Introduction

The health emergency resulting from the coronavirus disease pandemic 2019 (COVID-19) led to the suspension of in-person teaching activities in all educational establishments in March 2020^(1,2). The pressure on the healthcare system made it necessary to reorganize clinical practice and training and mobilize all available material and human resources. In Spain, the staff shortage in healthcare centers led to the involvement of health science students in caring for patients admitted to hospitals and other resources, as they were deployed to work before completing their degrees and training⁽³⁾. This measure was also adopted in other countries, such as the United Kingdom⁽⁴⁾, Italy⁽⁵⁾, and the United States⁽¹⁾.

In Spain and under Order SND/232/2020 of 15th March for the adoption of measures in terms of human resources and means for the management of the health crisis situation caused by COVID-19⁽⁶⁾, Medicine and Nursing students in their final years were offered voluntary employment in the health systems of different autonomous communities, mainly contracted under the call for ‘health assistance,’ to carry out their healthcare activity in a support capacity and always under the supervision of a qualified health professional. Student nurses, in particular, were integrated into the staff of healthcare resources, such as hospitals, residences, and medicalized hotels^(7,8). Until then, they had completed all their theoretical training before finishing their Final Degree Project and part of their practical training⁽⁹⁾. Several studies have measured perceived stress⁽¹⁰⁾ and anxiety⁽¹¹⁾ levels during the first months of the COVID-19 pandemic. In nursing students, stress and anxiety increased during the pandemic due to academic uncertainty and the health situation experience⁽¹²⁾.

The present study aimed to compare anxiety and acute stress levels among nursing students who joined the labour market during the first wave of the COVID-19 pandemic with those who did not.

Methods

Results

The questionnaire was sent to 413 students, and a total of 240 questionnaires were collected, with a response rate of 52.3%. Of those, 24 were excluded because of missing information, resulting in 216 valid questionnaires. The distribution of the students in the sample by university was 20.3% from UAM, 43.1% from University Y and 36.6% from UPV/EHU. Most participants were female (88.3%), and 88.5% were in final-year (4th year).

A total of 42.6% of respondents had entered the labour market in healthcare before completing their undergraduate degree. Among students at UdL (25.0%) started working the week before data collection, whereas 85.7% of the students at UAM and 65.0% at UPV/EHU had been working already for one month or more (Table 1). The type of contract differed between students at different universities; 66.7% from X and 60% from Z were employed as health assistants, whereas for Y, the most common contract was as a nurse (50.0%), these differences being statistically significant (p = 0.047).

Statistically significant differences (p = 0.004) were found among universities, depending on the service the students joined: for UAM, medicalized hotels were the most common type of service provided (23.8%), whereas for Y, it was other healthcare centers (52.4%) and for Z it was hospitalization wards (57.5%).

Globally, 70 (84.3%) students attended patients suffering from COVID-19, with no statistically significant differences among universities (p = 0.464). In addition, 47 (56.6%) participants from the three universities acted as backup for another nurse. However, 9 (40.9%) students from UdL had full responsibility for patients’ care, while this was 22.5% of students from UPV/EHU and 9.5% for UAM participants, and being these differences statistically significant (p = 0.029).

For 47 (58%) students who entered employment, no specific information relating to protection against infection was received from their employing institution, with no significant differences between universities (p = 0.245). A total of 44 (54.3%) respondents considered that they had the necessary protective measures to carry out their work safely, with the higher value (n=13, 65%) for the students from UdL.

The Zung Anxiety Self-Assessment Scale was responded by 168 (78%) participants, and the Stanford Acute Stress Reaction Questionnaire (SASRQ) by 157 (77%). The results show that 84 (50%) students were anxious. The mean obtained value corresponds to a low level of anxiety (x̄ = 36.31; SD = 5.71), with no statistically significant sex differences (p = 0.057) among participants from the three universities. The highest values were found among the students from UPV/EHU (x̄ = 37.44; SD = 6.31), with no statistically significant differences (p = 0.139) with the other two universities. Students who joined the workforce (x̄ = 35.67; SD = 5.78) had lower levels of anxiety compared to those who did not join (x̄ = 36.73; SD = 5.67), but these differences were not statistically significant (p = 0.237). Among the entering employment students, females obtained higher values (x̄ = 36.31; SD = 5.71) of anxiety compared to males (x̄ = 33.90; SD = 4.6), and this situation was repeated in those not entering employment (x̄ = 36.99; SD = 5.78 vs. x̄ = 33.87; SD = 5.7). None of these differences were statistically significant among the students from the three universities (p = 0.274;p = 0.138) (Table 2).

The mean acute stress score in the surveyed students (n = 157, 59 students did not answer this scale), was 82.39 (SD = 30.84). Globally, 92.4% of students experienced acute stress (score of 40 or more). 91,5% of the newly entering employment students presented acute stress, while 93% of the students out of employment. Scores were higher in female students (x̄ = 84.46; SD = 30.80) than in male students (x̄ = 67.37; SD = 27.38), and these differences were statistically significant (p=0.023). The highest mean values were found in students from UdL (x̄ = 83.51; SD = 31.97), with no significant differences between universities (p = 0.747). It was observed that students who entered the labour market had lower levels of stress (x̄ = 80.01; SD = 28.92) compared to those who did not (x̄ = 84.35; SD = 32.38), although these differences were not significant (p= 0.382). Female students had higher stress scores than males in both the entering employment and not entering employment groups, these values being statistically significant in the not entering employment group (p = 0.017). Caring for patients with COVID-19 was not significantly related to stress or anxiety (table 2).

A high level of anxiety (moderate, severe or clinically significant) was reported by 36.4% of respondents who believed they had the essential protective measures in place compared to 51.5% of those who did not or not always, and this difference was statistically significant (p = 0.005). Regarding stress, the difference between having or not having protective measures was not statistically significant (p = 0.291). (Table 3).

Discussion

The study results showed that nursing students, whether they had entered clinical practice or not during the final two years of their studies, experienced levels of anxiety and stress during the first wave of the pandemic, especially female students not entering employment.

Several international studies have shown how the mental health of health science students worsened during the pandemic, with varying degrees of depressive symptoms, anxiety, and stress^{(9,10,19,20,21)}. In line with our results, another study found that the stress level of female students was higher than that of male students⁽²⁰⁾. Similarly, anxiety levels among female students were not only higher during the pandemic, but previous studies have shown that anxiety levels among female students are higher than among male students under normal conditions⁽²²⁾. Moreover, among students who carried out their internships during the pandemic, women were found to have higher stress levels and psychological difficulties in coping with their work ⁽²³⁾.

Studies carried out in the Spanish context indicate that, during the pandemic, nursing students were at greater risk of suffering mental health problems -specifically two times higher as many as their peers on the same course in previous years⁽²⁴⁾. In Spain, students lived under great uncertainty due to the initial lack of clarity about the end of the academic year and how their pending subjects were going to be assessed⁽²⁵⁾, as well as concern about the knowledge not acquired due to the interruption of their clinical practice, in line with what happened in other European countries⁽³⁾.

The results suggest that, despite the potentially stressful experiences in healthcare institutions, those who started their careers perceived positive aspects of this incorporation that helped reduce their anxiety levels. Despite the negative emotions and their consequences, they developed coping strategies and saw the experience as a learning opportunity, reinforcing the feeling of being useful at a crucial time for public health⁽²⁶⁾.

However, for student nurses, although the experience of the pandemic may have contributed to reinforcing their desire to become nurses⁽²⁵⁾, other research found that high anxiety levels led to greater reluctance to practice their profession in the future⁽¹¹⁾.

On the other hand, the results may suggest a healthy worker effect⁽²⁷⁾so that the high levels of anxiety and stress could explain why some students decided not to join the labour market. It is possible that, based on their high self-perceived levels of anxiety and stress, students decided not to participate in the work activity, making their self-care prevail at that moment, as final-year students were forced to choose between the option of being confined at home or starting their professional career under adverse conditions⁽²⁸⁾.

Although not statistically significant, the students at UPV/EHU scored the highest on stress and anxiety. This could be explained by a possible delay in communication from the university on how to compensate for pending assessments and the offer of contracts by the regional health system⁽²⁹⁾.

It is worth reflecting on the suitability of interventions described in other countries to alleviate the psychological effects. For example, psychological support programmes for students^(11,23) and nurses⁽³⁰⁾, in order to help them cope with the fear, anxiety and stress caused by the pandemic and the resulting work situation, should focus on building resilience⁽²²⁾ and the importance of taking care of oneself in order to care for the patients⁽³¹⁾.

Universities should protect the health and well-being of their students⁽³²⁾ and address the possible emotional consequences by opening lines of research in this regard and implementing intervention programmes.

The study has some limitations mainly due to its cross-sectional nature not allowing us to determine how long the high levels of anxiety and stress lasted or whether there were any specific mental health problems developed since the pandemic in these students. It would, therefore, be interesting to analyze the medium- and long-term mental health consequences, including potential post-traumatic stress disorder.

In a pandemic, online teaching made it challenging the recruitment of a larger sample of nursing students. Another bias may be convenience sampling through the virtual campus and institutional email since only the students who use these online communications choose to participate, compared to others with connectivity problems. Aware of it, we sent several emails to encourage students to participate.

Among the strengths of the study, the geographical location of the participating universities in three different autonomous communities where students were entering employment offered the opportunity to enter into clinical practice, providing a greater diversity of participant profiles. In contract, other studies in Spain have been carried out only in one region^(8,25,26). The data collection between April and May 2020 allowed us to gather impressions close to the cessation of face-to-face teaching for the whole group of students and the moment of incorporation for the entering employment students.

In conclusion, the pandemic exposed nursing students to a new situation that caused stress and anxiety. Despite students entering the workplace showed lower anxiety and stress levels, both students in employment and not presented acute stress levels. On the other hand, a healthy worker effect could not be ruled out. This study also showed the ability of nursing students who joined the workforce to cope with stress in exceptional situations such as the COVID-19 pandemic.