Stressors in Nurse Students’ Formation in the New Normality Post COVID-19 ()
1. Introduction
According to UNICEF (2021), mental health deterioration is highlighted. Numbers show that in Latin America and the Caribbean 15% of girls and boys, aged 10 - 19 years, had a diagnosed impairment in their mental health in the COVID-19 context. In addition, “1 out of 5 surveyed young, 15 - 24 years old, mentioned that they feel depressed or have a minor interest in doing any kind of activity, on average” [1] [2] . Worldwide persons’ mental health had been impaired and at risk due to the COVID-19 pandemic [3] . The consequences of confinement impacted every scenario, and this directly influenced the daily activities of all persons who must stay at home for a long time: Many job opportunities were lost; students faced difficulties to access classes; many social connections were also lost. It is possible to observe the mental health deterioration in persons, whose anxiety, anguish, uncertainty and confusion sensations increased. Particularly in nursing students, due to the scope of the career, where theory and practice go hand in hand, there is continuous exposure to stressful situations that require a distinct approach; the student faces different situations each semester since complexity and exigency on knowledge, skills, and competencies increase. Confinement led to students’ formation in digital platforms without laboratory practice, and training in hospitals impairing such significant knowledge, a requirement to better develop in clinical area avoiding the stress that places them at risk; which should lead us to strengthen the link between pedagogy and nursing knowledge, to search for social processes and realities that take place in nurse students along their formation, and in the new normality post COVID-19 confinement. This is a great starting point to reach a holistic approach and a better understanding of the teaching-learning process in a current context [4] . This approach incorporates categories like subjectivity and inter-subjectivity of the person, of the interpersonal relationships, of learning, of a discipline and inter-discipline, as well as the permanent need of transforming the educational tasks leading to rethink, recreate, and resignify nurse education, through the generation of new educational paradigms centered in the student, that guide innovative models in formation and guarantee significant learning, seeing the student as a person with needs [5] [6] . This also implies several dimensions of analysis, i.e., pedagogic, curricular, didactic, and psychosocial from an interdisciplinary perspective.
About this, we highlight the need to innovate and strengthen the theoretical-pedagogic aspects from a student-centered and contextual approach, where the student is seen as a human being with his own needs and problems, which will share with others in a constant process of health disease so that it is needed along his nurse formation; being ready to face them daily during his development without self-invisibility, his needs and emotions, the transition from life to death and facing the emotions involved, the health and disease along lifespan which involves him in different ways, making face stressing situations that could lead to fear, uncertainty, insecurity and trigger anxiety. It is possible to endure if the student has physical stability and companionship in his mental health, which allows him to do professional interventions without being “trapped” in mourning or changes in the discipline’s dynamic [7] [8] .
The stressful situation of being back in university classrooms after two and a half years of confinement, where classes were limited to synchronic and asynchronous sessions of the different platforms, as well as interpersonal relationships were based on text messages. Conversations on WhatsApp and other media have highlighted the importance of isolation during the pandemic. This isolation has deprived students of the opportunity to interact with their peers, making it difficult for them to readjust to the school settings and their first hands-on experience in the hospital. As a result, they may experience fear, uncertainty, and anxiety as they only had virtual knowledge and minimal or no hospital practice due to the cancellation of activities. It is necessary to encourage students’ mental health to favor the nurse-patient interaction to obtain significant learning, avoiding self-disqualification and insecurity that could obstruct students’ development. Mental health is a state of well-being for each person to face daily pressure, and it is formed by the emotional, psychological and social welfare state of the individual [9] . To talk about mental health is to have self-peace, reflected in proper daily working and activities in the community, since mental health has a direct influence on a person’s life quality. Today, more than ever, youth mental health is fragile and it is important to care about it [10] .
During nurse formation, professionals must be prepared to use different strategies, both personal and professional. If needed, to intervene in different health problems; so, having a previous panoramic of the phenomenon will suggest the way to do it. It is the objective of this work to identify the stressors in nurse students’ formation in the new normality after COVID-19. Since favor, the recognition and validation of stressors in students along their formation in nursing, and their identification and categorization will allow them to timely intervene and change paradigms.
2. Method
Qualitative research permitted comprehension of phenomena around participants’ experiences, through a careful collection and analyses of the narrative material; since this approach is characterized by focusing the personal experience, and considers that human beings are interconnected emphasizing their life experiences, that appear in their relationships with persons, events, objects, and situations. In addition to descriptive, phenomenological and interpretative design, focused to identify stressors in nurse students of a public university in the new normality after COVID-19, in the different settings of their training including classrooms, laboratories, and hospitals without computer support for theoretical elements. Phenomenology pretends to the comprehension of social phenomena through a perspective, recognition of the perceived reality as important to individuals; as well as subjective perceptions and interpretations, emotions that emerge from experience, objectives, actions, behaviors in the context they develop, phenomena description that, depicted in conscience, reveal the nature and structure of the experience as lived by the individual, without a generalization [11] .
2.1. Inclusion Criteria
Twenty-seven participants, students of fourth, fifth and sixth semesters of nursing from a public university of the State of Mexico, 20 - 25 years old from both genders, were selected by convenience.
2.2. Information Collection
Information was collected from four focal groups with 6 - 7 members each, the focal group privileges to talk and promotes interaction about a topic, in addition to comprehending the way of thinking, feeling, and living of individuals [12] . The guidance questions used were validated by expert judges, and their suggestions were included in the preliminary test. The questions were: Which are the stress triggers you have as a nurse student in the new normality after the pandemic, in your return to classrooms, laboratories, and hospitals? How do you experience this new normality? How are your interpersonal relationships with peers, teachers and staff in hospitals? Which emotions and thoughts do you identify in these new experiences? Eight sessions of 2 hours each were conducted, in university classrooms from February to April 2023. Verbal testimonials about their vivid experiences after the pandemic and in the new normality were shared, which were audio-recorded; testimonials were complemented with the observed participation and field notes. The observed participation was the most important, and it is the basic source of human knowledge, of the perception of the systematic daily world in social sciences. The confidentiality of participants was kept by using pseudonyms, and their acceptance was after the informed consent to be involved in the research.
2.3. Data Analysis
Data analysis was according to Miles & Huberman, along three moments: information acquisition, data transcription, and coding that allowed for conclusion. The obtained information was transcribed and tagged in order to keep the anonymity of the interviewees. Qualitative data analysis allowed questions about their vivid situations and their expectancies [13] .
2.4. Ethics and Legal Aspects
For the current research ethical issues were considered to support the validity of the work, according to diverse sources: Ethical principles of the declaration of Helsinki [14] , point number 6 says “Always must respect the rights of persons to safeguard their integrity. All precautions were needed to intimacy respect of persons and to minimize the impact of the research on their physical, mental and personality integrity must be observed”. To reach those goals, the secrets exposed by the informants must not be revealed, and the recordings must be confidentially used only for this research, and along it limits persons imposed on information must not be exceeded, giving them complete freedom to withdraw. The Belmont reported [15] clause B, essential ethical principles, considering respect for persons, benefit and justice; as well as clause C, writing the informed consent, a document that contained the required elements such as information, comprehension, and willingness; in addition, to evaluate risks and benefits explaining that no risk exists for this investigation.
3. Results
Informants’ characteristics are shown in Table 1, anonymity was kept for each one so that primary and secondary emotions names were assigned to them, since stress triggers emotions. Females (59.2%) and males (40.7%) aged 20 - 25 years participated in the study and, after the qualitative analysis, four categories emerged with nine sub-categories supported by their speeches and the frame of reference shown in Table 2.
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Table 1. Informants’ characteristics.
Source: Students from 4th, 5th, and 6th semesters of the Nurse career. State of Mexico, 2023.
4. Discussion
There is a current increment in mental health problems and its prognosis foresee an augment in the future; mental health problems will be the first cause of disability worldwide by 2030, with almost 800,000 persons committing suicide each year, and being the second cause of death in persons 15 - 29 years of age [16] . The importance of public education around mental health care is a social need in the world; it is crucial to increase risk awareness in vulnerable populations, encourage a search for help, and plead for new interventions and prevention strategies in persons at risk. It is necessary to know the global as well as local panoramic on youngsters and their different fields, to identify risk and protection factors for mental health in order to acquire practical strategies, to create safe and inclusive locations that improve youth’s mental health. It is urgent to incorporate judging elements in social debates for better comprehension of the processes around mental health. In this research, the identification of stressors in nurse students’ formation, living in the new normality after COVID-19 is an opportunity to intervene for their mental health protection, and also to create safe settings. The return to school in a face-to-face condition implied great challenges for nurse students, it is a difficult reality per se and its standardization requires complex monitoring and solutions.
Each participant in the teaching-learning process is immersed in a different recovery phase, they came from more than two years of confinement and have serious needs, potentiated by the situation; as observed in Category 1, Cumulative stressors with sub-categories 1.1 Uncertainty, 1.2 Isolation, 1.3 Invisibility, 1.4 Mockery, 1.5 Exclusion. The sub-categories list allowed us to enforce, in the collective consciousness, the idea that mental health is a topic that affects us all, and requires placing a person as a social being that needs a social role to reach his psychical well-being. After that, the nurse students experienced drastic changes, such as the abandonment of university spaces, laboratories, hospitals and others, the learning strategies moved to online platforms and synchronic and asynchronous sessions, isolated them from their peers, and placed them facing a computer screen.
[ ] I had to get a job since my family’s economy was affected by the pandemic, and the time to go back to classes changed my plans, due to time-consuming in transportation to school and to the job, then I get stressed to adjust and trying to coordinate activities and reach the daily goals. I did not know if I had to quit my job or school. (Distressed)
[ ] I guess that the main trigger was the interaction with peers, working on line I had to do every task not dependent on others, which was easier for me than working in a team or being part of a team since I do not like to participate or give public speeches; then my main trigger was going back to in-person, being part of a team and its activities. (Shame)
[ ] Once we came back the change was total, for me adapting to being in-person was very difficult and I remember crying very often during the first weeks of classes, because I thought not going to do it, and had fear of being ridiculized by not knowing topics, it was a burden; then I got sick and along time I was adapting and now I feel better, but it was a great problem to adapt. (Ridiculous)
Going back to in-person conditions made them face shocking scenarios which affected their mental health, triggering disqualification thoughts like they will not conclude their career, as observed in Category 2, Eagerness states with sub-categories 2.1 Low self-esteem, 2.2 Insecurity, 2.3 Anxiety, 2.4 Depression, 2.5 Temporary leave, 2.6 Search for authenticity.
Reported data show that 6.7% of the world population is affected by anxiety, the same value as those depressed and in which females show twice as men, i.e., 9.2% vs. 4%, respectively. Two million youngsters aged 15 to 29 years suffered signs of mental disorder in recent years [16] [17] . From these studies, their numbers, and a retrospective view allow us to see several impacts of COVID-19 on young population, showing the need to pay attention to mental health and emotions, a neglected topic as observed in the following speeches:
[ ] To leave home gave me an anxiety attack, I could not breathe when entering the subway, I was shaking and arrived in bad condition to school. I was afraid of leaving home and sometimes thought of dropping school, and have a temporary leave since I did not know to talk to people, or ask for directions, it was very tough to interact with people. (Fear)
[ ] To had online courses made a pause in my brain and all my activities, and when I went in person to the hospital the staff and chiefs of departments bombarded me with questions, I entered in panic for unanswered them; later, calmly I recalled that knowledge, but not when they asked me, sometimes I cried in the bathroom being desperate by not answering, I felt powerless of finishing my career. (Humiliated)
[ ] The most stressful condition for me was being inside a classroom with other 30 persons and thought that someone could bear COVID-19 and be infected, and later we infect our families, I was very tense. (Intimidated)
Stress leads to feeling a close threat and to maximize the sensation, radical changes increase this sensation and it becomes a real menace to the one who experiences it, triggering maximized emotions that somatize that stress conducting to depression [18] . It is important to consider a student’s perception of his surroundings and activities to do, in order to have student’s focused companionship such that an important aspect in the formation process of a person, is to recognize his progress without comparison with others, since it needs encouragement to advance and reach his goals; then, it is necessary to develop emotional intelligence that gives the chance to identify emotions of the person and those whose it interacts with, allowing communication and decisions making that lead to its independent life project [19] [20] .
Somehow, the changes due to in-person return provoked hopelessness in students, promoting thoughts about themselves that make it very complex to acquire and develop learning, since they gave it for granted not accomplishing the tasks, activities or engagement, as observed in Category 3 Internalization processes with sub-categories 3.1 Social rejection, 3.2 Self-censorship, 3.3 Self-disqualification, 3.4 Disempowerment. The risks being tied with thoughts and feelings of scorn might lead the student to risky situations, like rejecting the task, being convinced that they would not reach success, not being responsible for the process and blaming another one, denying that their role is important, as well as the accumulation of bad experiences leading to failure and loss of values; these behaviors are known as “movements of social distancing” [21] .
[ ] It was very difficult to me leave my home milieu after the pandemic because I got used not to interacting with anyone else besides my family, and most of the time I was alone, then going back to clinical settings the interaction with patients was very complex because I got nervous; I realized that patients would reject me looking that I was insecure. I do not know what to call anxiety but I was out of breath due to being nervous, and I guess not to do things properly due to my nervousness; in addition, during online courses I asked for a temporary leave for one year, because I thought that I was not learning on line such that, now that I attend in-person, in practice and in classroom teachers asked me and I did not remember how to answer, even they tell me that the topics were studied last semester but they are unknown to me. Nurses at the hospital said the same, since they believe that is knowledge already studied do not explain it, they command you to do it and if you do not do it, they do not explain, they scold you, and ignore you; you are not taking in account, and I do not tell my teachers since I consider it was my fault to receive their attitude, this makes me feel very bad. (Demoralized)
[ ] At the hospital nurses’ contact, their expressions, and the way they talked were very sarcastic, they pressured me a lot to work at their rhythm and if I did not catch it they make me feel very bad, i.e., like ignorant and I even thought that nurse career was not for me. (Hurt)
When stress intenses a person could be distracted, repeating his thoughts and feelings of fear and disqualification, it is necessary to focus on the student’s companionship in the teaching-learning process, improving his learning to be connected and centered on himself and in the activity, knowledge, and procedures, to reach success [21] .
Confinement during the COVID-19 pandemic, the need to shift the learning’ settings to online classes promoted several factors added against the training process in nurse students, since nursing implies irreplaceable actions, as observed in Category 4 Affected academic aspects with sub-categories 4.1 Deficient study habits, 4.2 Deficient knowledge consolidation, 4.3 Knowledge archived in the computer, 4.4 Lack of practice from previous semesters:
[ ] My main obstacle was a lack of knowledge because I was confident about any question they asked me, a rapid search in the computer files and I answered, that was my participation in classes. For me, it was difficult to learn due to the boring of online classes, and during the first year I did learn almost nothing: lots of information that I got distracted, then the first in-person contact was brutal for me, I was frightened to harm the patient, that almost everything I do was wrong for my lack of knowledge and always asked for help to the nurses on duty if my procedure was correct, and if they could supervise me since I was afraid to harm the patient. (Frighten)
[ ] The staff attitude in the clinical settings was the most difficult because they wanted that I knew the procedures and did not realize that it was my first contact in the clinic, and that I did not have laboratory practice due to the pandemic; they wanted that I had the previous semesters’ experiences, to work fast at their rhythm which made me feel very bad, they were rude if I did not work as they wanted so that difficulty things to me in the clinic, they made me cry and got doubts about myself, they were very rude. (Vulnerable)
To evolve in hostile surrounding is a challenge for a student, the first step is to identify what is experienced from emotions, thoughts, and once this give a clear scope the next is to identify what is true and what comes from hopelessness, so that knowing the elements the individual has to touch the ground allows how to get a better situation, avoiding negative emotions, and to get rid of stress. Taken together, all the abilities and procedures related to nursing require practice and repetition, these tasks cannot be ignored so they require patience, reflection, constructive critical sense and will [21] .
Practice makes a master, recognize all the ways a hostile surrounding could be modified regarding nursing students’ formation, will contribute to their physical and mental health. This will lead to authentic care for others and for the community.
5. Conclusion
To have identified the stressors in nurse students’ formation in the new normality post-COVID-19 allow to create scenarios that help students be confident; a safe surrounding promotes abilities and competencies that permit teachers recommend, in the classroom and laboratories, to fill spaces seen as empty by the student and to intensify companionship in clinical settings, which are the scenarios where students perceive as aggressive. It’s conscious that more than two years of the pandemic will not be recovered; however, being empathic and willing to solidarity, learning will be rescued for students, patients, and the community.
Authors Contributions
All authors collaborated in the research. NSVR and DCTP, designed the protocol and wrote the manuscript. NSVR, DCTP, GGJ and ALRM, collected and analyzed data. NSVR and DCTP revised and edited the manuscript for publication. DCTP main tutor. All authors read and approved the final manuscript.