providers as the COVID-19 pandemic spread.

The earlier editorial highlighted that even in pre-pandemic times, the pressures on nursing students were substantial; a mixture of academic expectation, assessment of practice competence and personal commitments, resulting in high prevalence of stress and anxiety.2 Since early 2020 though, the pandemic has magnified these pressures on nursing students across the globe.

The importance of this issue was highlighted in a systematic review that explored the prevalence of mental health problems and sleep disturbance among nursing students during the pandemic.3 The review suggested that over a quarter of respondents were experiencing sleep disturbances, nearly one-third were feeling stress or anxiety, and more than half reported suffering from depression. This review, and others, have highlighted -the substantial impact that the pandemic has had on nursing students, but what does the evidence tell us about *why* this group has been hit so hard?

There are few members of society who have been untouched by the COVID-19 pandemic. Many have lost loved ones; many have suffered ill-health (and many continue to do so as a result of long COVID-19); most have lived with societal restrictions and uncertainty about the future. However, the evidence suggests that nursing students are a group upon whom COVID-19 has had a disproportionate impact.

This is due to nursing students being what Drach-Zahavy *et al* describe as a ‘poly-vulnerable’ group4—something which the broader evidence base supports. The research of the past 2 years demonstrates that nursing students have been impacted by COVID-19 in three distinct but connected ways:

## As a student

One of the most immediate impacts of the pandemic across education providers was the rapid transition to remote education. Though the need to do this in a bid to slow COVID-19 transmission rates was unquestionable, the effect on students generally—and nursing students specifically—was enormous. Fitzgerald and Konrad surveyed 50 undergraduate nursing students in the USA, finding that 80% of them were anxious about the impact of the move to remote learning on their ability to succeed academically, with 62% expressing concerns about being able to manage their academic workload during the pandemic.5 To explore students’ experiences in greater detail, Wallace *et al* carried out a qualitative study in the USA. They discovered that particular causes of anxiety linked to the move to remote learning were the technological challenges faced (such as having access to a reliable internet connection), and the perceived loss of support mechanisms through not spending time in class with peers and educators.6 

## As a nurse

During the earlier stages of the pandemic, students were ‘recruited to the frontline to join the fight against COVID-19’ (wartime terminology was especially prevalent at that point). This need to work in clinical practice during a time of particular challenge impacted on students in different ways, and several papers focused specifically on this issue. The rapid move to support the healthcare workforce, referred to by Gómez-Ibáñez *et al* as ‘rushed labour insertion’,7 was a dichotomous experience for students. It did give them the opportunity to practise their skills, gain practice hours and contribute directly to the care of those suffering from COVID-19. Equally, though, moving into frontline care also caused substantial anxiety, sometimes as a result of fear regarding the impact on their studies, sometimes due to the personal risk that this encompassed and sometimes because they were concerned about the risk it might present to those around them.

## As a person

As with all members of society, nursing students were concerned about their well-being and that of their family during the pandemic, were impacted by societal lockdowns and, in some cases, were subject to periods of illness and self-isolation. One of the most commonly cited causes of stress and anxiety among nursing students during the pandemic has been the potential for their role to endanger their friends and families through transmission of the disease.4 5 8 Indeed—and perhaps indicative of the unselfish attitudes demonstrated by nursing students throughout the pandemic—fear of infecting others was a much greater source of anxiety than become infected themselves. The personal impact for students was increased through the steps that many of them took to reduce the risk to infect others: Gómez-Ibáñez *et al* outline how nursing students deliberately chose to self-quarantine at home, to avoid direct contact with friends and family, and sometimes even to seek for temporary accommodation to live alone.7 By doing so, these students may well have reduced the risk to others, but they also stripped away many of the support mechanisms that were so important—notably those provided by family, friends and peers.

This perhaps demonstrates one of the key lessons from the literature: those elements of nursing students’ lives that have been impacted on by the pandemic do not exist in isolation. The challenges associated with each—as a student, as a nurse, as a person—influence and magnify each other. In their qualitative study of the experiences of final-placement nursing students, Diaz *et al* found that it was the enormity of the changes in *all* aspects of life—personal, academic and nursing—and the speed with which these changes took place, that led to such a substantial impact on the mental health and well-being of nursing students.9 

So what conclusions can we reach from the research into nursing students during COVID-19? First, the pandemic has demonstrated just what important roles nursing students play in healthcare delivery; not just as the workforce of the future, but as the workforce of now. We can also see how their responsibilities as a person, as a nurse and as a student interact in a way that makes them especially vulnerable.

The research into the impact on nursing students also provides us with some other, more positive, insights though. There is evidence that throughout the pandemic, the quality of online education and of the support provided by academics and practice supervisors was instrumental in reducing stress and anxiety in nursing students,5 highlighting that it has been possible to mitigate the impact. The evidence base also shows us how some nursing students welcomed and embraced the opportunity to support clinical practice, gain experience and make a direct contribution to the effort to counter the impact of COVID-19.7 Equally, there is evidence that facing these multiple challenges may have enhanced personal resilience4 6 and enabled the development of new skillsets, such as enhanced information technology skills.6 

Those cohorts of nursing students who studied through COVID-19 have faced pressures like no others—they have had to meet academic requirements of their studies, while taking on additional clinical commitments and trying to keep themselves and their families safe. Their response has been extraordinary, and they will have developed skills and experience that will make them better, more resilient nurses. They should be proud of what they have achieved and who they are.

## Ethics statements

### Patient consent for publication

Not required.

## Footnotes

*   Twitter @barrett1972

*   Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

*   Competing interests None declared.

*   Provenance and peer review Commissioned; internally peer reviewed.

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