Pre‐registration undergraduate nurses and the COVID‐19 pandemic: Students or workers?

The COVID-19 pandemic has changed our perspective on a myriad of things as it sweeps across the globe. One issue we are forced to pay more attention to is the risk that COVID-related care entails and the fact that nurses have tragically lost their lives in this pandemic (Cook, Kursumovic, & Lennane, 2020). This loss of life has included student nurses (Ford, 2020). The pandemic has put the nursing workforce under stress in many parts of the world, and because of this, in some parts of the world, nursing students are being offered a choice to undertake extended work in hospitals to bolster the nursing population that is apparently required to deal with the (actual or predicted) vast increase in critically ill patients. Given this, the universities to which these students belong are having to engage with a level of risk that is unprecedented. This is not to say that universities have been neglecting the protection of their students—far from it. However, until the COVID pandemic the concerns have been focussed on areas such as ensuring students are protected from more existential threats, such as “microaggression” and advocating for the provision of “trigger warnings” in lectures should the subject matter (potentially) create anxiety. Now, these same universities are allowing, enabling and even possibly encouraging their students to enter high-risk health environments where some student nurses have already lost their lives. A simply incredible volte-face it would seem. Many questions are raised when we contemplate this strategy. These questions are complex and involve the consideration of many factors—factors that are individual, location and service-based. What is the evidence that students are needed? How many students are needed? How can they best be deployed? Are some students more “at risk” of harm than others? Will students from at-risk or highly vulnerable groups be kept safe? Will students who choose not to undertake extended placement in the clinical environments be disadvantaged? What are the measures for ensuring the physical and psychological safety of all students? Reflecting on whether students are actually needed in this way, we have yet to see robust and extensive workload data on this. One thing is clear—critical care nurses around the world are engaged in the most stressful, difficult, risky work of their entire lives. We recognise their skill, dedication and—in far too many cases around the world—their sacrifice in responding to the pandemic. However, in many countries the COVID-19 pandemic has also resulted in a marked reduction in other healthcare services. In many parts of the world, elective surgeries are suspended, outpatient clinics are closed, day surgeries are significantly reduced and emergency presentations have plummeted, meaning there is also a group of nurses who would normally work in these areas who have seen a large reduction in their workload. How have these nurses been effectively utilised by hospitals before looking to universities to supply students as labour? Nursing students move between sectors as a part of their studies. Over the duration of their studies, they move between the university sector and the health sector and occupy the position of learner in both. In the usual course of events, students’ placements exist primarily to meet student learning needs (rather than operational health needs), and most universities and healthcare providers have various strategies in place to enhance student learning when in clinical placement. Such strategies include the use of mentors and clinical teachers, guided reflection activities, prebriefing and de-briefing. These strategies not only enhance the learning of the student through helping them to draw meaning from events that happen in the clinical environment, but also allow for the early identification and remediation of any problems or issues that students encounter in the clinical setting. It is uncertain whether these or similar strategies will be available to students opting to work clinically in extended placement (and if so, what form they would take) in this current environment. Writing from the United Kingdom, Swift et al. (2020) have raised the issue of students possibly feeling some pressure to enter the practice environment to support the COVID-19 efforts. This is very concerning and raises questions about how this is being presented to students. Are some using emotive messages to put emotional and professional pressure on students to enter practice? We have heard and seen messages and tweets that suggest that students have a “duty” to undertake this work, that it good preparation for qualification and also that—as they will be registered soon—this is a responsibility they should take on now. We think that universities need to manage their message—officially and unofficially—to ensure students do not feel pressured one way or another. There also needs to be close monitoring of student social media platforms to manage any attempts to unduly influence students to alter their programmes and help with COVID-19 care. This issue also needs to be addressed in the longer term—is this response risking the creation of two cadres of nursing student—the ones who did “help” and the ones who did not? Clearly, universities are indicating they want to help in the face of the COVID-19 epidemic—which is laudable and admirably reflects the civic duty of universities. However, they also seem very keen to publicise these efforts on their websites and social media—as if there is a need to be seen to be doing something. This could be seen as virtue signalling in our minds, and we must honestly appraise whether nursing students are or should be a part of this. For those students who do opt to undertake this, very careful thought needs to be given to student safety and welfare when redeploying them specifically to meet the needs of the health service. These individuals are being redeployed purely on the basis of their status as university students. It is important to remember that universities have a duty of care to students. Contemplation of this fact raises questions that universities must address. Are universities putting the right support measures in place? How will universities monitor student well-being? Whose responsibility will it be if a student suffers damage to their health or death as a result of this university sanctioned activity? There is a considerable body of information suggesting that even experienced heath staff can develop post-traumatic stress and other undesirable sequelae as a result of working in pandemics (Li et al., 2020), so there is a need to carefully weigh up potential risks. Questions must be asked. Is there a heightened risk of students experiencing harm? If so how will it be recognised and managed? The above 10 points should act as a basis for the current pandemic—and help shape the response to future events of a similar nature. The COVID-19 pandemic has highlighted the fact that—unsurprisingly—many nursing students have a strong desire to help during a health emergency. This is laudable and a sign of professionalism—however, which does not remove the fact that universities have a moral and legal duty of care to protect the health and welfare of their students. We will look back at many things once this pandemic has passed we are sure—one question we will need to ask is this; does the decision enabling nursing students to enter the COVID-19 front line represent a valuable intervention by universities to fighting the epidemic or a reckless placing of nursing students in harm's way with little evidence to support the necessity to do so?