key: cord-0876095-vpbpjxal authors: Casafont, Claudia; Fabrellas, Núria; Rivera, Paula; Olivé-Ferrer, Maria Carmen; Querol, Elena; Venturas, Montserrat; Prats, Judith; Cuzco, Cecilia; Frías, Cindy E.; Pérez-Ortega, Silvia; Zabalegui, Adelaida title: EXPERIENCES OF NURSING STUDENTS AS HEALTHCARE AID DURING THE COVID-19 PANDEMIC IN SPAIN: A PHEMONENOLOGICAL RESEARCH STUDY date: 2020-12-17 journal: Nurse Educ Today DOI: 10.1016/j.nedt.2020.104711 sha: 5d0c0a54760b5390c4ab4c22aac8150762a1b311 doc_id: 876095 cord_uid: vpbpjxal Background The coronavirus disease (COVID-19) pandemic has caused a worldwide health and social crisis directly impacting the healthcare system. Hospitals had to rearrange its structure to meet clinical needs. Spain has been experiencing a shortage of working nurses. Student nurses in their last year at university were employed to help the National Health System respond to the COVID-19 crisis. Aim The aim of this study was to explore and understand the experience of nursing students’ roles as healthcare aid in responding to the COVID-19 crisis. Methods A qualitative phenomenology design was used to explore undergraduate nursing students’ perceptions of their experiences as HAs during the COVID-19 outbreak. Open face-to-face interviews were conducted to nursing students (n=10) in May 2020. Data was analyzed using the hermeneutic interpretative approach. Results All participants were women aged between 21 and 25 years. Seven main themes emerged: learning, ambivalent emotions and adaptation were classified at a personal level; teamwork, patient communication, and unclear care processes were categorized under hospital structure; and coping mechanisms were part of external factors. Conclusions: Orientation, follow-up, and emotional support in crisis situations are key to unexperienced healthcare workers overcoming stressful emotions. Previous academic education and training may help novice future nurses feel more confident about their tasks and responsibilities as well as improve patient outcomes, resource management, and staff safety. The coronavirus disease pandemic has caused a worldwide health and social crisis directly impacting the healthcare system. Spain confirmed its first case on 31 January, 2020. Since then, the virus has spread rapidly and the country has been severely affected. The government declared a national lockdown on 14 March, 2020, post which citizens being confined to their homes until 21 June, 2020, gradually became the new normality (Spanish Ministry of Health, 2020). The COVID-19 pandemic poses a serious challenge to health system resilience worldwide. In particular, hospital capacity and availability of intensive care unit (ICU) beds and respirators, which have been rendered scarce in a number of countries during the first wave of COVID-19, have been identified as among the most relevant factors (Pericàs et al., 2020) . The Hospital Clinic is a public 750-bed tertiary teaching hospital. As the COVID outbreak was spreading, the hospital had to rearrange its structure to meet clinical needs. In addition, the Health Hotel was set up to provide medical assistance for in-patients with mild COVID-19 symptoms (Pericàs et al., 2020) . As soon as the hospital admissions peaked, specialised units were filled with COVID-19 patients, nurses and doctors focused on COVID-19 patients, and day care units were converted into ICUs. All these adaptations prompted a need to hire healthcare staff, especially nurses. The recent World's Nursing Report (2020) reveals a significant lack of nursing staff, depicting a global deficiency of 5.9 million professionals. As is the case J o u r n a l P r e -p r o o f now, nurses have always been at the forefront of the global fight against healththreatening epidemics and pandemics (WHO, 2020) . In fact, Spain has been experiencing a shortage of working nurses, which is concerning for nursing boards and organizations. In 2017, Spain had 5.7 nurses per 1,000 inhabitantsone of the lowest among the OECD countries, among which the average is 8.8 nurses per 1,000 inhabitants. Nursing graduates are also on the lower side, with 21 graduates per 100,000 inhabitants in 2018; this number was 86 in Finland. In addition, the problem of nurses migrating to other indicators represent a healthy transition, as well as family support and the contextualization of the phenomenon in time and space (Schumacher & Meleis, 1994) . Understanding the transition experience in this case is situational (natural disaster), organizational (being hired by the hospital), and developmental (becoming a nurse). Interventions can be developed to facilitate transitions and provide support to ensure better outcomes, expertise, and minimise the impact on students" wellbeing. Hence, it is essential to understand the experiences of nursing students, especially under the unique circumstances of the COVID-19 pandemic, which could help develop better responses in future healthcare crises. For all the above explanations, we aim to explore and understand the experience of nursing students" roles as HAs in responding to the COVID-19 crisis. A phenomenology design was used to explore undergraduate nursing students" perceptions of their experiences as HAs during the COVID-19 outbreak. The study setting was the Hospital Clinic Barcelona (Spain), a technology teaching hospital that includes specialised wards for nursing students" training. The study was conducted from April to June 2020. Participants were fourth year students from different nursing schools in Catalonia, whose previous nursing degree clinical placement was interrupted, and who were hired as HAs. A purposive sample of fourth year students contracted as HAs was recruited (n=10) until data saturation was reached, including students from all working shifts in the hospital (morning, afternoons, and night shifts) and the Health Hotel who responded to the COVID-19 outbreak. No male student was found to meet the inclusion criteria to be included in the study; we had recruited two male participants, of which one was hired as an HA to work in a non-COVID-19 unit and the other had become infected. To assess the rigour of this qualitative research, we followed Lincoln and unclear care processes were categorized under hospital structure; and coping mechanisms were part of external factors (see Figure 1 ). For all students, this experience was highly valued because of the skills they gained. As pre-graduated nurses, they considered it an opportunity to gain real clinical experience and confidence before their employment insertion and felt that they were somehow caring for patients with a lower degree of responsibility. They felt that learning as an HA compensated for the cancelled clinical experience. They also learned about optimising equipment and adapting themselves to special circumstances. "I have certainly learned, I learned a lot…about how to protect myself, how to use all the equipment…the scarce material we had or what we could use, how… to use it… the minimum possible times and… also lessening contact with the patients who were very lonely, but equally ensuring that they are in good care…" (P. 2). pandemic, which made them feel helpful and proud of being there. A study reported that Spanish nursing students showed high willingness (74.2%) to look after COVID-19 patients, although most of them (65.3%) did not feel prepared (Cervera-Gasch, González-Chordá & Mena-Tudela, 2020). The high clinical pressure to respond to COVID-19 made the hiring process as HAs unconventionally speedy and participants felt that the orientation period was not sufficient. Participants also felt insecure because they did not know what they could or could not do. They all suggested the need to have protocols in which the activities they were allowed to do are indicated. As novice professionals, they need to follow guidelines and instructions to feel secure (Cervera-Gasch, González-Chordá & Mena-Tudela, 2020; Carter et al., 2014; Benner, 1982) . Nursing students find, under normal circumstances, their clinical practice to be rather stressful (Suarez-Garcia, Maestro-Gonzalez, Zuazua-Rico, Sánchez-Zaballos, & Mosteiro-Diaz, 2018) . Bearing in mind the impact of the pandemic, negative emotions such as stress and anxiety were superimposed. For instance, fear of infection, especially with regard to family members, and the uncertainty of what was going to happen caused more stress and anxiety. As graduate nurses, HAs" empathy with patients arose sadness and anger, and they felt impotent because they did not know how to provide the best care for patients. However, on the positive side, emotions such as feeling helpful, proud usually open. Certainly, this was not fulfilled as restrictions were imposed, and the workload increased rapidly. As stated by the students, having more nurses could have undoubtedly helped achieve better patient outcomes, staff safety, and, consequently, more satisfaction. HAs found communicating via videoconference very helpful (Schmitt & Lancaster, 2019) . Moreover, sufficient PPEs should be available in advance, especially if new waves come along. Hence, as facilitators to overcome stress, the students received full support from family and friends, resulting in beneficial expression of emotions. Family and social support is beneficial in achieving a healthy transition and also after traumatic experiences which may cause post-traumatic symptoms (PTS) (Tortella-Feliu et al., 2019) (Li et al., 2020) . The HAs also expressed that they had their own coping mechanisms for stress and to disconnect from reality, namely running, reading, or practicing yoga. These activities may be effective in decreasing stress levels (Stubbs et al., 2017) (Cocchiara et al., 2019) . These results might help universities and nursing schools prepare students for future pandemics, with simulation labs and clinical situations connecting theory and practice. This would improve the preparedness of students" skills and their emotional strategies to cope with their feelings. In addition, hospitals should strengthen their guidelines and the emotional support they provide during future pandemics. The findings of this study should be interpreted cautiously, as the sample was homogenous, predominantly female, and mainly drawn from one public J o u r n a l P r e -p r o o f Journal Pre-proof university. Thus, findings also cannot be generalised to the whole of Generation Z. In addition, older students might have different experiences. This study reflects the experiences of HAs in a prestigious high-tech teaching hospital in Barcelona. Experiences in other community hospitals could vary as resources may be different. The COVID-19 outbreak has certainly impacted nursing students hired as HAs, both in their personal and professional lives. Ambivalent emotions were common, and the participants were excited initially, before adapting to the situation. Their first experiences as workers exposed them to the great value of teamwork while responding to the COVID-19 crisis. However, anxiety, sadness, fear, and uncertainty were also common, especially because of the lack of protocols and guidance. Orientation, follow-up, and emotional support in crisis situations are key to unexperienced healthcare workers overcoming stressful emotions; in particular, hospitals need to establish systematic guidelines for what students perceive as unclear care processes. Previous academic education and training may help novice future nurses feel more confident about their tasks and responsibilities as well as improve patient outcomes, resource management, and staff safety. 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