The impact of educational concerns and satisfaction on baccalaureate nursing students’ distress and quality of life during the Covid-19 pandemic; a cross-sectional study

During the coronavirus disease 2019 (COVID-19) pandemic, elevated levels of psychological distress and reduced overall quality of life (QOL) have been identified among students in higher education, globally and in Norway [1‐3]. A Norwegian survey during the pandemic found a general decline in measures of life-satisfaction and mental health with young adults and students more severely affected [4]. Yet, during the second wave of the pandemic (January and February 2021) we observed that fear of COVID-19 in Norwegian nursing students accounted for only minor parts of the deteriorated psychological health and overall QOL [3], suggesting that other factors related to being a student during a pandemic may contribute to the observed changes. Identifying education-related predictors of students’ well-being throughout the course of the pandemic may be important for adequate handling of restrictions in higher education institutions.

College and university education, i.e. the years where mostly young adults aim to acquire knowledge or skills that will be decisive for their professional lives, is recognized as a high-stress period [5], and psychological distress may lead to poor academic performance [6, 7]. For instance, in undergraduate students prior to the COVID-19 crisis, academic performance, pressure to succeed, and post-graduation plans were the students’ top three concerns [8]. For nursing students in particular, psychological distress has been identified to negatively impact QOL, educational and clinical training performance [9].

For educational institutions, the pandemic necessitated improvised reconstructions of curriculums, rapid move to online distance learning, and restrictions in practical placement or simulation training both in and outside of campuses, all possibly inducing additional stress [10]. Such changes were implemented with similar rigidity during the second wave of the pandemic beginning in Norway in November 2020. Thus, finding ways to mitigate psychological distress and sustain overall QOL may benefit students’ learning and society’s need for competent future professionals.

Student satisfaction has gained global attention as a measure of effectiveness of educational curriculums [11]. Instructional effectiveness, student support facilities, internet and library access, administrative staff efficiency, university environment, and student characteristics such as gender, ethnicity, and age are all factors identified to impact overall student satisfaction in higher education [12‐15]. Furthermore, empirical analysis and deconstruction of the concept student satisfaction suggest academic and pedagogic quality of teaching to be crucial determinants of student satisfaction, potentially overlapping with students’ assessment of teaching [16]. In Norway, aspects of students’ views on educational quality, including overall student satisfaction are assessed by national surveys annually [17].

Nursing students may face higher levels of stress than other health professional students, even under normal circumstances [18, 19] and may therefore be particularly vulnerable to educational constraints resulting from measures to restrict spread of COVID-19. The conduct of clinical training, essential in all nursing educations and accounting for up to 50% of most European and international curriculums [20, 21] may be particularly difficult during a pandemic. For a three-year baccalaureate education, restrictions beginning in March 2020 will for some students have been operative for up to half of the educational period. Hence, nursing students expressed concerns about interruptions in their clinical training and how these would affect overall quality of education and post-graduation careers [22].

The purpose of this study was two-fold. First, we determined baccalaureate nursing students’ satisfaction with their educational curriculum during the second wave of the COVID-19 pandemic, compared to pre-pandemic reference data. Second, we investigated how students’ satisfaction was related to concerns about the education quality, and finally how these two measures were associated with psychological distress and overall QOL.

In total, 2605 of the 6088 students responded to the survey, yielding a response rate of 43%, differing between the universities from 21 to 50%. Among these, 1591 (61%) reported to have been engaged in clinical training, either in primary or specialist care, including community-based and institutional services, during the pandemic. Cronbach’s alpha for FCV-19S was 0.87 (ranging from 0.84 to 0.86 if singe items were deleted), identical for the total sample and those engaged in clinical training, only. For SCL-5, Cronbach’s alpha was 0.88 (ranging from 0.84 to 0.87 if single items were deleted) both for the total sample and those engaged in clinical training.

At the peak of the second wave of the COVID-19 pandemic, we investigated Norwegian baccalaureate nursing students’ satisfaction with their educational curriculum and their concerns about the quality of their education, with emphasis on the conduct of clinical training. Compared to pre-pandemic reference data from the same institutions, satisfaction was lower, but with a small effect-size. Most students reported to be concerned about the quality of their education, influenced also by worries about conduct of clinical training. Satisfaction and concerns about quality were strongly associated with trust in universities’ handling of the pandemic. Educational satisfaction positively affected overall QOL, and to a lesser degree, psychological health, whereas concerns about quality only affected psychological health.

We aimed to determine educational factors that could explain reduced overall QOL and increased psychological distress, previously demonstrated in nursing students during the second wave of COVID-19 in Norway [3]. This analysis was prompted by findings that fear of COVID-19 was strongly associated with psychological distress, but only moderately accounted for the decrease in overall QOL in these students. Assessed by one claim, I am, overall, satisfied with the curriculum I am currently attending, we chose to evaluate satisfaction as it has been used in an identical manner in Norwegian students for many years prior to the pandemic, and representative data was available for comparison [17]. A major finding of our study was the relatively small decline in student satisfaction from pre-covid reference levels. Others have also analyzed nursing students’ level of satisfaction during the pandemic, mostly satisfaction with remote learning [33, 34] or imposed changes in clinical placement [34], but without comparisons to pre-pandemic levels of overall satisfaction.

We found trust in universities’ handling of the pandemic to be the major determinant of satisfaction, complying with studies suggesting that universities’ instructional effectiveness and student support facilities may influence overall satisfaction under normal circumstances [11, 14, 15]. Our data suggest that building trust may be important and that measures taken during a crisis need to be clear and understandable to sustain satisfaction. When analyzing satisfaction of nursing students with remote learning situations specifically, also institutions/’instructors’ attitudes towards these teaching situations and optimal use of technology were main determinants of satisfaction during the pandemic [33]. Thus, institutional handling of the pandemic, as any future crisis affecting nursing education, seems to play a major role in maintaining satisfaction.

Students’ satisfaction with the curriculum has attracted interest in research of higher education even before the COVID-19 pandemic [11, 35]. Satisfaction of undergraduate nursing students is important both for attracting students to a health profession, for their motivation to complete the education and enter a professional career as much needed nurses [36]. Of interest, the perceived quality of the education, and by inversion, concerns about a lack thereof, have been invoked as one of several factors influencing satisfaction [16]. Unfortunately, to our knowledge, no data with a similar question as ours, Due to the COVID-19 pandemic I am concerned that the quality of my education will be poorer than it would otherwise have been, is available to directly assess the level of change in worries that nursing students have experienced because of the pandemic. We found however, that in addition to a major impact of trust in universities’ handling of the COVID-19 crisis, concerns about overall educational quality were associated with satisfaction. With 61% of students in our sample having participated in at least some clinical training during the pandemic, their concern about the conduct of this activity affected the overall educational satisfaction only to a small extent (increase in explained variance of the models, Nagelkerke pseudo R², from 0.41 to 0.44). This may have to do with policies adopted by Norwegian universities, where clinical training in nursing homes and hospitals continued with precautionary regulations even before large-scale vaccination of the elderly population and health care professionals occurred. This reassuring finding of ours contrasts others where concerns about the clinical training have impacted overall perception of their education [37]. This may not come as a surprise since it may be particularly difficult to replace face-to-face “hands-on” training during a pandemic [34, 38]. Furthermore, higher levels of concern reported in first year students suggest better strategies may be needed to take care of certain groups of students. A Danish study of health profession students also reported young age, female sex and enrollment in baccalaureate curriculums to be associated with higher levels of educational stress during the pandemic, all characteristics typical for undergraduate nursing students [10].

In our sample, satisfaction with the educational curriculum was associated with overall QOL with a large effect-size in regression models, to an extent comparable with the effect of loneliness [3]. The effect of satisfaction on psychological distress was lower in magnitude, but these findings together indicate that universities may contribute to nursing students overall QOL, and thereby possibly to their academic performance. Efforts to build effective curriculums of high academic quality seem to be important, especially during a crisis. Overall concerns and those specifically related to disruptions of clinical training, were associated only with psychological distress. Thus, nursing students’ concerns about the educational quality seem to target specifically the conduct of education and does not affect the more general level of QOL in our sample.

The COVID-19 pandemic with different variants of the virus has hit the world in several waves over the last two years. Nevertheless, at some point students’ lives will return to a new state of normal where educational curriculums begin to transit back to the modalities previously used. Thus, time is due for institutions of higher education to consider structures and strategies that support students’ psychological health and educational trajectory during current and future pandemics or similar crises. In this regard, findings from the present study suggest that maintaining and building trust are important to improve student satisfaction, reduce educational quality concerns and benefit students’ overall QOL. Although not directly assessed in our work, pre-existing procedures for risk-adapted educational instruments (online learning, simulation training on campus, infection control measures during clinical training etc), as well as student counseling and transparent communication may well build trust in the baccalaureate nursing education.

Baccalaureate nursing students’ satisfaction and concerns about educational quality were strongly associated with trust in universities’ handling of the pandemic. Overall level of concern about the quality was moderately affected by concerns related to the conduct of clinical training, whereas student satisfaction was not. Furthermore, students’ satisfaction may significantly impact perceived overall QOL, and to a lesser degree, psychosocial health, whereas concerns about quality only affected psychological health.