INTRODUCTION:

Hilton and Hilton have published a book review on the Book ‘The Great Influenza’, where the author himself John M Barry describes the so-called Spanish flu of 1918-19 as the ‘deadliest plague in history’¹.

A historical account of scientists and academics is reported as is mention of the theory, the immune system, influenza strain descriptions, epidemiology, virus beginnings and attributes. Disease and illness associated with the First World War along with the pandemic waves are mentioned. Poor or misinformation and an absence of accurate case notifications or deaths is evident. In addition, there was an absence of serologic or virologic diagnostic methods. Nor were there antiviral agents or vaccines².

In this current outbreak, the World Health Organization (WHO) declared the novel coronavirus (COVID-19) a global pandemic on March 11, 2020³.

Hilton has previously published on the topic of COVID. These publications include one titled; “Brief comparison of the Current Coronavirus COVID-19 Pandemic (SARS-CoV-2) and the Spanish Flu Epidemic², while the second is titled; A literature review on COVID-19 [coronavirus] research specific to Australia including manuscripts on policy and media releases⁴. This manuscript in fact includes various documents that are detailed on the Coronavirus (COVID-19) pandemic [Internet] page of the Australian Government Department of Health (Australia) website⁵.

Finally, the third that Hilton authored on COVID is titled; Sars-Cov-2/Covid-19 [Coronavirus] Global Scientific Research and How it Impacts Workplace Health Management and Health Services, Including Policy Implications⁶.

These publications mentioned above highlight the stark contrast between the 1918-19 Spanish flu Epidemic and the current Coronavirus COVID-19 Pandemic (SARS-CoV-2).

While the current situation for nursing undergraduate students seemed rather daunting with lockdowns, mask wearing and restrictions, in comparison to the Spanish flu era, if you consider the Spanish flu difficulties; it does diminish the severity and impact of the implications and changes in the current crises. However, it must be remembered that people in this current era, have not experienced the Spanish flu, so in some ways it is not comparable and the impact on current trainee requirements is real, considerable and of upmost concern to both undergraduates, educators and policy makers.

There are real and substantial challenges for graduate nurses transitioning to professional practice⁷. The abstract of this paper by Davies and colleagues, doesn’t mention the pandemic, but reports on these transition issues generally stating that it has been a concern for nurse educators and industry collaborators about the practice preparedness of graduate nurses.

Firstly, if we consider a country in Africa, that of Ghana. A cross-sectional study in Ghana reports on online learning experiences among nursing and midwifery students during the Covid-19 outbreak⁸. Ghana is a technologically deprived country so adaption to learning during a COVID-19 pandemic has added difficulty. This work involved a cross-sectional study design using online methods from March to June 2021 in the five regions of Northern Ghana and included students of nursing and midwifery training. Socio-demographic factors, Internet access and outcomes being experiences were analysed with SPSS. Pleasant experiences were related to connectivity, aging, year of study, and southern Ghana residency, while challenges included data cost and home interruptions.

Next if we consider an Asian Country, that included students at the University of Calgary in Qatar⁹. The authors report that Coronavirus disease (COVID-19) can have a negative impact on University students that can relate to fear and anxiety. 135 participants completed the survey and it reported that learning online and switching teaching has detrimental impacts on participants' fear and stress. A cross-sectional study of nursing students in an Iranian context examined e-learning in the Covid-19 pandemic¹⁰. 228 undergraduate nursing students participated and using phones to learn was hampered by frequent Internet failures and typing obstacles. Students preferred to not attend more than two online classes in one day and the overall attitude to e-learning was positive. Research in India aside from students, but in relation to telehealth has also documented Internet connectivity as vital¹¹.

Lockdowns and an absence of in class learning maybe detrimental. It is previously reported that structured teaching and demonstration regarding Basic Life Support among higher secondary students can improve knowledge¹². Structured teaching has also been assessed in relation to nursing students’ knowledge regarding polycystic ovarian syndrome¹³. 50 samples were selected by using purposive sampling technique and knowledge were assessed using self-structured questionnaire. Adequate knowledge, moderate knowledge and inadequate knowledge was assessed pre and post and there were improvements in adequate and moderate knowledge after structured teaching and a lesser percentage had inadequate knowledge after structured teaching. A structured teaching programme regarding oral cancer was also performed with 60 nursing students and this improves the level of knowledge¹⁴.

Research conducted in India, being an effectiveness of structured teaching programme on knowledge regarding Covid-19 and perinatal care of mother among nursing students in selected Colleges at Mysuru¹⁵. In the pre-test, 43.3% had good knowledge, while this increased to 63.33% post-test [0.05 level of significance], hence structured teaching is effective.

Even not considering nursing students, but if we consider 5th 6th 7th year students from a rural primary School at Ankola, a sample of 30 students who were given knowledge re; personal hygiene were included. They were provided with information re; importance of hand washing and it was reported that prior to the education knowledge was under 5%, but post education four out of five had knowledge attainment¹⁶. Venturing to a further age group, that of college students, HIV knowledge including disease attributes, diagnosis, transmission and incidence rates were reported on. There was a positive correlation between information source and knowledge¹⁷. Conveying knowledge whether it be via classroom or online, must have an accurate information source. Not only knowledge, but coping and adjustment strategies are important. Sixty students from selected Boarding schools, Kottayam, Kerala were included and as the level of coping strategies increased the level of adjustment problems decreased¹⁸. Kale has also researched the topic of coping, stress, psychological and physical health¹⁹. If the HSC students in selected colleges were considered approximately half experienced moderate stress and mild physical-psychological health problems, while seven out of ten used adaptive coping strategies.

Further research in India, includes, ascertaining the feelings of nursing students using a conceptual framework based on the modified Irvin Rosenstock‘s health belief and personal health behavioral model, 1966²⁰. The open-ended questions were analyzed using opinion mining, or sentiment analysis technique. Mental health challenges related to the disrupted study routine, were handled by strategies such as watching COVID-19 reports on TV, washing hands, using online learning and engaging in other diversional activities such as prayer and exercise. Irrespective of COVID, the majority of nursing students in a study of fifty 1st year B.Sc nursing students were reported to have moderate levels of stress using a modified stress scale²¹.

If we turn to Australia, for students who commenced studies in 2020, they were forced into lockdown, stay at home measures and mask wearing, which resulted in a strange different learning environment. The initial first year of learning remote via a computer in a home environment was not as conducive to learning practical skills as compared to a simulation laboratory. Students enrolled in undergraduate courses previously would have learnt of pandemics via textbooks, being a theoretical based learning experience. They may have heard the term ‘Spanish Flu’, but had not been through a pandemic themselves.

Unlike the Spanish Flu era, we’ve benefitted from rapid advances in technology, medical and scientific research, meaning COVID-19 case numbers and deaths are now more accurately documented, in addition to the availability of rapid diagnostic methods, antiviral agents and vaccines.

There are several implications arising from the pandemic on student’s learning opportunities. Three issues will be mentioned in this manuscript. Firstly, the lockdowns resulted in closure of labs so hence less simulation practical sessions. Secondly, the students had to adapt by completing some online learning in the home environment, via a virtual learning session which required digital online equipment and skills. Thirdly, for students who were completing practical placements within a hospital during the pandemic, there was additional donning and doffing of PPE. These three issues will be mentioned in the discussion below and elaborated on in terms of how this may impact students.

Clinical placement is a vital and fundamental mode of learning for undergraduate nursing students ²². Factors influencing learning may vary depending upon the placement and the differences with respect to who are the peers, units, coordinators, or facilities. More understanding is required about how social context which is grounded in self-determination theory influences therapeutic relationship.

In order to assess the impact of the current pandemic on trainee nurses, a literature search as described below was performed.

MATERIALS AND METHODS:

PubMed® is accessible to both the public and scientific community [Pubmed]²³. Available to the public online since 1996, PubMed® was developed and is maintained by the National Centre for Biotechnology Information (NCBI), at the U.S. National Library of Medicine (NLM), located at the National Institutes of Health (NIH). According to the website, when accessed in 2021, PubMed® information comprises more than 33 million citations for biomedical literature from MEDLINE, life science journals, and online books. In various instances, citations may allow access to full-text content from PubMed Central and other publisher and journal websites.

The MeSH Browser was utilised. The MeSH (Medical Subject Headings) is the NLM controlled vocabulary thesaurus used for indexing articles for PubMed. https://www.ncbihttps://www.ncbi.nlm.nih.gov/mesh

The MeSH search terms used were; ("Education, Nursing"[Mesh]) AND "Australia"[Mesh]. In addition, filters were applied to select articles in the last 1 year.

In addition, the search as follows was conducted; ("Education, Nursing"[Mesh]) AND"Ghana"[Mesh] with the same filters.

In addition, the search as follows was conducted ("Education, Nursing"[Mesh]) AND "Asia"[Mesh] with the same filters.

Lastly, manuscripts published in the journal; A and V Pub Journal of Nursing and Medical Research that included nursing students were reviewed in addition to several others that focused on other survey participants.

RESULT:

Twenty-two manuscript results were retrieved with the first search. Various of these related to the pandemic impact on the University closures, student’s placements, lectures and simulation laboratories. The reference lists of these articles also retrieved additional articles which shed further light on the topic. The 2^nd search retrieved one manuscript. The 3^rd search retrieved 65 articles, of which five directly related to the Covid-19 pandemic impact. Various manuscripts from the A and V Pub Journal of Nursing and Medical Research were included. Some of the relevant points and issues from these documents will be described in the discussion.

DISCUSSION:

Below are some details gleaned from the literature search that was done as described in the methods above, that relate to the pandemic impact on students.

Previously a manuscript was published on self-confidence in clinical skill: A descriptive study of the perspective of first-year nursing students ²⁴. The abstract of this manuscript does not mention the pandemic at all however it is useful for the reason that it mentions the clinical work areas that students view as important. Utilising a digital workbook that allowed a descriptive study design, anonymous data was gleaned from first year nursing students at a regional Queensland University. Identified by participants as important to prepare for clinical work were seven key practice areas: respiratory care, cardiac care, medication, manual handling, wound management, vital signs and infant care. These psychomotor skills are important for informing nurse education, and these students rated their own confidence favourably across these areas as identified.

Learning and clinical teaching are critical in linking the theory-practice gap in nursing education ²⁵. In Ghana, a descriptive qualitative study was conducted using telephone-based interviews with 16 final-year nursing students. Factors identified as important to fostering learning included autonomy, new opportunities and supervision. Clinical opportunities were also seen as vital, while poor resources, poor staff disposition and inadequate supervision or opportunity created barriers. These clinical challenges are crucial for learning.

A qualitative descriptive study was performed by Ridgway and colleagues and published in 2022 ²⁶. This study aimed to describe Australian postgraduate Maternal, Child and Family Health nurse educators' perceptions of COVID-19 impacts on theory and practice knowledge, and lessons acquired as a result. Restricted placement opportunities resulted in rapidly changing practice requirements and there were also concerns about risk of disease transfer between workplace and placement locations. Various strategies included; teachers and educators learning and incorporating new skills and approaches into the teaching methodology, that helped them aim to meet professional standards while still ensuring education excellence.

The World Health Organization reports on the psychological impact of COVID-19 on healthcare professionals yet there is an evidence lack in terms of the impact on university nursing and midwifery students, and the impact of the COVID-19 pandemic on their educational readiness and/or on their clinical placements²⁷. The study included replies from 637 (22%) of the 2907 students invited. Of the respondents, at least 45% provided a reply to at least one of the three open-ended questions. The three major themes associated with the impact of the pandemic on psychosocial well-being and learning included: pandemic psychosocial impact, the change to new methods of teaching and learning, and worries about progress through the study and then in the career.

As mentioned in the introduction, three areas that this paper also wanted to focus upon included simulation lab closures, the change to virtual online learning, and stress related to the increased time and effort in utilising PPE equipment when on placement and these will be mentioned below.

Pre-registration extended immersive ward-based simulation can provide opportunities for students to rehearse the role of registered nurse before completing their degree ⁷. These learning opportunities provide experience for students to think and work autonomously as a result of pre-registration extended immersive ward-based simulation. This allows application of knowledge and an understanding of work expectations, applying this knowledge gained from simulated experiences to similar scenarios that may occur once they commence as a registered nurse.

Also, if we consider a study performed in Ghana, being a cross-sectional survey of 225 undergraduate nursing and midwifery students this sheds light on clinical placement experience using the Clinical Learning Environment and Supervision + Nurse Teacher (CLES +T) evaluation scale ²⁸. T-test and ANOVA reported that 2/3^rds of the sample were nurses with 4/5 in their third year. Supervision included by a nurse (57%) and also team supervision (67%). Private supervision and successful supervision resulted in improved clinical experience as compared to unsuccessful supervision or team supervision.

The undergraduate student of nursing whom was acknowledged for her contribution to this manuscript, commenced her nursing studies during the first year of the pandemic. The absence or limits/ cancellation of various simulation and practical lab sessions for those students in her year, meant that these practical skills were not as astutely or judiciously developed, fine-tuned, repeatedly practiced or performed in group scenarios as compared to the level that other students in past years participated in, when there was not a pandemic. Rather some skills were learnt in a home environment, via online remote computer learning which is not a practical lab equivalent.

The technology growth has created challenges globally for healthcare, and in fact documents that include nursing guidelines, standards and codes of professional conduct don’t currently incorporate how to utilise and access on campus digital technology, and during combined work learning. This may include how it relates to expected abilities, knowledge, attitudes and actions of undergraduate nurses ²⁹.

Nursing governance documents don’t include developing the advancement of digital professionalism, which is essential in order to identify as a professional before graduation as a registered nurse ²⁹.

Students were required to purchase, utilise and adapt to new technology platforms of virtual online learning, which took time, effort and resources. This posed challenges for students and families, placing additional financial burden on already stretched budgets.

The third area of concern is that the usage of PPE equipment when on clinical rotations/placements are an added time intensive procedure. One manuscript in the literature discusses this very point. A total of 2600 nurses participated in this online survey questionnaire assessing the perceived level of stress associated with the usage of PPE during the COVID-19 pandemic³⁰. PPE can have physical ramifications like headache and pain. Significantly higher stress levels were reported in nurses who wore masks for greater than 8 h than those who used the masks for a lesser time.

The publication by Ridgway and colleagues that assessed nursing students’ adaptation to learning during the COVID pandemic, found that participants recognized difficulties, prospects and innovations within three key themes:

1. "We've learned how to be flexible": Grappling with COVID-safe teaching and assessment;

2. "Chat rooms and Zoomland": Learning in a virtual community; and

3. "We've had a few struggles": Clinical placement tensions ²⁶.

There was a sense of indecision, increased adaptability, change opportunities and new ways of communicating described by educators. New online resources were developed, the curriculum was expanded, and assessment necessities changed to address new practice tactics including telehealth.

Aside from COVID, a research study in Jodhpur explored the use of e –learning among students from JIET College of Nursing³¹. In fact, 85% of the 40 sample of students had moderately adequate knowledge and three quarters had a favourable attitude. This maybe related to the global uptake of e-learning, but it is advised that it is used in conjunction with class learning for better outcomes.

A Web-Based Survey in China, assessed Academic Burnout Among Nursing College Students due to the COVID-19 Pandemic³². A range of scales were utilised including the Academic Burnout Scale, Connor-Davidson Resilience Scale, Impact of Event Scale-6, Patient Health Questionnaire-2, the Professional Identity Scale in addition to a social-demographic information questionnaire. Just over 50% reported academic burnout to a varying degree.

It is important during crises situations such as COVID-19 when students are training that they be self-compassionate. In fact, one research study in the State University in Indonesia assessed this trait during the time of COVID ³³. Utilising a cross-sectional design, with a proportionate stratified random sampling technique (n=260), the authors assessed the self-compassion scale. Self-kindness, self-judgment, common humanity, isolation, mindfulness, and over identification were the six sub scales included. In fact, self-compassion was determined as moderate by 60% of students during the time of COVID.

Screening for mental health disorders is also useful and was reported on by researchers ³⁴. Thai nursing students (n=3,705) during the COVID-19 outbreak participated in online learning and validation of the depression, anxiety, and stress scales (DASS-21) was performed. The psychometric features of this tool will support Thai psychologists and researchers to identify common mental disorders.

Alternative and variable teaching modes allow students to balance their varying responsibilities that may include study, family, and employment responsibilities. It assists to reduce students’ stress and anxiety if they receive support from academic staff and clinical facilitators/mentors which also includes clear and timely communication of PPE risk management strategies. There also needs to be ways to support and maintain motivation among students during these altered learning environments.

Alternative therapies have also been shown to be successful in alleviating stress and mental health conditions. In fact, authors Rashmi and Sunitha reported that laughter assisted by video reduced academic stress among nursing students at 0.05 level of significance ³⁵. In fact, Hilton has also documented that laughter medicine is useful for mental health ³⁶.

CONCLUSION:

Australian, Asian, Indian and African countries have reported on the impact of COVID-19 on nursing students. Research has included various aspects of impact, outcomes and thoughts related to the changed learning environment and the ramifications that resulted in terms of altered learning modalities. In summary, these modern Florence Nightingale nurse students have learnt first-hand about pandemics and infection control. Internet connectivity variations in different countries across Asia, Africa, India and Australia impact learning opportunities. Regardless of this, students are now well trained and equipped, having learnt directly, with a more practical as opposed to theoretical understanding of infectious diseases as a result of the pandemic. They remain much more advantageous even despite these obstacles when compared to health professionals working in the Spanish flu era who were so much more incredibly disadvantaged in comparison. Undergraduates even in the 1980s had considerable challenges despite no pandemic, as they completed learning and study generally without any modern telecommunication channels such as mobile telephones or Internet availability. Learning to deal with any adversity makes a person more resilient, determined and strong. Life always poses hardships as well as success and the students graduating during this current pandemic are very much congratulated on their truly remarkable learning achievements given the conditions/obstacles.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

Natasha Jade Hilton [Commenced undergraduate studies in 2020; 2021 - Registered Undergraduate Student of Nursing [RUSON]; 2023 - Graduated with a Bachelor of Nursing (Clinical Leadership) – with distinction from Deakin University, Burwood].

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Received on 22.03.2024 Modified on 16.04.2024

Asian J. Nursing Education and Research. 2024; 14(2):103-109.

DOI: 10.52711/2349-2996.2024.00020