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Nurse Faculty Provide Essential Support to Graduate Nursing Students During COVID-19 Pandemic

      Abstract

      Nurses in formal and informal leadership roles have been stretched to fulfill duties in their own role and be pulled into staffing. These emerging leaders have little energy to pursue an advanced academic degree when they are already considering leaving the profession. In a health care industry filled with ambiguity and volatility, continued efforts to support, retain, and recruit nurses in graduate leadership programs are essential. This article describes how graduate nursing faculty provided support to graduate students in unprecedented times.
      Key Points
      • Many nurses are exhausted, which may cause them to leave the profession instead of advancing their education.
      • The use the psychological PPE should be encouraged.
      • A check-in, implemented as a time of nonjudgmental listening, can contribute to the well-being of graduate students.
      In January 2020, no one understood the acute and long-term impacts of the COVID-19 pandemic on health care systems and the population at large. Health care disaster mode processes and systems used to augment daily routines were suddenly thrust into the role of lifeline. Nursing leaders soon realized that the pre-pandemic status quo in all care settings made it difficult to keep up with the pandemic’s impact and demands.
      • Harris G.H.
      • Rak K.J.
      • Kahn J.M.
      • et al.
      US hospital capacity managers’ experiences and concerns regarding preparedness for seasonal influenza and influenza-like illness.
      Nursing education faculty also needed to change direction to support graduate students who were both attending school and leading at work during this challenging time.
      The International Council of Nurses (ICN), in a recent policy brief, reports on the impact of the pandemic on the disruption of education as reflected by 64 responding National Nurses Associations (NNA) from around the world.
      International Council of Nurses
      International Council of Nurses (ICN) policy brief: nursing education and the emerging nursing workforce in COVID-19 pandemic.
      The report found that 54% of responding NNAs reported disruption in graduate education, citing obstacles to completing required clinical hours during the pandemic, possibly contributing to a disruption in nursing’s needed workforce supply chain. Considering existing shortages in the nursing workforce, such delays will only worsen the shortage.
      Recently released results from the 2021 American Association of Colleges of Nursing (AACN) 2021 annual national survey of nursing schools revealed a 4% increase in DNP program enrollment over the previous year.
      American Association of Colleges of Nursing (AACN)
      Nursing schools see enrollment increases in entry-level programs, signaling strong interest in nursing careers. April 5, 2022.
      However, the same survey reports a 3.8% decrease in master’s program enrollment.
      • Iheduru-Anderson K.
      • Foley J.A.
      Transitioning to full online teaching during Covid-19 crisis: the associate degree nurse faculty experience.
      At 1 nationally ranked nursing school in Texas, MSN applications are down even more in 2022. Nurses in formal and informal leadership roles have been stretched and asked to fulfill duties in their own role and be pulled into staffing. The concern is that these emerging leaders have no remaining energy to apply for an advanced academic degree when they are already considering leaving the profession.
      Findings are consistent across these various surveys and underline a concern for faculty to support our nurse leaders in their graduate programs, retain those who are struggling with competing priorities, and even recruit into graduate programs. The purpose of this article is to describe how graduate nursing faculty provided support to graduate students during an unprecedented time.

      Challenges for Faculty and Students

      Graduate nursing faculty adapted overnight to several challenges to the teaching/learning function, but also to creative new ways to keep graduate students engaged in their academic pursuits amid a pandemic and stressors on so many fronts. Graduate programs that offered on-campus face-to-face student–faculty interactions quickly transitioned to a remote virtual platform. Decisions regarding the virtual platform included the use of synchronous and/or asynchronous classes. Faculty who were not proficient in providing online courses were challenged to transition courses to a virtual platform. The accessibility of information technology support and platform mentoring proved to be an asset for faculty as learning platform functionality changed almost daily. Effort by graduate nursing programs was needed to evaluate their current content delivery and educate faculty to meet the challenges of providing meaningful and engaging courses in a virtual environment.
      • Iheduru-Anderson K.
      • Foley J.A.
      Transitioning to full online teaching during Covid-19 crisis: the associate degree nurse faculty experience.
      During the height of the pandemic, the state and national accrediting agencies supported educators by offering a wide range of regulatory exemptions to support degree-seeking nursing students.
      American Association of Colleges of Nursing (AACN)
      Student enrollment surged in U.S. schools of nursing in 2020 despite challenges presented by the pandemic. April 1, 2021.
      ,

      Texas Board of Nursing. COVID-19: Governor Abbott waives several board of nursing regulations. TX Board Nurs Bull, LI(II). 2020, April:1-2.

      Assignments were adjusted to assure students obtaining clinical hours could use simulation hours as replacement or additions. Faculty observed exhausted graduate students struggling to prioritize their education. Retention of students took priority as students requested late submission of assignments or notified faculty of COVID-19 exposure. Students faced issues of moral distress and unprecedented challenges in their places of employment.
      • Altman M.
      • Delgado S.
      The importance of nurse well-being and how to achieve it.
      With many of the students in middle management positions, they were dealing with staffing shortages, personal protective equipment (PPE) shortages, and childcare issues, as well as personal health and safety issues.
      • Altman M.
      • Delgado S.
      The importance of nurse well-being and how to achieve it.
      Faculty heard frequent requests from students for flexibility as they struggled to complete assignments created for non-COVID times.

      Fewer Clinical Sites

      A different challenge emerged for students needing to demonstrate clinical skills. Students maneuvered through fluctuating barriers driven by pandemic surges that prevented learning at planned clinical sites. Offsetting these challenges required faculty to find alternative clinical rotations, provide access to academic coaching, foster a supportive environment, and offer virtual simulations.
      Virtual simulation is a cutting-edge technology that healthcare providers often use to augment learning. Kobeissi and colleagues
      • Kobeissi M.
      • Christopherson K.
      • Kearney K.
      • Aggarwal S.S.
      Expanding clinical education during a time of crisis: innovative virtual simulation.
      used live virtual simulation during the COVID-19 pandemic to help nurse practitioner students obtain clinical hours to satisfy graduation requirements. The students participated in faculty simulated clinical scenarios aligned with course objectives. Debriefing helped the students understand clinical rationales and reflect on the experience. These activities helped support experiential learning outside of onsite clinical opportunities utilizing Donald Schon's reflection-on-action and quizzes to measure competency.
      • Kobeissi M.
      • Christopherson K.
      • Kearney K.
      • Aggarwal S.S.
      Expanding clinical education during a time of crisis: innovative virtual simulation.
      ,
      • Schön D.
      Educating the Reflective Practitioner.
      The collective experiences highlighted the value of virtual simulation amid the COVID-19 pandemic.

      Psychological PPE for Student Support

      During the COVID-19 pandemic, students reported a variety of stressors and difficulty coping, depression, loneliness, lack of motivation, difficulty focusing on schoolwork, restless sleep, appetite changes, and job loss concerns.

      Birmingham W, Wadsworth L, Lassetter J, Graff T, Lauren E, Hung M. COVID-19 lockdown: impact on college students’ lives [e-pub ahead of print]. J Am Coll Health. https://doi.org/10.1080/07448481.2021.1909041. Accessed May 23, 2022.

      Faculty can help students cope as they work in our complex, rapidly changing health care environment. As a way for nurses to take care of their mental health and well-being, the Institute for Healthcare Improvement (IHI) outlined ideas to encourage nurses to use “Psychological Personal Protective Equipment (PPE).”
      Institute for Healthcare Improvement
      “Psychological PPE”: promote health care workforce mental health and well-being.

      Time Away from Work

      Physical and mental work demands increased exponentially during the COVID-19 pandemic and resulted in significant negative impacts for health care workers.
      • Chan G.
      • Bitton J.
      • Allgeyer R.
      • Elliott D.
      • Hudson L.
      • Burrell P.
      The impact of COVID-19 on the nursing workforce: a national overview.
      As we recover from the worst of the pandemic, faculty can advise students who may benefit from a simple intervention such as time away from work. Time away from work includes leisure activities, which can be anything a person enjoys, including taking part in hobbies, participating in arts, taking educational classes, reading, socializing, shopping, listening to music, and engaging in sports activities.
      • Fancourt D.
      • Aughterson H.
      • Finn S.
      • Walker E.
      • Steptoe A.
      How leisure activities affect health: a narrative review and multi-level theoretical framework of mechanisms of action.
      Published evidence describes the positive consequences of leisure time for both mental and physical health. For mental health, engagement in leisure activities is known to prevent and manage depression, anxiety, and stress.
      • Fancourt D.
      • Aughterson H.
      • Finn S.
      • Walker E.
      • Steptoe A.
      How leisure activities affect health: a narrative review and multi-level theoretical framework of mechanisms of action.
      Faculty can help students recognize symptoms of burnout, verbalize benefits of leisure time, and even advise how students can approach employers with time off requests.

      Avoid Social Media/Media Coverage

      An estimated 4 billion people use Facebook, Twitter, or Instagram as their primary source to share and consume information.
      Statista
      Most popular social networks worldwide as of January 2022, ranked by number of active monthly users.
      Potential negative effects of social media are associated with certain activities, including social comparisons, incitement of moral outrage, cyber bullying, and trolling.
      • Kross E.
      • Verduyn P.
      • Sheppes G.
      • Costello C.
      • Jonides J.
      • Ybarra O.
      Social media and well-being: pitfalls, progress, and next steps.
      During and after COVID-19, perhaps the biggest problem is misinformation that causes confusion, anxiety, and loss of control.
      • Brailovskaia J.
      • Margaf J.
      The relationship between burden caused by coronavirus (Covid-19), addictive social media use, sense of control and anxiety.
      Ways faculty can promote a positive relationship with social media are to raise awareness of potential negative consequences of intensive social media activity, enhance the sense of control a person has over social media use (i.e., conscious reduction in daily time spent on social media), promote increased physical activity that does not require expensive equipment, and promote mindfulness activities.
      • Brailovskaia J.
      • Margaf J.
      The relationship between burden caused by coronavirus (Covid-19), addictive social media use, sense of control and anxiety.
      Advocating for health policy to foster governmental accountability in designing programs to decrease negative effects of social media is another option.

      Mental Health Support

      Faculty can help students cope by having a basic understanding of mental health diagnoses and associated etiologies, genetic and environmental factors, symptomatology, and treatments. With an understanding of mental health diagnoses, faculty can identify warning signs of a struggling student. Faculty should also be able to comfort students and refer them to appropriate help in a non-judgmental manner. Perhaps the most important factor to support mental health in students is building a quality faculty–student relationship. Connecting and actively engaging with students, especially in an online environment is also important both before and after the COVID-19 pandemic.
      • Kalkbrenner M.
      • Jolley A.
      • Hays D.
      Faculty views on college student mental health: Implications for retention and student success.
      Mindfulness-based interventions are another way to cope with stress, improve attention, mental health, and well-being. The goals of mindfulness-based interventions are to increase awareness in the present moment, regulate distressing thoughts and feelings, promote a view of the self in a non-judgmental way.
      • Weis R.
      • Ray S.
      • Cohen T.
      Mindfulness as a way to cope with COVID-19-related stress and anxiety.
      As an example, Weis and colleagues
      • Weis R.
      • Ray S.
      • Cohen T.
      Mindfulness as a way to cope with COVID-19-related stress and anxiety.
      implemented a 4-week mindfulness-based group therapy program designed to help college students cope with COVID-19. The intervention group reported significantly greater self-compassion, less stress, anxiety, and sleep problems, and better performance on attention-based measures when compared to the control group (p < 0.05).
      • Weis R.
      • Ray S.
      • Cohen T.
      Mindfulness as a way to cope with COVID-19-related stress and anxiety.

      Facilitate Opportunities for Gratitude

      Widely considered a virtue of “human strength,” gratitude is a character strength most strongly associated with life satisfaction.
      • Emmons R.A.
      • Crumpler C.A.
      Gratitude as a human strength: appraising the evidence.
      ,
      • Park N.
      • Peterson C.
      • Seligman M.E.P.
      Strengths of character and well-being.
      Interest in gratitude and its mental health benefits gained attention after authors of a landmark study reported that gratitude interventions (GIs) are associated with significant positive mental health and wellbeing benefits.
      • Emmons R.A.
      • McCullough M.E.
      Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life.
      The best approach to foster gratitude is by including GIs in combination with a social media or online approach that engages students in the autonomous giving and receiving of thanks, and supports them in developing a habit of practice.
      • Bono G.
      • Reil K.
      • Hescox J.
      Stress and wellbeing in college students during the COVID-19 pandemic: can grit and gratitude help?.
      Examples of effective GIs include writing a gratitude letter,
      • Adair K.C.
      • Kennedy L.A.
      • Sexton J.B.
      Three Good Tools: positively reflecting backwards and forwards is associated with robust improvements in well-being across three distinct interventions.
      use of an online app designed for students to express thanks to peers and faculty to genuinely practice gratitude, and use of a technology-based GI where the traditional letter-writing-and visit approach was modified to include note writing (instead of letters) and instant messaging (instead of face-to-face visits).
      • Bono G.
      • Reil K.
      • Hescox J.
      Stress and wellbeing in college students during the COVID-19 pandemic: can grit and gratitude help?.
      ,
      • Adair K.C.
      • Kennedy L.A.
      • Sexton J.B.
      Three Good Tools: positively reflecting backwards and forwards is associated with robust improvements in well-being across three distinct interventions.

      Reframe Negative Thoughts

      Cognitive behavior therapy (CBT) is useful for reframing negative thoughts and to enhance an individual’s awareness of their own thoughts, feelings, and circumstances. The goal is to recognize and challenge altered ways of patterns of thinking, ultimately building and restoring personal resiliency.
      • Surmai M.
      • Duff E.
      Cognitive behavioural therapy: a strategy to address pandemic-induced anxiety.
      In one study using CBT, the intervention included 3 steps: identifying the negative thought, replacing the negative thought with a rational and/or positive response, and writing thoughts in a journal or on a worksheet.
      • Surmai M.
      • Duff E.
      Cognitive behavioural therapy: a strategy to address pandemic-induced anxiety.
      The process of reframing negative thoughts results in constructive, rational, and positive perspectives. Other effective CBT interventions include deep breathing exercises, role playing, progressive muscle relaxation, and journaling.
      • Ackerman C.E.
      CBT techniques: 25 cognitive behavioral therapy worksheets.
      See Table 1 for specific actions faculty might use to promote psychological PPE.
      Table 1Specific Actions for Faculty
      Psychological PPE (IHI, 2021)Specific Actions to Support Students
      Take a day off and create space between work and home life
      • Recognize symptoms of burnout
      • Verbalize benefits of time off/leisure activities
      • Suggest leisure activities
      • Give “permission” for time off
      • Coach students how to approach employer for time off
      Avoid social media/media coverage of COVID-19
      • Raise awareness to negative effects of social media
      • Make students aware of their control over social media use (i.e., conscious reduction in daily time spend on social media)
      • Consider increased physical activity that does not require expensive equipment
      • Consider mindfulness-based interventions
      • Advocate for health policy to address negative health effects of social media
      Receive mental health support during and after crisis
      • Build quality faculty–student relationships
      • Understand mental health diagnoses
      • Identify warning signs of a struggling student
      • Avoid judgment
      • Empathize and comfort students
      • Refer to appropriate self-help resources and/or mental health professional
      • Consider mindfulness-based interventions
        • Weis R.
        • Ray S.
        • Cohen T.
        Mindfulness as a way to cope with COVID-19-related stress and anxiety.
      Facilitate opportunities to promote gratitudeOffer modern gratitude interventions (GI) including the following four elements:
      • Ensure faculty themselves practice GI as part of the classroom routine
      • Incorporate an emphasis on expressing thanks (interpersonal gratitude)
      • Include familiar modern advancements in the GI, such as social media use.
      • Create a broad experience of gratitude that is personally and socially valued within school contexts
      • GI examples aimed at promoting a growth mindset:
      • Gratitude Letter
        • Adair K.C.
        • Kennedy L.A.
        • Sexton J.B.
        Three Good Tools: positively reflecting backwards and forwards is associated with robust improvements in well-being across three distinct interventions.
      • Three Good Things
        • Seligman M.E.P.
        • Steen T.A.
        • Park N.
        • Peterson C.
        Positive psychology progress: empirical validation of interventions.
      • Online app to express thanks and genuinely practice gratitude
        • Bono G.
        • Mangan S.
        • Fauteux M.
        • Sender J.
        A new approach to gratitude interventions in high schools for supporting student mental health and wellbeing.
      • Technology-based note writing and instant messaging to express gratitude
        • Renshaw T.L.
        • Hindman M.L.
        Expressing gratitude via instant communication technology: a randomized controlled trial targeting college students’ mental health.
      Reframe negative experiences and reclaim agency

      The Check-in

      Building strong relationships and effective communication skills is a cornerstone of education for the nurse leader. Considering the mental and emotional exhaustion experienced by nurse leaders because of the pandemic, these skills are even more important. A “check-in” activity can be used at the beginning of each live or synchronous meeting day. Students often comment that check-in time is one of the most valued portions of the meeting time.
      Lasting up to an hour depending on the number of students, the check-in time offers the opportunity and the permission to be open and honest about happenings in work or home life that are impacting the student physically, emotionally, and mentally. Students are asked to rate their current well-being on a scale of 1 to 10 where 1 indicates they are at the lowest of lows and 10 reflects being on top of the world. The students then share some of the contributing factors to their ratings. Many check-ins include the joys of buying a first home, the expectations of starting a new job, revealing a family illness, or announcing a pregnancy. Since the pandemic, students have shared stories about the challenges of staffing and losing valuable staff. The students hear what peers are experiencing and share something of themselves, promoting a bond and receiving support from their peers. It is a time of sharing, support, connection, and nonjudgmental listening; time even more important since the pandemic drove courses online.
      Check-in time can contribute to the wellbeing of nursing graduate students. Students often comment they thought they were the only ones feeling this way. This opportunity for sharing is a time for self-reflection and can be a gauge of fitness for duty for these nurse leaders as they voice their struggles and victories contributing to their emotional health and well-being, knowing how important it is to check-in on ourselves before checking-in on others.

      Retaining and Recruiting Future Nurse Leaders

      Graduate nursing students are unique in that most work as registered nurses while in graduate school.
      • O'Keefe R.
      • Auffermann K.
      Exploring the effect of COVID-19 on graduate nursing education.
      These students are in a variety of roles ranging from direct care providers to holding leadership positions. As such, faculty are cognizant of the multitude of stressors faced by the students. At the height of the pandemic, communication lines were maintained through a variety of methods. Students are encouraged to network with each other and faculty during virtual class times. Based on the climate noted during the class check-in time, assignment dates are adjusted to provide more time and to reduce stress for the student.
      Faculty checked on students who seemed to struggle with course work. As a result, students were supported when making decisions regarding continuing in the program or dropping a course, thus degree plans were changed to meet the needs of students. Faculty also reconnected with inactive students with several returning to resume their degrees.
      Recruitment of graduate students is a challenge faced by nursing schools across the country. Many nurses are tired, stressed, and burned out, causing them to leave the profession instead of advancing their education.
      • Weissman S.
      Struggling to fill a dangerous and growing labor gap. Inside Higher Ed. November 4, 2021.
      Although general informational sessions provide program information for potential students, more direct strategies may be needed. For example, connecting with area chief nursing officers and nurse leaders provides an opportunity for faculty to dialogue with key stakeholders ensuring graduates are prepared to meet the needs of future employers. Seeking feedback from program alumni is another way to ensure the program meets the needs of students.

      Conclusion

      Our emerging and rising nurse leaders are experiencing potential disruptions of their academic goals. Faculty have embraced new learning platforms and have adopted many ways to support the emotional health and wellbeing of students in graduate leadership programs. The examples presented here are only some of those ways. In the days and years to come, we will need nursing leaders in settings from the bedside to the boardroom who have the knowledge and skills to lead the nursing profession into the future. In a health care industry filled with ambiguity and volatility, continued efforts to support, retain, and recruit nurses in graduate leadership programs are essential.

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      Biography

      Francine Snow, DrPH, MSN, RN, CNE, NPD-BC, is Assistant Professor, Clinical and Associate Faculty, McGovern Center for Humanities & Ethics in McGovern Medical School and also serves as a faculty member in the Nursing Leadership MSN Program and an advisor in the Nurse Executive DNP Program at the University of Texas Health Science Center at Houston Cizik School of Nursing in Houston, Texas. She can be reached at [email protected] . Linda Cole, DNP, RN, CCNS, CPHQ, CNE, FCNS, is Assistant Professor, Clinical, Lisa Boss, PhD, EdD, RN, CNS, CEN, CNE, is Associate Professor, Clinical, Susan Stafford, DNP, MPA, MBA, RN-BC, NEA-BC, is Assistant Professor, Clinical, Latarsha Cheatham, DNP, RN, FNP-BC, is Assistant Professor, Clinical, and Marie McBee, DNP, MSN, RN, NEA-BC, is Assistant Professor, Clinical at the University of Texas Health Science Center at Houston Cizik School of Nursing.