The Nursing Students’ Perspectives and Experiences on Modified Clinical Experience during the Corona Virus Disease (Covid-19) Pandemic in Kenya (Review Paper).

The Nursing Students’ Perspectives and Experiences on Modified Clinical Experience during the Corona Virus Disease (Covid-19) Pandemic in Kenya (Review Paper).

Dr Mukthar, Vincent K. (PhD)

Senior Lecturer_, Nursing Department, Egerton University, P.O. Box 536-20115, Egerton

DOI: https://dx.doi.org/10.47772/IJRISS.2025.90300302

Received: 03 March 2025; Accepted: 12 March 2025; Published: 16 April 2025

ABSTRACT

Background:  The Coronavirus Disease 2019 (COVID-19) pandemic indiscriminately affected every part of the world. As a pandemic, it posed a serious threat to global health and society, and brought an impact to both the education system and healthcare services. The Public health measures that were instituted to control the spread of the Coronavirus in Kenya consisted of implementing lockdowns/quarantine and social distancing. Nurse educators were compelled to be creative, flexible, quick, and agile in the integration of theory with practice for skills teaching and learning during the Covid-19 pandemic. One such radical change in approach to the overwhelming challenge of sustaining nursing education was changing the method of teaching/learning delivery. Other settings had no choice but to adjust (compress, lengthen, or shorten) the time frame of clinical placements. Owing to the methods enacted to manage the pandemic, the clinical setting also became confined for the students, faculty, and general public.

Objective: This review paper sought from literature study the perceptions and experiences of nursing students regarding these adapted clinical experiences.

Findings: The participants expressed that they have mixed perceptions and experiences of the adapted clinical experiences. Students reported feeling diverse emotions, including but not limited to, confusion, anxiety, frustration, positivity, and excitement. They, the nursing students, acquired new competencies during the pandemic such as core subject competencies, coordination of service/human resource, standard precautions, soft skills in nursing, crisis preparedness and management. The students expeditiously adapted to the new normal environment because of strong coping mechanisms and support systems. The nurses also noted and were grateful for the limited support from hospital leadership and faculty staff. Their concern was that heavy PPEs and restrictive regime made patient communication difficult. The never-ending evolving processes and procedures were quite bewildering.

Conclusion: The change during the Covid-19 pandemic in clinical experience in context of how it was delivered, length, and setting was out of the box, yet fantastic. The study concludes that there is a modification of clinical experiences amid heightened excitement and satisfaction along with strong adaptation or coping. Having said that, this study highlights the shortcomings of modified clinicals including uncertainty, anxiety, fear of the unknown, a mix of sadness and anger, undue fatigue, unclear communicating to the patient through the process of care and very little supporting systems.

Recommendations: It is recommended that this study incorporates blended clinical techniques alongside other emerging strategies into the teaching modules for undergraduate nursing students. In addition, there should be strong support from hospital leadership/mentors and preceptors for better students’ experiences/outcomes towards patient outcome improvement, resource management, and staff safety.

Keywords: Covid-19, Nursing Students, Nursing Interns, Clinical experience and perspectives

BACKGROUND

Coronavirus Disease 2019 (COVID-19) came into existence in December 2019 and had negative effects on the world. The Coronavirus Disease 2019 (COVID-19) pandemic in particular dealt an unparalleled blow to the world and Kenya in particular. It caused global crises in health and society which affected the education and healthcare systems. This pandemic suffocated economies of multiple nations, disturbed the social order, limited travel, closed public facilities and institutions and implemented strange social distancing rules (Domaradzki 2022; Suprapto, Linggi, and Arda 2022; Casafont et al. 2021).

Public Health measures considered most effective in controlling the spread of the virus include lockdowns/quarantine (movement restrictions) and the application of social distancing which was counter to the contemporary modern academic thinking. The Covid-19 pandemic has impacted the education system profoundly in terms of teaching methods and schedules. The most significant impact on the academic calendar was the suspension of learning activities within educational institutions (Suprapto, Linggi, and Arda 2022).

Nursing universities and colleges, as well as other allied health faculties either closed in full or else operated at a minimal (bare) level which created a huge demand for Personal Protective Equipment and more personnel to deal with the upsurge in hospital admissions because of the Covid-19 pandemic (Domaradzki 2022).

The onset of Covid‐19 has made it necessary for health professional educators to be innovative, flexible, and adaptable which has also come with some challenges. One such unprecedented response to the existential predicament facing nursing faculty was “shifting” classes and instruction to online/virtual learning or blended learning, designing and providing alternative clinical simulation experiences, and redefining assessment and grading processes (Morin 2020).

In the other jurisdictions for example in the United States, the United Kingdom, Italy and China embraced different innovative practices to alleviate worsening nurse workforce shortages. One such intervention is the use of senior and intern students to fulfill the ever-growing demand. Some of these countries fast-tracked the completion of academic programs and graduation so these students could immediately join the other frontline clinicians to fight COVID-19 (DeWitt 2020; Casafont et al. 2020). With the benefit of hindsight, this noble endeavor was indeed a privilege disguised as difficulties for the nursing faculty and the nursing students.

University teaching shifted to online models during the COVID-19 pandemic, which included an undergraduate nursing clinical course that implemented student pre-assignments, case study analyses, virtual simulation sessions, and video conferencing taught by faculty. Such approaches to clinical education were unprecedented and could have posed challenges to nursing students. In the clinical setting, nursing students face different levels of stress due to the following stressors: professional knowledge and skills inadequacies, theory-practice gaps, impaired communication with patients, fear of making errors, feelings of inadequacy, and observation of patients who are suffering and dying (Suprapto, Linggi, and Arda 2022; Esposito and Sullivan 2020).

Another configuration had to be modified (lengthened, shortened, or compacted) the duration for the clinical experience. The modification of clinical experience duration in time was either to accommodate increased demand for workload or to expedite program completion to catch up after the lockdowns during the early part of the pandemic. The clinical setting was also changed to a point where it was restrictive for both students and the general public due to new pandemic containment measures such as the excessive donning of full Personal Protective Equipment.

For the purpose of writing this review paper, I tried to find literature that would describe the nursing students’ perceptions and experiences regarding this modification of the clinical placement (Casafont et al, 2021; Esposito and Sullivan 2020; Domaradzki 2022; Suprapto, Linggi, and Arda 2022).

In fact, the clinical learning environment has been shown to both support and constrain student learning (Manninen et al., 2022). The persistent Covid-19 pandemic had, and continues to have, dramatic effects on the world’s undergraduate nursing education systems. It has put medical schools into a situation where they have to sustain intense didactic and clinical teaching and learning while trying to mitigate risk for students, faculty, staff, and patients (Haskett et al. 2022). With this in mind, the purpose of this literature review was to determine what has been said about nursing students’ perceptions and experiences regarding modified clinical placements during the Covid-19 pandemic.

FINDINGS: STUDENTS’ PERCEPTIONS AND EXPERIENCES

Mixed feelings

Excitement

As noted by Casafont et al, 2021, in their study on “Experiences of Nursing Students as Healthcare Aid during the COVID-19 Pandemic in Spain”, Students had some ambivalent positive and negative experiences. Feeling helpful and proud of being there was excitement, because of the new experience.

The pandemic’s impact was particularly harsh on students’ professional identity with 84% of them reporting a loss due to their changed educational experience. Merely 12% of students expressed any satisfaction regarding their personal academic achievement. A diminished sense of peer connectedness was recorded by approximately 84% of students, along with 26% reporting an uptick in substance and alcohol use. Student loans posed a problem for 48% of the students surveyed. Discontented with the education system, thirty-four students provided additional comments in open text format bringing forth three major themes. The first theme captures the overwhelming burden from the truncation of clinical rotation hours and balancing academic workload with preparing for compounded-syllabus mock exams. The second theme showed apprehension toward perceived reduction or alteration in instructional delivery without relaying the reduction in tuition fee. The third theme illustrated students’ appreciation regarding the contingency plans (Haskett et al. 2022)

Both virtual and blended approaches to learning were met with moderate to high satisfaction levels from nursing students. Additionally, students deemed the blended learning approach more beneficial than the other learning methodologies (Ruiz-Grao et al. 2022).

Satisfaction

The pandemic’s adverse effects on students were marked with over 84% of students reporting dissatisfaction and a lack of professional identity due to altered education structure. Only 12% of the students reported satisfaction regarding their academic outcomes, which is a cause of concern.

Almost all the students 84% reported there was decreased connectedness among peers while 26% noted increase in alcohol and other substance use.48 % of students marked student loans as a concern. Free text comments were given by thirty four students from which three notable patterns emerged. The first one encapsulated the overwhelming burden from the truncation of clinical rotations and the need to balance academics alongside preparation for modified high stakes tests. The second theme highlights a potential concern regarding the perceived decrease or change of education provided relative to the cost without a corresponding decrease in tuition value. The third theme encapsulates students’ satisfaction with the contingency plans (Haskett et al 2022).

Moderate to high satisfaction was reported by nursing students for both virtual and blended learning approaches. They highlighted the blended learning approach as the most appreciated one (Ruiz-Grao et al. 2022).

Fear and anxiety

Haskett et al (2022) had reported that a majority of the students 54% were overstressed in all domains of life. Along with that, overwhelming stress due to the Covid-19 pandemic was supported by the nursing students’ agree or strongly agree responses. There was an increase in reported anxiety/nervous 75%, tiredness/exhaustion 68% and sleep disorders 45%.

In the earlier stages, nursing students felt great apprehension and uncertainty because they had no clue about what to expect from the team, how they would operate, and what guidelines were set. Most of the nursing students experienced the fear of the unknown. (Casafont et al. 2021; Dewart et al. 2020).

Sadness and anger

The profound sadness and anger stemmed from the lack of family presence visiting the patients in their rooms. The patients that were unable to communicate made the situation worse. As these students tried to balance between being a caretaker and a family member to their patients, they became confused. The helplessness accompanied with lack of ability to make things better was overwhelming and left these students frustrated. (Casafont et al. 2021; Cant, Cooper, and Ryan 2022).

Fear and anxiety

Infection as well as the risk of infecting vulnerable family members escalated as the students was living with family, friends, or other relatives. The students had set in place their own sanitation guidelines of how they would wash themselves after entering their houses. Overall lack or inadequate availability of PPEs has shown to cause concern among different parts of the globe and is associated with an increase in anxiety levels of students.

Furthermore, the distressing image of the staff in full PPE gear for the patients and/or significant others, in addition to lacking intimacy and lacking concordance to patients and/or the significant other, were also hugely unsettling. To minimize exposure, entering the room was kept to a minimum which brought about an overwhelming sense of coldness and lack of warmth and human contact (Casafont et al. 2021; Ganesananthan et al. 2021). Suprapto, Linggi, and Arda (2022) attest that Female students demonstrated significantly higher stress levels than male students

Ganesananthan et al., noted that multiple concerns were observed with a flexible online exam format, including lack of a reliable internet connection (82%), non-verbal communication (74%), and being understood when speaking (72%).

Exhaustion

Daily work routines induced physical and emotional fatigue that significantly impacted their mental well being. Such circumstances were described as harsh and restrictive, contributing towards stress (Dewart et al. 2020; Manninen et al. 2022).

Learning

The additional experience enhanced comprehension for nursing students as they gained a new vantage point from which to view and discuss shared common experiences (Esposito and Sullivan 2020).

Additionally, nursing students felt that they were already at the very basic level of employment caring for patients. This is because, as noted by Casafont et al. 2021, students had incredible self-clinical opportunities that aided them to appreciate their level of work. Students’ appreciation with a distinct set of tools, Personal Protective Equipment (PPE) and an overwhelming amount of workload made them value the principles of resource efficiency and quick adaptation to unique situations.

Despite, on the other side another research study (Haskett et al. 2022) noted that the majority of students reported that the pandemic had a negative impact on their clinical education. Most however presented with better coping strategies and were more resilient so were relatively more positive about clinical experiences. Roughly 66% of students claimed that didactic education was adversely impacted.

With regard to clinical performance, most students expressed concern about their performance on newly structured clinical examinations. On the other hand, around 30% expressed concern about general academic performance. The worry was related to not only the new clinical examination approach but also about the unfamiliarity of the content, process, and the environment. Haskett et al. (2022) reported that a considerable number of students, mostly women, were worried that the pandemic would lead to the postponement of graduation timelines (36%) suggesting that students with strong coping mechanisms were less affected by such concerns.

Adaptation and Coping Mechanisms

Students progressively learned new skills and made small adaptations to this peculiar situation. The applied safety measures of isolation and restriction were somehow internalized as normal habits or automatic behaviors over time. In a way, the situation was rationalized as standard routine work (Casafont et al, 2021).

Students seemed to use different strategies to help process the emotions stemming from the experience. They had a robust support system which consisted mostly of family and friends through whom they could express their emotions over videoconference. They also engaged in sports, yoga, and other activities like reading that decreased anxiety and ruminative thinking (Casafont et al, 2021). A very small number of nursing students considered stopping their studies due to the overwhelming stress and anxiety caused by the pandemic and poor coping strategies (Michel et al, 2021).

Team spirit

The students learned, acknowledged and practiced enhanced teamwork. The students dealt with the collaborative strucuture of the unit as single problematic concern. In spite of the hesitation, they eventually started forming strong bonds with the team. All students reported to have felt member of the family and or unit. Each team member helped one another organize their shift as per the workload (Esposito and Sullivan 2020; Casafont et al 2021).

Patient communication

Students identified barriers to communication with patients. Students could not see patients directly and patients were confined to their rooms which had no windows. The only means of interaction available was through the bell intercom. Students found this to be dehumanizing and quite distressing. Also, some personal protective equipment (PPE) stifled both speech and body language (Casafont et al. 2021).

Unclear Care processes

Restrictive or lack of resources has been identified as the main reason for all the students lacking understanding of the provided scope and sub-documents in guided framework based syllabus. Students reported that all documents created by the faculty were too vague regarding their identity within the group and their individual activities. Provisions in the hospital were quite dynamic due to lack of evidence or resources (Casafont et al. 2021; Haskett et al. 2022; Manninen et al. 2022).

Leadership and Support

In terms of perceived support from leadership, students positively replied by 52% but those with greater stress coping capacity at the coping stage of the pandemic felt less supported (Haskett et al. 2022). The gaps that students reported concerns about included a lack of psychosocial support, (irregular) contact with clinical placement supervisor, recognition of difficult work situation, and the need to unwind more (Ulenaers et al. 2021). In a comparative study done by Thomas (2022) Nursing students reported having greater levels of student-life stress but fewer depressive symptoms compared to students from other academic programs, which was attributed to their clinical learning environment and the coping mechanisms and support system available within it.

CONCLUSION

The modification in clinical experience during the Covid-19 pandemic in terms of delivery, length and setting was novel, brilliant, and praiseworthy. This study concludes that the modification of clinical experiences was accompanied with intensified learning and adaptation or coping and mixed feelings of glee and contentment.

This study highlights the shortcomings of modified clinicals such as uncertainty, anxiety, fear of the unknown, anger, sadness, fatigue, poor communication with the patient, inadequate care processes, support systems, and less than optimal care.

RECOMMENDATIONS

It is recommended that blended clinical approaches be added to the curricula of undergraduate nursing programs. As proposed by Cant, Cooper, and Ryan in 2022, there is a need to construct curricula that enable student nurses to actively seek and critically evaluate reputable clinical resources for rationale arms. Moreover, it is recommended that modified clinical approaches be incorporated but with strong additional support to enhance the students’ experience and the outcome, as well as patient outcomes, resource management, staff safety, and overall nurse experience improvement. This study highlighted the impact of the preceptor as a vital unit of support within the clinical placement in times of crisis/pandemic. The preceptors would train students on the relevant skills, oversee their work, and provide the necessary psychosocial support.

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