The first COVID-19 new graduate nurses generation: findings from an Italian cross-sectional study

From the onset of the COronaVIrus Disease 19 (COVID-19) pandemic in March 2020 [1], nursing programmes in Italy have been exposed to a tremendous stress-test and forced modifications to their well-established educational processes. Since 1994, Italian undergraduate nursing programmes consist of taught modules within the university and clinical placements within the National Health Services (NHS) [2]. Specifically, the third and final academic year has been designed to prepare students to identify nursing care needs and prioritise interventions among critically ill patients and those cared for in the community (mental health included) and paediatric settings, as well as to ensure patient safety and evidence-based care [3]. After the theoretical education, around > 550 h of clinical practice in critical care, mental health, paediatric, general medical, surgical and community care settings are offered according to European Directives [4], harmonising education across Europe. By law, graduation requirements have also been established as homogenous across universities, both in methods (examination regarding the competences expected and thesis dissertation) and time (November, first session; April, second session).

With the onset of the first COVID-19 wave [1], nursing education in the classroom was interrupted and transformed into online synchronous teaching. On the side of clinical learning, despite several national laws [5] recommending that clinical placements would have to be continued, Health Care Trusts imposed the interruption of clinical rotations to all health care students, mainly due to the lack of personal protective equipment and to prevent units’ overcrowding [6]. As a consequence, more than 50,000 nursing students were left at home; initiatives were suddenly implemented by nursing faculties and clinical training were re-established in a number of regions, while not in others [7]. Clinical placement priority was given to third year students because they were better equipped and also to enable them to graduate sooner to address the dramatic shortage in the NHS. However, as a consequence of the health service transformation, several units devoted to nursing education were disrupted: the number of available clinical placements was reduced, and the majority of health care facilities denied students access to COVID-19 areas. To minimise cross contamination the universities introduced a series of changes to clinical placements. These placements were limited to one or two long experiences (> 8 weeks) in non-Covid-19 areas with a small number of students in each area[5]. By law [8], universities have been allowed to compensate for the lack of opportunities in real-world settings by offering distance learning for clinical modules. No more than 40% of the time devoted to clinical rotations were allowed to be delivered online, and small groups of students to promote their active participation (e.g. debating clinical scenarios) were involved. At graduation, the first COVID-19 new graduate generation was recruited immediately to face the pandemic.

The changes undertaken in the patterns of nursing education on a large scale, and in that of the first employment experience, are unprecedented. Nursing education has been re-designed mainly around student safety and infectious disease control principles; by implementing urgent responses mixing online and limited clinical exposure in contexts undergoing dramatic changes in their mission (e.g. changing from medical to COVID-19 patients), in staffing (e.g. high turn-over) and in the patients cared for, given that several surgical procedures and other programmed activities were suspended or delayed [9, 10]. Moreover, no assessments have been performed on the quality of clinical environments to maximise the clinical competences achieved [11, 12]; also, new clinical tutors have been appointed without any training [13], and the continuity of the clinical experience has not always been ensured, due to the continuous changes in the mission of units and episodes of isolation or quarantine [14]. Furthermore, only limited transition programmes have been offered [15] to help new graduates to enter their first working environments using supervision and peer support in good clinical settings [16].

The main features of the clinical experiences attended by post-COVID-19 third-year students and their employment status and placement one month after graduation have been not documented to date; similarly, no data on perceived competences possessed by the first COVID-19 new graduate generation have been traced to date. Specifically, some individual variables, or learning experiences during the COVID-19 pandemic, and competences perceived are assumed to differ according to the employment status and placement of new graduates one month after graduation: for example, being employed in a COVID-19 unit may have decreased the perception of competences, given the absence of learning opportunities in these settings as compared to those working in non-COVID-19 units or still unemployed. Therefore, we undertook an exploratory study investigating the last year of clinical education up to graduation and one month after among the first COVID-19 new graduate generation. Specifically, the primary aim was to detect any differences at the individual and nursing programme levels and between the competences perceived among new graduates according to their working status (in COVID-19 units, in non-COVID-19 units and unemployed) one month after graduation. The secondary aim was to compare the perceived competences of the first COVID-19 new graduate generation with those reported by the pre-COVID-19 generation.

To our best knowledge, this is the first study involving the new graduate generation one month after graduation to explore their individual profile, learning experience in the nursing programme during the COVID-19 pandemic and their perceived competences according to employment status, defined as employed in a COVID-19 unit, in a non-COVID-19 unit or unemployed. In other countries, nursing students have been offered extended work in hospitals to support the vast increase in critically ill patients [26, 27]. In Italy, although nursing students have been allowed to attend clinical placements, these have been either suspended for many months or re-initiated with one or two longer placements in some units, albeit with limited hours. In addition, online learning has been offered to compensate for the lack of real-word opportunities, thus transforming the clinical learning strategies offered in the final years of education [23]. All of the unprecedent changes introduced in the nursing programme to face the consequences of the COVID-19 pandemic may have affected new graduates’ perceptions of their own competence as well as their employment status and location one month after graduation.

The profile of the first COVID-19 new graduate generation is similar to that documented recently at both at the national and international levels [21], suggesting that the sample, despite the limited response rate, might reflect the profile of Italian new graduated nurses. Most participants were immediately employed in units caring for COVID-19 patients, with around a quarter employed in non-COVID-19 units and another quarter still unemployed at the time of the survey. Graduates might have perceived a moral obligation to help the system in facing the pandemic [28], also agreeing to work in units caring for COVID-19 patients. Moreover, the majority refused one or more work offers, suggesting that they were given several opportunities and decided to work in COVID-19 or non-COVID-19 units, or to remain unemployed. Interestingly, the reported reasons for refusal included unsatisfactory working conditions/positions, in addition to the distance from home—cited significantly more often among those unemployed as compared to employed. This may suggest the need to stay closer to home—a habit that can be triggered by the sense of insecurity and movement restrictions imposed in the last year to deal with the pandemic [29].

During their last year of education, after the onset of the outbreak, students attended nine weeks of clinical practice on average, with a total of around 300 h (36 h/week). Moreover, around five weeks were spent on distance learning, totalling 180 h (36 h/week). Therefore, a strong reduction in the duration of clinical education was seen, given that > 550 h were used to be required during the third year. Moreover, only a few students have been allowed to learn in COVID-19 units, and the majority were also restricted from accessing these areas, suggesting that they were protected at the cost of learning in a surreal world. Despite their lack of preparation in this field, the majority of new graduates were recruited to COVID-19 units, and these graduates perceived themselves, in some areas of the NCS, even more competent than the other groups did. On the one hand, they may have accepted to work in these units due to a sense of feeling valued by the staff for their contributions, given the uncertain and stressful period in which this study took place. On the other hand, the immediate recruitment into COVID-19 units suggests some reflections. First, there is a need to discuss the ethical implications regarding the restrictions imposed during education and the immediate recruitment just after graduation, as exposing students during their clinical education to a safe learning environment and practice [26] would have allowed them to develop important competences. Second, there is a need to reflect on the quality-of-care received by COVID-19 patients, given the substantial absence of specific clinical experience in caring for these complex patients by new graduates. Third, reflections should be conducted also regarding the safety implications, both at the nursing and system levels, given the significantly lower proportion of COVID-19 units offering a transition programme compared to non-COVID-19 units, mainly due to a shortage of nurses. The recruitment of new graduated nurses into COVID-19 units, which was forbidden during their education, is a point of debate in the attempt to balance clinical placements, including conditions of high risk, and in recruiting nurses to high-risk situations without any previous education or support during their entry-level transition.

The findings from this study indicate that new graduates felt safe in their clinical practice after the onset of COVID-19 in line with the sparse available literature [30], suggesting that they were not exposed to intense stress that might prevent effective learning in line with the sparse literature available [31]. These perceptions did not influence their employment status after graduation. Moreover, most of them were supervised by nurses as previously reported [32], regardless of employment status and location: specifically, how clinical supervision was implemented in times of social distancing merits further investigation. However, during their clinical rotations, few students reported interruptions due to COVID-19 issues (quarantine, isolation), and this was reported more often among those working as new graduates in COVID-19 units. This finding seems to suggest that having personal experience with COVID-19 might have increased their confidence around this clinical issue and thus, their acceptance of working in these challenging settings. By contrast, and surprisingly, participants reporting greater satisfaction with their nursing programmes regarding how the COVID-19 pandemic was managed were significantly more often among those unemployed as compared to those employed, an aspect that should be investigated further.

New graduates reported that they considered themselves ready to undertake the responsibility of nursing care both in COVID-19 and in non-COVID-19 units. Those working in COVID-19 units reported higher exposure to patient death, indicating that specific support when facing stressful situations should be offered alongside the transition programme. Moreover, given that these students have been exposed to a dramatic situation never seen before that may have prepared them to deal with challenging situations, with the return to normality, learnings from this novel situation should be explored to adapt educational programmes and build future preparedness by considering the possible role of simulation and that of disaster preparedness courses [33].

The competences perceived were consistent across groups, suggesting that these did not play a role in the decision of whether to accept a work placement or not, or to work in a COVID-19 unit or not. Findings ranged from > 50 to 75 in the possible range of 0–100, thus reflecting the perception of possessing ‘Good competences’. Only in the ‘Managing situation’ competence new graduates working in COVID-19-units reported a higher frequency of use compared to their colleagues, but this difference (COVID-19 units 1.96; vs. non-COVID-19 units 1.76; unemployed 1.70) does not appear to have a practical relevance.

By contrast, comparing the perceptions of the first COVID-19 new graduate generation with those who graduated previously [21], despite a significantly lower perception of competences having been reported in the ‘Helping role’, others were higher (‘Therapeutic intervention’, ‘Ensuring quality’) or consistent, suggesting that the strategies adopted to ensure the achievement of competences during the pandemic demonstrated some sort of effectiveness. Moreover, new graduates perceived the same degree of overall competence as in the previous study [21], despite their less frequent use of such competences. On the one hand, the lack of clinical opportunities might have maximised the motivation to learn and achieve the expected competences, optimising the learning processes. On the other hand, the increased duration of the clinical placement offered, more than nine weeks in the same unit, might have helped students to develop their competences, to be independent and develop a sense of belonging and closeness to the team—also due to the absence of other students—factors that have all been documented to affect clinical learning outcomes [16, 34]. In this light, the implementation of online education might have supported the initial development of some competences [28], prior to training in the real word, an outcome that should be investigated further.

Since the start of the COVID-19 pandemic, nursing faculties in Italy have undertaken unprecedented decisions to prepare their students to the best level and continue the education of those close to graduation, aiming to respond to the dramatic shortage of the NHS nursing staff. In a context where clinical learning placements have been interrupted by health care facilities, nursing faculties adapted the student educational pathway: one clinical placement, which was longer in duration with no peer education, and preceded by online distance learning, was offered to third year students prior to graduation. At the point of graduation, the majority were employed, mainly in COVID-19 units without a transition programme, imposing an ethical debate regarding the role of nursing education in preparing students for the emerging challenges and the need to ensure the implementation of transition programmes, especially in challenging situations. Alongside an appreciable sign of professionalism from the side of new graduates, nurse managers and executives should consider a moral and legal obligation to protect both new graduates and patients. The competences perceived were homogeneous across employed and unemployed nurses, suggesting that these did not play a role in the decision to accept a work placement or not, or to work in a COVID-19 unit or not. In contrast, comparing the perceived competences of the post-COVID-19 new graduate generation with those of previous graduates, in the same universities, the majority were higher or similar, suggesting that the strategies adopted to ensure the acquisition of competences during the pandemic demonstrated some degree of effectiveness.

Above all, when there is a shortage of something, there is a greater emotional investment and a greater appreciation for what we can have. In the Italian educational tradition, internships have always been experienced as ‘obvious’, which may have reduced students' perceptions of ‘conquering’ and appreciating something as valuable as clinical learning. The pandemic emergency may have helped to highlight the essential nature and importance of clinical learning, where every hour spent in the field can and should generate learning. Future studies in times of the ongoing COVID-19 pandemic could also contribute to the building of a transition programme with a competence scale specific to working in endemics and pandemics to assess and promote preparedness among newly graduated nurses.