Nursing students' perceptions of how the COVID-19 pandemic impacts mental well-being and educational environment

Abstract

Background

Challenging work conditions put over 20 million U.S. health workers, including nurses, at risk for mental health problems. Mental health concerns among nurses and nursing students include anxiety, burnout, and stress which can lead to substance abuse and suicidal behavior. Nursing students practice in environments where they are exposed to complex challenges and high-stress situations that can lead to a higher prevalence of psychiatric disorders. As nursing students attempt to adapt to a post-pandemic educational environment, it is important to identify perceptions of nursing students' mental well-being.

Methods

A qualitative design was utilized using a descriptive method. Semi-structured interviews were conducted with a purposeful sample of BSN students (n = 11) from the southeastern U.S. Content analysis and coding were utilized in the study.

Results

Coping strategies and coping skills are imperative for nursing students to thrive in the educational environment, which includes a multitude of stressors that can negatively impact academic success. The rigorous workload of nursing schools, lack of support, financial challenges, and lack of experience are contributing factors that lead to decreased mental well-being among nursing students.

Conclusion

Interventions that aid in recognizing students at high risk for negative mental health outcomes must be implemented to ensure academic success. Implementing interventions to support healthy mental well-being among nursing students can also create an educational environment that prepares students to provide high-quality, safe, and effective patient care.

1. Introduction

Nursing education and healthcare will be forever changed as a result of the COVID-19 pandemic. The mental well-being of the future nursing workforce plays an important role in providing safe and quality patient care. The mental well-being of nursing students and the educational environment can affect their academic success. The mental well-being of students greatly impacted retention rates, intent to stay, and drop-out rates of nursing programs in the U.S. during the COVID-19 outbreak [1]. Nursing shortages highlight the importance of addressing nursing students' psychological needs and providing them with an educational environment conducive to safe and effective learning, especially in the U.S. By 2030, the U.S. will need 1.2 million new nurses to address the shortage [2]. Adjustments in the educational environment must be considered and interventions must be implemented to approach the post-pandemic effects and changes.

1.1. Mental well-being

Mental health issues among college students have increased since the COVID-19 pandemic, with 80% reporting that the pandemic has negatively impacted their mental well-being [3]. Numerous studies have found that up to 41% of nursing students have reported experiencing depression, stress, and anxiety [4]. Multi-faced demands of nursing students including personal responsibilities, in addition to the rigorous curriculum and workload of nursing school, can exacerbate mental health issues [5].

1.2. Educational environment

The nursing educational environment was greatly impacted by the COVID-19 pandemic. Hands-on clinical practice is a requirement to obtain a nursing license and necessitates that nursing students gain experience through hands-on patient care within a healthcare setting [3]. The COVID-19 pandemic has brought about a change and transformation within nursing education and prompted the development of innovative ways to simulate direct hands-on patient care were needed. Nursing schools in the U.S. were able to replace hands-on clinical experiences with virtual simulation clinical experiences [6]. Studies in the U.S. describe the nursing student experiences during this abrupt transition as traumatic, stressful, and filled with fear, uncertainty, loneliness, and missed opportunity [7]. The overall aim of the study was to identify perceptions of the impact of the COVID-19 pandemic on nursing students' mental well-being and educational environment. The following research questions were developed to identify these perceptions:

• 1.How has the COVID-19 pandemic impacted nursing students' mental well-being?
• 2.How has the COVID-19 pandemic impacted nursing students' educational environment?

2. Methods

2.1. Study design

A qualitative design was utilized using a descriptive method to identify perceptions of how the COVID-19 pandemic has impacted nursing students' mental well-being and their educational environment. The Institutional Review Board (IRB) carefully reviewed and approved this study at the University of Southern Mississippi (IRB-20-551).

2.2. Participants

BSN (n = 11) students were recruited with the utilization of purposeful sampling. Interviews were conducted via phone or via zoom, an online platform that allows for virtual meetings, during the Spring semester of 2022. Twenty students expressed interest in participating in the study, with only eleven students meeting the criteria to participate. Those students who did not meet the criteria (n = 9) were attending Licensed Professional Nursing (LPN) programs or RN-BSN programs. The researcher utilized the Student Nurses Association (SNA) and the Southern Association of Colleges and Schools (SACS) to obtain listservs in recruitment efforts. Other methods of recruitment included the utilization of social media platforms such as Facebook and Instagram where advertisements for participation in the study were posted. Most of the participants (n = 16) were recruited through social media platforms, while other participants (n = 4) responded to emails they received from their nursing programs. A flowchart of the recruitment process can be seen in Fig. 1.

Fig. 1.

Recruitment strategy.

The researcher aimed to obtain a heterogenous group for the study sample size. With the guidance of [8], the researcher determined that a group of 3–15 individuals [9] interviewed via phone or zoom would ensure that saturation was achieved. Interviews were conducted in January 2022, after the peak of the COVID-19 pandemic. At this time, participants noted that their programs were practicing social restrictions such as face-to-face courses moved to online platforms, the use of face masks, social distancing, and closures to multiple clinical sites.

In order to meet the criteria to participate in the study, individuals had to be 18 years of age or older and enrolled full-time in a Baccalaureate Science in Nursing (BSN) program located in a Southeastern state. Variability among the participants to ensure heterogenicity was found with students attending BSN programs in Mississippi (n = 5), Alabama (n = 2), Georgia (n = 1), Florida (n = 2), and Tennessee (n = 1). Other Southeastern states included Kentucky, North Carolina, South Carolina, West Virginia, Virginia, and Maryland [10].

2.3. Interview methodology

The development of interview questions within the study was guided by a directed content analysis approach. Individuals that showed interest in participating in the study were contacted via email to ensure that inclusion criteria were met. Those individuals that met the criteria for the study were contacted via email or phone to make arrangements for obtaining consent as well as availability for meeting dates and times. The average time for the phone and Zoom interviews were approximately 25 min. During a 4-week period, the interviewing process and data collection ensued. During the interviews, individuals were asked open-ended questions regarding their experience with the impacts of the COVID-19 pandemic on their mental well-being and educational environment. Interview questions can be found in Table 1.

Table 1.

Interview questions.

1.The researcher prompted students to discuss how the COVID-19 pandemic affected their academic performance.
2.The researcher prompted students to discuss their social support system. Students were also prompted to discuss how their support system affected their progress during nursing school.
3.The researcher prompted students to discuss any improvements needed within their support system that would have affected their progress during nursing school.
4.The researcher prompted students to discuss possible factors resulting from the pandemic that might have affected their mental well-being.
5.The researcher prompted students to discuss coping strategies utilized to decrease stressors as a result of the pandemic.
6.The researcher prompted students to discuss concerns about their physical and mental well-being as a result of the pandemic.

The interview process included accurate documentation of findings and observations regarding the participants' responses. In preparation for data analysis, reflection after each interview was conducted by the researcher and accurate and precise transcription of the interview recordings ensued.

2.4. Data analysis

The researcher was able to approach each research question for qualitative data analysis by transcribing the data electronically and utilizing data analysis software [9]. In preparation for qualitative analysis, the researcher ensured that each interview response set was transcribed verbatim and then input into a categorization matrix. Excel, a spreadsheet software, was utilized to develop the categorization matrix. The researcher aimed to conduct coding using a directed content analysis approach with guidance from [9], which includes cataloging overarching themes, concepts, and defining ideas found within the response sets.

Interview questions were separated within Excel and worksheet tabs were created. Respondents' names were removed, and each participant was assigned a number. Within the categorization matrix, overarching themes, concepts, and defining ideas were separated into columns and flagged within the response sets. The frequency and intensity of the flagged items were noted to identify the prevalence of overarching themes. The response sets were reviewed and word choice, content, and extensiveness within the data were noted.

The researcher aimed to reach validity and trustworthiness by documenting corresponding codes and categories within flowcharts to ensure that the categorization matrix sufficiently represented the overarching themes [11]. Flowcharts helped the researcher to depict the process of the coding breakdown. The researcher utilized coding and qualitative content analysis as the best approach to develop theoretical explanations generated from the overarching themes, ideas, and concepts found within each response set [12]. In efforts to establish trustworthiness, the researcher ensured that a combination of different methods, such as interview methods via phone and Zoom were utilized in data collection [13].

During the qualitative data analysis process, the researcher ensured the accuracy and correctness of each transcript by conducting careful listening, reviewing transcripts multiple times, and excluding contextual information such as verbal signifiers and background noise. To ensure conformability, the researcher did not add any additional information to the response sets, the data accurately represented the participants' responses, and each code included supporting quotes [14]. For each of the 11 participant response sets, the codes for each question were refined further to identify an accurate overarching theme.

Two independent reviewers, including the researcher, conducted the coding process. Each coder identified overarching themes and inter-rater reliability (IRR) was established within the process of consensus coding when the reviewers reached an 80% agreement on 95% of the codes [15]. Methodological triangulation, which has been noted in research to increase qualitative validity, was also utilized within the study. Methodological triangulation approaches a phenomenon or research question by utilizing a multitude of methods.

3. Results

The study sample (n = 11) was young adult students. The ages ranged from 19-25 years with a mean age of 22 years. Most of the participants were Caucasian (n = 73%) and female (n = 82%). The BSN students were mostly single (n = 91%) and not working (n = 64%). One participant (n = 1%) reported that they worked a full-time job outside of nursing school and three participants (n = 27%) reported that they worked a part-time job while in nursing school.

After careful analysis of the 11 participant’s response sets, 12 codes were identified. There were 8 codes that impacted the students' mental well-being. The codes that impacted nursing students' mental well-being include transmission, communication, unchanged, encouragement, support, unknown, time, and breaks. There were 4 codes that impacted the students' educational environment. The codes that impacted the students' educational environment included: experience, finances, workload, and online learning.

3.1. How has the COVID-19 pandemic impacted nursing students' mental well-being?

Overarching themes regarding social support were identified within the participants' response sets. The overall perception found among the students included the notion that social support was imperative to maintaining a healthy mental well-being. Social support from family and friends among the participants was found to be very good and 100% (11/11) of the participants voiced that either a family member or friend was a source of ongoing support while in nursing school. The coding breakdown revealed 3 common themes: encouragement, unchanged, and communication. During the interview, students discussed family members or friends that offered encouragement while they were in nursing school. Participants also discussed the positive impact as a result of those that encouraged them during the COVID-19 pandemic. Looking back on their COVID-19 experience, participants voiced that they did not feel the need for their family members or friends to change or do anything differently regarding social support. Overarching themes regarding coping were identified within the participants' response sets and revealed that coping skills were imperative in dealing with the stressors that accompany nursing school. Several types of coping skills were presented in the participants' responses. Common themes that were identified included taking breaks and having adequate support. Other common themes of coping skills included exercising, engaging in sports, and hanging out with friends.

Overarching themes regarding causes of anxiety, stress, or psychological stress as a result of the COVID-19 pandemic were identified within the participants' response sets. Common themes of contributing factors to anxiety included the fear of the unknown and a lack of time. Participants voiced that the demands and the workload of the nursing school contributed to a lack of time and the need for time management skills. In one of the interviews, a participant discussed the challenges of having multiple tests in one week that added to their anxiety. Similar responses included the stressors of long hours of studying or completing assignments that restricted their time for anything else. Multiple participants discussed their anxiety and fear of not knowing what their future in nursing school will look like. Some participants even questioned continuing in their nursing programs and stated reasons such as not knowing if their courses will be able to return to face-to-face settings or if they will be able to conduct their clinical practice in the hospitals.

Overarching themes regarding general health were identified within the participants' response sets. A common theme among participants included fears of contracting or transmitting the COVID-19 virus as well as concerns for their families and friends. Nursing students attend clinicals in various patient care settings, such as hospitals, and are at risk for exposure to the COVID-19 virus. In multiple interviews, participants discussed their fears of caring for patients that were positive for COVID-19. They were afraid of contracting the virus and becoming sick. Students voiced concerns and fears about not having adequate personal protective equipment (PPE) while caring for these patients. Other participants discussed concerns about restricting contact with their loved ones in fear of spreading the COVID-19 virus. Most of the students were concerned about being under quarantine, should they get sick or become exposed to the COVID-19 virus. The main concern was regarding the amount of school that would be missed with most universities requiring students to isolate and quarantine for up to 14 days [16].

3.2. How has the COVID-19 pandemic impacted nursing students' educational environment?

Overarching themes regarding nursing students' educational environment were identified within the participants' response sets. A common theme included negative experiences with online learning and the abrupt transition from face-to-face courses to online courses. Contributing factors to the negative online experience include the unfavorable delivery of course content. In one of the interviews, the participant discussed the challenges of trying to learn online. The student stated that the move to online courses made them feel isolated and easily distracted. The need for human interaction and active learning within a face-to-face setting was mentioned multiple times. Other common themes that were identified among participants' response sets included increased workload, financial challenges, and a lack of experience. Participants voiced these themes as contributing factors to a negative educational environment and even noted that these factors decreased their academic performance. The extreme workload that nursing students are given was also a common theme identified among the response sets. Participants stated that there was difficulty in finding a work-life balance. Multiple students voiced concerns about “not having enough time.” One student stated that they were always behind with multiple assignments due and the long study hours required to be successful on exams.

Another common theme among the participants' responses included financial challenges while in nursing school. The rigorous workload and high demands of nursing programs limit the ability and find time to work. The nursing students that worked while in school stated that they are only able to work part-time or very few hours. One of the participants that worked part-time discussed the financial challenges and stated that money is a constant stressor as they need to work in order to be financially stable, but do not have the time because of nursing school. Another contributing factor that negatively impacted the educational environment was the lack of experience. Participants' responses highlighted that some of the lack of experience was due to COVID-19 hospital restrictions and the lack of hands-on experiences when nursing courses transitioned online. Multiple participants discussed feelings of “missing out” or that they were not getting the best practice and hands-on experience. Some of the students discussed that restrictions from in-person practice have decreased their educational environment. There were multiple students that discussed challenges with support and help from their nursing schools and instructors. Multiple participants stated that the move to online courses made them feel disconnected. Another common theme identified among the participants' responses included the negative effect that lack of communication produced on the educational environment. Participants voiced the need for change or improvement regarding communication between the nursing school and students. Ineffective or lack of communication contributed to the stressors and challenges within the educational environment. In one interview, the participant discussed the lack of sympathy and encouragement from their professors. The student highlighted the need and the importance of building relationships between faculty and students and the positive impact that it could have on academic success.

4. Discussion

Responses from the interviews suggest that social support and coping abilities play an important role in mental well-being and the educational environment among nursing students.

Social support from family and friends is essential to maintaining healthy mental well-being among nursing students. Studies have shown that adequate social support can positively impact academic success among nursing students [17]. Having adequate social support in dealing with the lingering effects of the COVID-19 pandemic during nursing school can decrease the risk of negative mental health outcomes. Adequate social support among nursing students aids in psychological adaptability [18].

Healthy coping skills can improve mental well-being among nursing students and increase academic success. Responses from the interviews indicated that healthy coping skills included exercise or taking mental health breaks. Students also voiced that other healthy ways to cope with their stress include eating healthy, exercising, adequate rest and sleep, social support, and taking breaks. Healthy coping skills should be encouraged among nursing students [16].

Responses from the interviews suggest that lack of support from nursing faculty and the nursing program leads to negative impacts on their mental well-being. Research studies indicate that inadequate social support systems can produce negative mental health outcomes such as depression, isolation, stress, anxiety, and psychological distress [7]. Nursing faculty are highly influential for student success and progression within a nursing program. Effective nursing instructors should aim to facilitate an educational environment that increases motivation to learn [3] as well as establish abilities to recognize when students need further support. Responses from the interviews suggest that factors that greatly impact the mental well-being of nursing students include the increased workload, financial burden, and lack of experience. Many faculty members have observed their students' mental health worsening over the years, and many are concerned with declining student mental well-being as a result of the pandemic [19]. Increased efforts to address the mental health and well-being of nursing students are needed and nursing programs should be equipped with the skills and knowledge to address students' mental health needs or provide them with appropriate resources.

Research from countries around the world has highlighted the negative effects produced by the COVID-19 pandemic on healthy mental well-being [20]. The results of the study indicated that nursing students are vulnerable to those negative effects and are impacted more severely than those that are not in nursing school. Recommendations for future practice include creating an educational environment that promotes healthy mental well-being among nursing students. Healthy coping skills and self-care interventions should be encouraged and incorporated throughout the nursing curriculum. Preventative measures, such as improving self-awareness among nursing students and stress-reducing guidance should be implemented to prevent burnout and psychological distress. Incorporating such measures can provide nursing students with the ability to face challenges and stressors that are associated with a rigorous nursing program [21]. Providing nursing students with the tools, skills, and resources needed to prevent psychological distress can ensure that they practice safely, especially when providing patient care [21].

4.1. Limitations

The Inclusion of a population with only BSN students in the Southeastern U.S. can contribute to the limitations of the study. The study findings of a specific BSN student population may not accurately represent the findings of a larger BSN student population, causing an external validity threat. Limitations were also noted in the assumption that participants were truthful and accurate with interview responses. Future studies should include participants' background information regarding family and social dynamics, mental health history, and a baseline perception of mental well-being before and after the COVID-19 pandemic. Limitations were noted in the interview questions and did not address any positive impacts or perceptions that the participants may have had regarding the COVID-19 pandemic. Limitations were also noted in the participant's answers which were general and broad and could have been more specific.

5. Conclusion

5.1. Implications for practice

Preventative measures, such as screening tools, play an imperative role in the mental well-being of nursing students. Evidence-based screening tools or simple questionnaires regarding a student’s mental well-being can help faculty or qualified personnel in recognizing students that are at high risk for psychological distress. The nursing faculty and student relationship allows for faculty to spend numerous hours interacting and directly observing students, giving them the opportunity to note or recognize any psychological changes [22]. Faculty should be provided with resources regarding screening tools, how to approach students with psychological distress, and services that students can be referred to [22]. Nursing programs should consider training for nursing faculty, such as with the Mental Health First Aid courses or through training associated with the National Alliance on Mental Illness (NAMI). NAMI provides an abundance of information and resources that can support nursing faculty in facilitating student wellness and mental well-being [23].

Support from nursing faculty and nursing programs plays an important role in academic success among nursing students. Nursing faculty should provide students with resources to address stressors such as mental health stressors, financial stressors, or physical health stressors. Most universities have services that can aid students during challenging times, but students will not be able to take advantage of those services if they are unaware of the resources available. Nursing programs must support faculty as they fulfill the important role of addressing the mental health of all students [19]. Addressing mental health in nursing school arms our future nurses with skills to mitigate stress in the field. Inadvertently, managing stress would also decrease burnout and increase job retention, enhancing patient safety. To combat the risk of negative mental health outcomes among nurses, nursing faculty must promote a culture of mental health wellness by integrating coping skills into the nursing curriculum to foster a nurse equipped to promote well-being in a stressful environment. Promoting mental health well-being within undergraduate nursing courses will reduce the stigma surrounding mental health and promote well-being in the future generation of nurses. A summarization of recommendations for practice can be seen in Table 2.

Table 2.

Recommendations for practice.

1.Nursing programs should incorporate screening tools and survey tools within the curriculum to monitor the mental well-being of students.
2.Nursing programs should provide faculty with resources and tools to address decreased mental well-being among students.
3.Nursing programs should provide students with resources to address stressors such as mental health stressors, financial stressors, or physical health stressors.

5.2. Implications for future research

Insights for this study revealed significant factors affecting students' perceptions of the COVID-19 pandemic on their mental well-being and educational environment. In an effort to fully understand these effects, sub-specialty factors should be taken into consideration. Future studies should explore sub-specialty factors such as employment status, cultural background, and clinical experience. Nursing students that work part-time may have a higher risk for negative effects on mental well-being and may experience less satisfaction with their educational environment. Students who work every month receive on average 0.41 standard deviations lower GPAs than those non-working students [11].

Mental well-being among nursing faculty should be considered for future research. Just like nursing students, nursing faculty were not immune to the negative effects of the COVID-19 pandemic. The contributing factors of decreased mental well-being among nursing faculty as a result of the COVID-19 pandemic should be explored in efforts to improve the educational environment. Contributing factors to high levels of stress and anxiety among nursing educators can be attributed to the high demands and increased workload of having to quickly transition to online courses as a result of the pandemic [24]. The high demands and increased workload of the educational environment have also led to educators being at higher risk for depression and unhealthy sleep patterns [24]. Preserving and protecting the mental well-being of nursing educators is imperative to a healthy student's mental well-being and also ensures that students are provided with a safe and high-quality education [25].

In efforts to ensure progression and academic success among nursing students, nursing educators should be aware of contributing factors that can lead to negative student outcomes. Efforts to increase knowledge and awareness regarding the mental well-being of nursing students can provide nursing faculty with the means to address challenges within the educational environment. The impact and changes brought about by the COVID-19 pandemic have increased the need for nursing education to adapt and adjust to complex challenges. These complex challenges expose both nursing education and nursing students to psychological difficulties, which can lead to negative student outcomes. The study results play an imperative role to aid nursing educators in their determinations to adequately prepare nursing students to enter the workforce. Exploring perceptions of nursing students' mental well-being and educational environment in response to the COVID-19 pandemic can aid nursing educators in improving student outcomes and academic success among the future nursing workforce.

Declarations

Author contribution statement

Mayantoinette Watson: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

Data will be made available on request.

Declaration of interest’s statement

The authors declare no conflict of interest.