At the time of writing, more than 151 342 people within the UK have died from the coronavirus within 28 days of a positive test for SARS-CoV-2 infection, with 174 233 deaths recorded with COVID-19 on a death certificate. At the peak of the pandemic in January 2021, 39 250 patients were admitted to hospital (https://coronavirus.data.gov.uk/). Healthcare workers have had more than a seven-fold higher risk of severe COVID-19 in comparison with the general population, whereas those working in social care and transport occupations have had a two-fold higher risk, with non-white essential workers being at the highest risk of severe infection (Mutambudzi et al, 2021).
This article tentatively suggests that a relationship exists between being a nursing or midwifery student deployed during a public health emergency, the experience of delivering healthcare during a pandemic, and the level of moral distress experienced by students who deployed into clinical practice. A key characteristic of the moral distress experienced by participants in this study related to the sense of obligation they felt when making their deployment decision.
Research question
The research team were interested in the psychological impact of deployment on final-year nursing and midwifery students working in the NHS during an international public health crisis. They considered that the pandemic was a unique opportunity to understand the stresses placed on final-year students temporarily employed by the NHS—further details of this particular set of circumstances were set out in part 1 (Kane et al, 2021).
Moral distress
The concept of moral distress during a pandemic was of interest to the research team when students were placed in situations where difficult ethical decisions had to be made, such as whether to volunteer for deployment within a clinical area. Moral distress is the experience of psychological stress caused by a moral event (Morley et al, 2020). It arises from moral uncertainty (feeling torn or conflicted), moral conflict (feeling frustrated or upset), moral constraint (not being able to do the right thing and feeling complicit), moral dilemma (a feeling of injustice and guilt) and moral tension (an inability to express belief or powerlessness). Moral distress is different from moral blindness, which occurs when certain acts or categories of people are outside of normal moral obligations leading to moral numbness, or an attitude of indifference to what is happening in the world (Bauman and Donskis, 2013).
Methods
Sample
A total of 53 third-year student adult, paediatric and mental health nurses and midwives were surveyed out of a cohort of 246. The team sent an electronic survey to 246 healthcare students with a response rate of 22%.
Data collection and analysis
An announcement regarding the research study was placed on the university's virtual learning environment. Students who had chosen to be deployed into clinical areas were included in the study and recruited via email. An information sheet and consent form were sent to all participants with a link to the online questionnaire. Written consent was obtained as part of the online completion of the questionnaire. Data were collected over a period of 8 weeks during the pandemic, while the participants were in clinical practice.
The research team used the Maslach Burnout Inventory (MBI-HSS) (Maslach et al, 2001). The MBI-HSS is a 22-item questionnaire, with each item scored using a seven-point Likert scale from 0 (never) to 6 (every day) (Maslach et al, 2008). The 22 items on the MBI-HSS are divided into three domains: emotional exhaustion, depersonalisation, and lack of personal accomplishment. Findings analysed from quantitative data have been presented in part 1 (Kane et al, 2021).
To gather qualitative information on the experiences of deployed students, the research team adapted the questionnaire by adding free text questions (Box 1). Questions 1 and 2 were designed to explore the role of emotion in the decision-making processes of students with greater specificity than if the MBI-HSS questionnaire had been administered alone. Questions 3 and 4 were created in order to obtain feedback that could be shared with the practice partner on the quality and effectiveness of the induction and support provided by the NHS Trust. Questions 5 and 6 were designed to elicit perceptions from participants that could inform the university and practice partner to prepare for a further student deployment.
Box 1.Free text questions
- To what extent did you feel under obligation to work on the front line in the NHS during the pandemic?
- To what extent did you experience anxiety prior to starting work in your NHS Trust?
- How useful did you find the NHS Trust induction day?
- To what extent did you feel that the NHS Trust supported you in your role as a band 4?
- To what extent was the fact that you could not be guaranteed a practice placement until after September 2020, a factor in taking the band 4 role?
- Please feel free to share any other comments or experiences of being deployed during the coronavirus pandemic
Qualitative data were analysed using the constant comparative analysis method in order to generate abstract concepts and theories using a process of data comparison (Box 2). Data were combined to identify themes through an iterative process, which generated successively more abstract concepts and theories by comparing data with data, data with categories, categories with categories and categories with concepts (Gray, 2014: 680).
Box 2.Stages of data analysisStage 1Each member of the research team was required to read the transcribed free-text comments through a process of focused reading to identify key words or phrases. Nodes were used to ‘hold’ tentative categories and readers captured their initial thoughts and perceptions using memos such as dimensions, comparisons or contrastsStage 2The research team met together to generate, through an iterative process, a process of analytical coding and induction that revealed the properties of each code and therefore a theoretical explanation of the free text data. During the meeting ‘coding consistency testing’ was undertaken to uncover any inconsistencies between researchers. The ‘waving the red flag’ technique was also used to recognise when a researcher's own biases, assumptions or beliefs were intruding into the analysis
Ethical considerations
Ethical approval was granted by the university's Institute of Healthcare Research. All data were collected through a Microsoft Forms questionnaire. Names of participants or their email addresses were not recorded.
Findings
Five over-arching themes were generated from the free-text questions contained within the questionnaire. These were obligation, anxiety, support, uncertainty and resilience. Pseudonyms were used to ensure that the voices of participants could be differentiated as well as indicating the gender mix of the sample.
Obligation
Participants expressed a strong feeling of being obligated to work on the front line in the NHS during the pandemic. For Sue, Michaela, Alex and Chris the notion of obligation related to a need to complete their course of study on time as well as a sense of duty to patients and their communities:
‘I felt like we didn't really have a choice if we wanted to finish the course on time.’
Sue
‘I felt it was my duty to return to practice as if I was already qualified … if I did not opt in to practice when would I be able to finish my degree … I did not feel opting out was really an option.’
Chris
‘I felt a huge obligation. I have spent three years caring for women and didn't feel it was right to turn my back on them at this point.’
Michaela
‘I felt a social obligation as I am nearly qualified and so in a place to help my community. I also felt like I had no choice … either I work or I won't qualify in the near future and my plans will be disrupted.’
Alex
Bobbie, Maxine and Tyler felt obligated by virtue of their status as nursing student apprentices, employed by their NHS Trust while being seconded to the university to complete their degree programme:
‘I was studying via the apprenticeship route … we were not given much of a choice to go on placement as we had to go back to the NHS trust we work for and complete [an] extended placement.’
Bobbie
‘As an apprentice student, I was obliged to work during the pandemic … I feel that we were not given other options to opt out like other students.’
Maxine
‘I am still being currently paid at band 2 for the same workload … but was told I was not a student but an employee.’
Tyler
For Reena, there was strong sense that her decision to opt-in was framed by what would have been expected of her as a registered nurse, whereas Terri felt that peer group pressure strengthened the obligation to be deployed on placement:
‘I felt that it would be wrong of me as a student nurse who will be qualified in a few months to opt out … As a qualified nurse, I wouldn't have the choice … I felt obligated to opt in.’
Reena
‘… From peers in my cohort, there was a “I've already opted in why haven't you” mentality I experienced from multiple people.’
Terri
Whereas Sue and Chris cited pragmatic reasons for volunteering for deployment, Michaela and Alex felt a strong social obligation to support their patients and communities. Perhaps of greater concern was the extent to which Bobbie, Maxine and Tyler were reminded of their status as employees, whereas Reena and Terri's decision seemed to be shaped by a societal obligation. Bauman (1989) described societal obligation using the example of a civil servant whose honour is vested in their conscientious ability to respond to an order from a higher authority as if the order agreed with their own conviction, even if the order seems to be wrong, leading to behavioural response characterised by moral discipline and self-denial. Although Bauman was writing about the nature of organisational discipline that was the precursor to the Holocaust during the Second World War, the comments of the participants in this study are a stark reminder of the impact of societal pressure.
Anxiety
Study participants reported feelings of anxiety ahead of starting their placement and significant anxiety once deployed, particularly within clinical areas where patients had been isolated with either suspected or confirmed COVID-19. Dink, Andi, Anjanna and Reena's levels of anxiety related to the threat posed to their families of deployment within clinical areas:
‘[I] was very worried about what I was heading into and the health and wellbeing of my family that I was going home to.’
Dink
‘I was anxious because of hearing the numbers of people dying with Covid 19…’
Andi
‘I was so stressed. I was fearing for my family that they [might] contract Covid.’
Anjanna
‘I was highly anxious about starting work … seeing some of NHS workers losing their lives, it was scary.’
Reena
For Terri, Mel and Del, anxiety arose from confusion regarding their status as either students or support workers, the COVID-19 status of patients and the quality and consistency of guidance on the use of personal protective equipment (PPE) and infection control procedures:
‘It was confusing for everyone whether we were students or band 4 support workers.’
Terri
‘… patients in the hospital that were later diagnosed as being Covid positive must have been cared for as “normal” patient before the diagnosis. So the chance of caring for a Covid patient is high, even if the ward is not a Covid ward.’
Mel
‘… there was a big difference in how PPE/infection control protocol was delivered, as well as things being brought in when risk was lower, but when risk was higher there was little intervention or poor/unclear guidance, which was often conflicting from the guidance given previously.’
Del
‘I experienced the worst anxiety I have felt on this course … sometimes causing me to not function properly.’
Nicky
The theme of anxiety reflects findings from another study where nursing staff experienced moral distress arising from an inability to provide a good standard of care due to insufficient resources (Wolf et al, 2016).
Support
Although levels of anxiety among participants were reported as high, as clearly indicated by Nicky, most students felt that staff from the Trust were supportive. Jane, Chris and Reena felt that managerial staff were particularly supportive of students who had been deployed:
‘I felt well supported by the management team … less so from some midwives who did not agree with the continuation of placement.’
Jane
‘Great support given from the staff and management on the ward, although regular confusion as to what we were able to do as unqualified students at band 4.’
Chris
‘I was deployed to another team to minimise the risk. Both managers and my supervisor met with me weekly at the beginning and discussed my progress as well checking on my wellbeing … guiding me and [supporting me] with my learning.’
Reena
Chris and Reena's responses suggested that targeted primary interventions were used by management to reduce stress for students. These were effective in order to reduce frustration-induced behaviours (Mullins, 2013) through the restructuring of the workplace and effective communication to meet the needs and expectations of the students.
Uncertainty
In contrast, confusion relating to the supernumerary status of students and parity between the role of the band 4 support worker and final-year midwifery student characterised Neena and Sue's experiences:
‘We were told we were supernumerary and we weren't. I was often put down on the numbers.’
Neena
‘Some midwives made me feel uncomfortable … Our role as band 4 was scrutinised as being unsafe. Once the midwives realised that our roles were the same as that of third-year student midwives the tension decreased.’
Sue
Nursing and midwifery students were informed that if they chose not to be deployed, their next clinical placement could not be guaranteed after September 2020. Jane and Alex regarded this as a significant influencing factor in taking a band 4 role:
‘… opting out could lead to an unknown amount of time until I could qualify, leading me to worry about finances, job security and more.’
Jane
‘… either I work on the front line and face Covid or I don't qualify … my whole future could be disrupted.’
Alex
In contrast to Alex, Monica felt that opting in for deployment was an opportunity:
‘I felt this time would give me a unique experience.’
Monica
The theme of uncertainty resonates with recent work into compassionate care, which highlights a need for nursing and midwifery staff to have autonomy, a sense of belonging and to be able to make an effective contribution that leads to valued outcomes, in order for workplace stress to be minimised (West et al, 2020).
Resilience
Overall, participants felt that their experience of being deployed on placement during the pandemic was positive and strengthened their level of resilience. Dink, Mo and Maxine did not regret their decision to opt-in and saw the experience as an opportunity for personal development:
‘The best decision I made was to opt in as a Band 4 student nurse.’
Dink
‘The experience was horrendous at times due to the amount of people not surviving daily. However, the experience has been incredibly valuable and I feel it will make me a better nurse in the future … I don't regret my choice.’
Mo
‘I was involved in making some challenging decisions which probably I would have never been involved in had I not opted in. Though, physically exhausting and emotionally draining, I have developed strong emotional resilience.’
Maxine
In contrast, Dave and Maddie outlined the implications of being deployed in the context of their family, work-life balance and cost to their health and wellbeing:
‘For me it was juggling it all, university work, placement work, and child care. Usually I would have time to myself … because the children were at home I did not have time for myself to breathe, or do uni [sic] work … I had to do it during the night then get up and go to work.’
Dave
‘Balancing life, university studies and placement is emotionally and physically challenging.’
Maddie
Dave and Maddie's experiences reflect findings that suggest that the rates of self-reported work-related ill health in the human health/social work sector are statistically significantly higher than the average rate across all industries (Health and Safety Executive, 2022) and point to the relationship between work-life balance, wellbeing and mental health, which has been characterised as challenging for many UK nurses (Marangozov et al, 2017).
Discussion
Naturally, participants shared their experience of anticipatory anxiety where students were not sure what to expect, although this reduced as they got into practice and seemed to be alleviated by effective managerial support. A key cause of anxiety related to not being able to qualify on time, in addition to the experience of coping with a clinical and academic workload and the perceived danger posed by COVID-19 on home and family life.
A strong motivational factor was a sense of duty in meeting the needs of patients, the community and professional obligations. A significant finding within this study was the extent to which obligation was unassailable, as illustrated by the experience of the nursing apprenticeship students whose obligation was framed by their status as employees.
This study suggests that the phenomenon of moral distress arose from the conflict between a personal sense of professional duty clashing with the reality of completing a programme of study while juggling the needs of family in the face of a perceived deadly virus. The study tentatively suggests that moral distress was compounded by areas of frustration arising from a lack of clear guidance on PPE, perceptions of constant change and inadequate policies.
Limitations
An obvious limitation of this study is that a relatively small number of participants were recruited and that the sample was poorly differentiated. The research team did not feel that it was appropriate to send more than two emails to remind students to participate in the study, given the particularly challenging impact of the pandemic and the fact that students were continuing to study while being deployed. In addition, the suspension of almost all campus-based teaching meant that there were no opportunities to discuss the study with groups of students. The team has since extended the project to include students from other healthcare programmes, including paramedic science students who have also been deployed during the pandemic, in order to compare and contrast student experience between different professional groups.
Conclusions
Nursing and midwifery students who were deployed during the COVID-19 pandemic experienced a degree of moral uncertainty at the point of deciding whether they should volunteer for a placement. This was characterised by feeling torn and conflicted by the risk to themselves and their families. Students experienced a measure of moral constraint in the face of perceived societal pressure to serve their patients and communities, which strongly influenced their decisions to take up deployment within clinical areas. Some students experienced a moral dilemma that was characterised by a feeling of injustice at not being given a choice around deployment because of their status as employees. In turn, this generated moral tension because of the perceived powerlessness associated with being an apprentice in contrast to other traditional nursing and midwifery students who had been given a choice. Some students experienced moral conflict when guidance on PPE was not consistent, or when their roles as band 4 healthcare workers were not fully understood or appreciated.
KEY POINTS
- Students may experience moral distress when deciding to deploy to clinical areas during a pandemic and during their deployment as a result of being in situations leading to ethical challenges
- A key factor for students when deciding to deploy during the COVID-19 pandemic was the risk to their families, themselves and the impact on their studies, including being able to complete their degree course on time
- The experience of apprentices has been different from other students as their status as employees rendered deployment non-negotiable
- Practice partners and approved educational institutions must work in partnership to support students in their decision-making while recognising the different types of moral distress that may be experienced by learners, such as societal obligation and peer expectations, in the face of an international public health emergency
CPD reflective questions
- What dilemmas might nursing and midwifery students face in clinical practice during a public health emergency?
- What is the role of the practice supervisor in supporting students to build resilience?
- What are the ‘red flags’ that suggest that a student might be experiencing moral distress in practice?