Jan 18, 2021
By Kim M. Mitchell , Breanna L. Sawatzky

5 strategies for boosting nursing student wellness & resilience during COVID-19

istockphoto.com/kzenonThe students’ qualitative comments revealed there was no generic student experience with the emergency transition to online learning. For some, online learning helped them to thrive academically. For others, intersecting factors in their households (lack of study space, competition for internet, lack of motivation) meant they found the situation unmanageable.

Takeaway messages

  • During the pandemic-related transition to remote learning, several factors were associated with declining student wellness and resilience. These were income disruptions, unmet child care needs, being a person of colour, feeling anxious about returning to clinical practice, having a poor internet connection, finding online learning unmanageable, not having private study space, and being disconnected from peers.
  • While there was no single experience common to all, students appreciated program flexibility, instructor availability, regular communication, connection with peers, access to critical resources, and specific teaching/assessment strategies.
  • As nursing education adapts to COVID-19 realities, student well-being should be a key priority. Multi-level interventions should be explored, addressing institutional policies, teaching and assessment practices, program flexibility, peer connection, and access to key resources.

 

See the authors’ 5 recommendations for promoting student well-being and resilience

On March 6, 2020, I (K.M.) had my first encounter with someone who refused to shake my hand. She was a nurse from British Columbia, where COVID-19 cases were being diagnosed daily. In Manitoba, COVID-19 was still a problem happening in other communities. Over the next week I sat in several meetings in too-crammed boardrooms at our college — a practice that seems unfathomable now.

By March 12, Manitoba’s first lab-confirmed case was announced. Having had the privilege of watching other provinces make decisions ahead of us, Manitoba declared a state of emergency and, within a week, most of the province, as with most of the country, was shut down to public gatherings. Post-secondary education and nursing education changed in an instant.

Starting a new term in the middle of a pandemic

The Red River College nursing program is offered in a trimester format — three compressed 11-week terms per year with three intakes of 50 students into first year in each of August, December, and March. When the college shut down to in-person activity, we were in the break period between terms two and three.

While it appeared that traditional two-term programs were able to ride out the last few weeks of a term, we were in the unique situation of facing our entire third term while navigating ever-changing public health protocols. The shutdown, combined with a climate of COVID-19 uncertainty, meant that all Red River College programs were required to remove students from work placements. In our nursing program, this meant students were pulled from their final practicums and clinical practice rotations were cancelled.

We had our last in-person program leadership meeting days before we were orienting a new group of 50 nursing students into first year; we made the decision to proceed with their admission. The students beginning nursing education in March 2020 had been accepted with the expectation that they would be learning nursing in a face-to-face environment. They joined our program without hesitation, just as all faculty and students were thrust into an emergency online teaching context. Clinical practice was postponed, and instructors worked on the fly to figure out how to deliver high-quality nursing education.

istockphoto.com/ridofranzNursing programs must attend to students’ sense of well-being as a top priority, using multi-level interventions that target institutional policies, teaching and assessment practices, program flexibility, peer connection, and access to key resources.

The pre-COVID-19 term survey: understanding wellness and resilience in a challenging nursing program

We’ve always recognized the challenging nature of our program format. Offering a nursing program over three calendar years (nine terms) with a clinical practice rotation in every term but the first, under normal circumstances, contributes to increased stress for students. Prior to COVID-19, the demands for counselling and mental health services for nursing students were high.

In a joint initiative between the college’s student support services and the nursing program, we began data collection with the cohort admitted in December 2019, with the intention to assess baseline wellness and resilience as these students progressed through the program. During in-person lectures, that first-year cohort was surveyed twice in their first term — at the beginning (December) and the end (March).

A third data collection was planned for the end of their second term in June. We measured student wellness and resilience using two validated tools: the 14-item General Population Clinical Outcomes in Routine Evaluation (GP-CORE; Sinclair, Barkham, Evens, Connell, & Audin, 2005) and the 10-item Connor–Davidson Resilience Scale (CD-RISC; Campbell-Sills & Stein, 2007).

Manitoba nursing programs worked closely with our regulatory body to implement virtual simulation as an alternative or a supplement to hands-on clinical practice.

Adjusting the study to understand wellness and resilience of nursing students during COVID-19

The COVID-19 shutdown of all in-person activities at the college meant that our baseline “usual conditions” sample was no longer experiencing the in-class learning conditions we were familiar with for delivering nursing education. It also no longer seemed ethical to be planning a study to direct interventions toward a single cohort of students, when all students were experiencing varying levels of distress because of emergency changes to their learning environment.

We adjusted our study to assess the wellness of the entire student body and launched our June data collection with these changes in mind. We sought an ethically approved amendment to our study to explore factors affecting student adaptation to their courses being delivered in an emergency online environment that we felt could also affect their wellness and resilience. These factors included changes in household income due to COVID-affected job layoffs, poor home internet connections, caring for children while attending to their studies, having access to private study space, response to and management of the online learning environment, and the ability to stay connected with their nursing peers.

As pandemic conditions stabilized, students were permitted to resume final practicums in mid-May, and a limited return to clinical practice was initiated for students who were in their ninth term, closest to graduation. Thus, we were also interested in student anxiety about returning to clinical practice during the pandemic.

Clinical practice presented a large number of unknowns in terms of exposure to COVID-19. We found that clinical sites had varying comfort levels with students returning to practice owing to high-risk patient populations or increased numbers on the unit, making social distancing more challenging.

Collectively, Manitoba nursing programs worked closely with our regulatory body to implement virtual simulation as an alternative or a supplement to hands-on clinical practice.

We collected demographic and student characteristics as reported by the 149 student respondents to the post-COVID-19 term survey. Students were also invited to provide open-ended comments about their experiences during the emergency conversion to online learning. For detailed survey results, see below: Demographic and student characteristics of the post-COVID-19 term sample.

The data showed that COVID-19 placed additional strains on students’ lives

We found that greater than 50 per cent of students had income disruptions, poor internet service, and lacked private study space in their homes during the peak lockdown period. There were also significant proportions of students (24-37 per cent) who reported finding online learning unmanageable, were caring for children, and were moderately to extremely anxious about returning to clinical practice. Further, the fact that 42 per cent of students reported little to no connection with their peer support system was highly concerning to us.

We used t-tests and analysis of variance to determine whether and to what degree these factors affected wellness and resilience during the term. Gender and year in program garnered no differences in reported wellness and resilience. Caring for children and having income disruptions negatively affected sense of student wellness, but not resilience. Being a person of colour, anxious about return to clinical practice, having a poor internet connection, finding online learning unmanageable, not having private study space, and inability to stay connected with peers were the factors that most significantly affected student-reported wellness and resilience.

istockphoto.com/milkosAnxiety related to clinical practice was also triggered by the knowledge that being out of clinical practice due to postponement would mean that their nursing skills were rusty and in need of remediation. Students desired our program to be understanding if they felt they needed to delay their return to clinical practice.

Students revealed their academic stresses, preferences, and successes in their open-ended responses

The students’ qualitative comments revealed there was no generic student experience with the emergency transition to online learning. For some, online learning helped them to thrive academically. For others, intersecting factors in their households (lack of study space, competition for internet, lack of motivation) meant they found the situation unmanageable.

In all cases, students appreciated faculty flexibility in the online learning environment. They desired multiple options for synchronous and asynchronous participation in their courses that didn’t penalize intermittent attendance or their challenges to prepare in advance of a synchronous activity.

Students with unmet child care needs reported difficulties staying on track, meeting deadlines, and participating in scheduled testing. Student wellness and resilience is an intersectional problem, disproportionately problematic for non-white students. The effects of the pandemic should be continuously monitored for this group as they are at higher risk for attrition from programs (Loftin, Newman, Gilden, Bond, & Dumas, 2013).

Internet connectivity heavily affected online activities, especially when use of cameras was required. Students appreciated when alternatives to proctored testing, such as take-home exams, were offered. Group projects with large group membership were challenging.

The students were vocal about their confidence in their knowledge of infection control protocols. They felt they chose nursing as a career aware that they might daily be putting themselves at risk for contracting infectious diseases. Most felt they would be safe in the clinical environment. Those who were most anxious about returning to clinical practice were more anxious for vulnerable family members whom they could potentially expose to the virus.

Anxiety related to clinical practice was also triggered by the knowledge that being out of clinical practice due to postponement would mean that their nursing skills were rusty and in need of remediation. Students desired our program to be understanding if they felt they needed to delay their return to clinical practice. Thus, clinical anxiety related to the pandemic should be an ongoing conversation. Remediation of clinical skills prior to initiating practice rotations was built into our plan to help facilitate confidence for the fall 2020 term.

Students appreciated faculty flexibility in the online learning environment.

Peer-to-peer connection is a vital academic and wellness support. Institutions should do whatever is feasible to foster these connections. Students proposed that instructors create unmonitored discussion boards in online courses to facilitate informal student connection. Some cohorts stayed connected through a WhatsApp group or Instagram or Facebook messaging.

Instructors can stay informed of virtual social initiatives provided by other departments and communicate these to students. Virtual paint workshops or cooking classes are examples of social initiatives that could be offered. Alternatively, a nursing department can collaborate with other departments (student affairs, health and wellness) to provide targeted social opportunities for their students.

Efforts should be made to increase instructors’ awareness of how student well-being and resilience are correlated. We’ve prepared a 90-minute, live, virtual workshop to help faculty adopt proactive strategies to support student well-being.

5 recommendations for promoting student well-being and resilience

In light of our survey findings, we propose five recommendations for promoting student well-being and resilience. Implementing these recommendations in nursing programs will facilitate students’ well-being as they navigate the ever-changing pandemic conditions we faced this past fall.

1. Promote equity by expanding access to resources

Students who were less resilient to the stress imposed by alternative delivery were those who did not have access to private study space, had child care responsibilities, and had unreliable internet access. We recommend:

  • Opening the library with reduced capacity, exploring the option of booked study slots if needed.
  • Opening some child care spaces and surveying students to determine need.
  • Considering strategies/partnerships to ensure reliable home internet access for students who lack adequate access.

2. Facilitate social connection

Peer-to-peer connection is a vital part of well-being and academic success. We recommend:

  • Creating an unmonitored discussion board with the institution’s learning management system to facilitate informal student connection. Students note that when discussion boards are monitored by instructors, they can become anxious about their grammar/impression and are less likely to post informal chatter that would otherwise assist in forming bonds with other students.
  • Facilitating virtual ice-breakers and/or fun, low-stakes activities.
istockphoto.com/fizkesInternet connectivity heavily affected online activities, especially when use of cameras was required. Students appreciated when alternatives to proctored testing, such as take-home exams, were offered.

3. Remain flexible in content delivery and assessment

Not treating pandemic conditions as “business as usual” is key to student well-being and success. Instructors who were easy to contact and willing to be flexible helped immensely. We recommend:

  • Frequent lower-stakes assessment as opposed to high-stakes mid-terms and final exams.
  • Recording live virtual learning sessions so that students with other responsibilities can still benefit.
  • Design assessments that do not require a robust internet connection. Provide adequate technical support during tests.
  • Create simple and equitable extension policies with the expectation that flexibility will be required.
  • Avoid assignments that require work in large groups.
  • Ensure that content, including videos, is posted well in advance and remains available to watch for a long window.

4. Ensure virtual “face time” with instructors

A strong instructor–student relationship, in which the student feels mentored, seen, and supported, can considerably mitigate stress. We recommend that instructors:

  • Regularly acknowledge that having difficulty coping during this time is common, and remind students of supports and resources.
  • Host virtual group meetings, with optional webcam, and record these for future viewing.
  • Maintain virtual office hours and be sure to meet with each student.

5. Communicate often

When students feel their concerns and questions are not only heard, but responded to, their ability to adapt is enhanced. When on-campus learning was first suspended, many students felt the regular communication updates were relevant and helpful. Others felt that our college lagged behind other institutions in planning and communication. We recommend:

  • Being transparent and swift when communicating decisions. This approach will reduce “leaks” and speculation. Communicate even if there are no changes or no new information.
  • Communicating college policies, plans, decisions, and supports via social media. This is key.

Consistently applying these recommendations across programs, cohorts, and sections will not only support student well-being and retention, but will prevent student dissatisfaction stemming from the impression that others are getting a better-quality education experience.

As case numbers rose in our province in fall 2020 to higher than we experienced in the spring, we continued to adjust to ever-changing public health recommendations.

COVID-19 requires flexible and creative thinking to nurture student wellness and resilience

It is critical that registered nurses continue to receive an exceptional education despite the effects of COVID-19, which we expect will linger for many years to come. Our research supports a social-ecological approach (Bauer et al., 2003; Stokols, 1996) in which the community, institution, program, peers, and self all play a role in individual outcomes.

Based on our findings, we feel that nursing programs must attend to students’ sense of well-being as a top priority, using multi-level interventions that target institutional policies, teaching and assessment practices, program flexibility, peer connection, and access to key resources.

Our only certainty is that our knowledge of how this pandemic has affected the health of society is continuously changing. For the 2020-2021 academic year, we face instructional conditions where nearly 100 per cent of our students are out of step with their original program path. How our program may need to be adjusted and redesigned to best meet the supply of nurses to the health-care system is in continuous flux.

As case numbers rose in our province in fall 2020 to higher than we experienced in the spring, we continued to adjust to ever-changing public health recommendations. We as a nursing program plan to continue assessing the well-being of our students and to be responsive to their needs through the current and future academic years.

Demographic and student characteristics of the post-COVID-19 term sample, June 2020 (N = 149)

Age
Mean: 27.2
Range: 19.4–50.7
(N = 134; missing = 15)

Gender
Female: 139 (93.3%)
Male: 8 (5.4%)
Other/missing: 2 (1.3%)

Year in program
1st year: 43 (28.9%)
2nd year: 52 (34.9%)
3rd year and practicum: 52 (34.9%)

Race
White: 100 (67.1%)
All others: 40 (26.8%)
Not reported: 9 (6%)

How manageable have you found the transition to online learning?
Extremely manageable: 30 (20.1%)
Moderately manageable: 83 (55.7%)
Unmanageable: 36 (24.2%)

Has your household’s income been negatively impacted during the pandemic?
Yes: 85 (57%)
No: 61 (40.9%)
Missing: 3 (2%)

Have you had unreliable or intermittent internet access which has negatively affected your ability to accommodate online learning?
Yes: 83 (55.7%)
No: 66 (44.3%)
Missing: 0

Are you having to care for young children during the pandemic while also completing your own schoolwork?
Yes: 36 (24.2%)
No: 112 (75.2%)
Missing: 1 (0.7%)

Do you lack private study space in your home which makes it difficult to concentrate on your own studies?
Yes: 89 (59.7%)
No: 60 (40.3%)
Missing: 0

How well have you been able to remain connected with your peers since the conversion to online learning?
Very connected: 37 (24.8%)
Moderately connected: 49 (32.9%)
Little to no connection: 63 (42.3%)

How anxious are you about returning to clinical practice?
Not at all anxious: 58 (38.9%)
A little bit anxious: 36 (24.2%)
Moderately to extremely anxious: 55 (37%)

Acknowledgments

We based our work on an applied-research and quality improvement project conducted by a team from the college’s nursing department and student support services, and we wish to thank Laureen Janzen, Melanie MacPhee-Sigurdson, Joanna Simmons-Swinden, Patrick Griffith, Sandra Holben, and Cindy Boughen.

References

Bauer, G., Davies, J. K., Pelikan, J., Noack, H., Broesskamp, U., & Hill, C. (2003). Advancing a theoretical model for public health and health promotion indicator development: Proposal from the EUHPID consortium. European Journal of Public Health, 13(suppl. 3), 107–113. https://doi.org/10.1093/eurpub/13.suppl_3.107

Campbell-Sills, L., & Stein, M. (2007). Psychometric analysis and refinement of the Connor–Davidson resilience scale (CD-RISC): Validation of a 10-item measure of resilience. Journal of Traumatic Stress, 20(6), 1019–1028. https://doi.org/10.1002/jts.20271

Loftin, C., Newman, S., Gilden, G., Bond, M. L., & Dumas, B. (2013). Moving toward greater diversity: A review of interventions to increase diversity in nursing education. Journal of Transcultural Nursing, 24(4), 387–396. https://doi.org/10.1177/1043659613481677

Sinclair, A., Barkham, M., Evans, C., Connell, J., & Audin, K. (2005). Rationale and development of a general population well-being measure: Psychometric status of the GP-CORE in a student sample. British Journal of Guidance & Counselling, 33(2), 153–173. https://doi.org/10.1080/03069880500132581

Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 10(4), 282–298. https://doi.org/10.4278/0890-1171-10.4.282

Kim M. Mitchell, RN, MN, PhD, is coordinator of research scholarship and quality improvement at the Red River College’s nursing department in the school of health sciences and community services, Winnipeg.

Breanna L. Sawatzky, BA, is mental health coordinator, Red River College, Winnipeg.

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