Abstract
In March 2020, the World Health Organization declared the global COVID-19 pandemic outbreak and the Norwegian government declared lockdown to stop the virus from spreading. In Norway, universities were immediately closed, and all teaching and learning were done digitally for the rest of the spring semester 2020. Our aim was to explore nursing students experience with studying and learning, as well as the psychological consequences it may incur during a period of social isolation during the Covid-19 pandemic lockdown. The study is a qualitative study based on a focus group with 6 nursing students. The analysis was conducted following Kvale’s approach to qualitative analysis. Three main categories were identified: (1) psychosocial learning environment, (2) personal and social challenges, and (3) communication. We found that the restrictions due to social isolation and pandemic restrictions such as closing of the university campus, has impacted students` study situation significantly, both psychosocially and academically. If social isolation should be necessary in the future, universities need to use methods such as group discussions, quizzes, and short breaks in the lectures to prevent unnecessary problems among the students. Personal challenges due to the social isolation, such as anxiety or other mental health issues are more difficult to avoid or prevent, but the universities must be better prepared to give students more personal communication, have unformal meetings and providing more information to the students in times of crisis.
Keywords
Social isolation may be affecting nursing students negatively.
We have explored nursing students’ experiences in periods of social isolation.
Our findings should be of interest to those working in an educational setting.
Introduction
In March 2020, the World Health Organization declared the global COVID-19 pandemic outbreak and the Norwegian government declared lockdown to stop the virus from spreading. The lockdown in Norway was instigated following several similar lockdowns in European and Asian countries. Most of the population was restricted to their homes, with only health professionals and other essential workers being allowed to go work. In Norway, universities were immediately closed, and all teaching and learning were done digitally for the rest of the spring semester 2020.
Social isolation is defined as the insufficient quantity and/or quality of contact or interactions with other people. This includes contact that occur at the individual level, group level, and/or community level. 1 One aspect of social isolation is external isolation referring to the frequency of contact with other individuals. Another aspect is internal or perceived social isolation which refers to perceptions of loneliness and satisfaction with their relationships. 2 Several studies have found that emotional stress may occur from a feeling of physical or social isolation. 3 During the pandemic, additional stress may have been added from worrying about getting infected by COVID-19 and losing family or friends to the disease.1,3 Symptoms, problems and disorders that may emerge during and after extended periods of social isolation are anxiety, obsessive-compulsive symptoms, insomnia symptoms, digestive problems, as well as depression and post-traumatic stress. 4 The evidence also suggests that adolescents are hit hardest from social restrictions and isolation during the pandemic. 5 In the US, 61% of young adults between 18 and 25 years reported high levels of loneliness. 5
The transition from late adolescence to young adulthood may be a particular vulnerable period for university students due to social isolation. 6 They often leave their childhood home for the first time to pursue higher education. While this time is mostly constructive and exciting, the physical separation from home and the move to greater independence signify an important developmental transition that can be accompanied by loneliness. 7 Going to university often involves moving to a new place, a situational change that adds to the risk of loneliness since university students not only are separated from their family, but also from established social networks. 8
According to sociocultural learning theory, learning is a social and cultural activity where the historical, cultural, and institutional contexts are important. 9 The theory suggests that human learning is largely a social process, with our cognitive functions being formed based on our interactions with those around us who have more experience or knowledge. Since all teaching and contact with teachers and faculty were digitalized during the lock down period of the pandemic, the relationship between students and teachers weakened. 10 The evidence in previous studies shows that support from teachers and peers is vital for motivation, learning strategies, academic performance, mental health, and wellness in university students.11 -14 In nursing education, both theoretical lectures and clinical based learning are emphasized: it is essential to not only have clinical skills such as administration of medications and injections, and wound care, but also relational skills such as therapeutic communication. Thus, the restrictions in face-to-face interactions between teachers, peers and students may have presented considerable barriers to learning nursing. 15
Therefore, the aim of this study was to explore nursing students experience with studying and learning, as well as the psychological consequences it may incur during a period of social isolation during the Covid-19 pandemic lockdown.
Methods
Sample
This study is a qualitative study aiming to assess nursing students’ experience of the closing of the university campus and the following social and academic isolation from peers and teachers. The study was based on a focus group methodology to investigate the students` experiences. The use of focus groups in qualitative research is useful when seeking in-depth knowledge of this nature. 16 One focus group discussion with 6 nursing students, which is the desirable size to give the participants enough time to tell their stories, 17 was conducted. The focus group consisted of 5 females and 1 male between 23 and 38 years old.
Data Collection
All students enrolled in the last year of the nursing study program were invited to participate in the study through written and oral invitations with information about the purpose of the study. Six students responded to the invitation. The focus group was conducted on 7th June 2021 by 2 of the researchers (LBS and MEBE) who had no prior relationship with the participants. Because of the ongoing pandemic, the focus groups were done digitally using a virtual meeting point. A semi-structured interview guide was developed before the focus group discussion by all authors and the interview lasted about 1 h. The participants were asked questions about how they perceived the information from the university while campus was closed, how it affected their learning experience and how their social life at the university were affected. Because of the covid restrictions, we did not achieve saturation. The focus group interview was recorded and transcribed by a skilled transcriber.
Data Analyses
The researchers systemized the transcribed interview, and then discussed the content and the meaningful units using Kvale’s method for qualitative analysis. 18 All authors read the transcribed material individually and coded the material and then we discussed and interpreted every statement. (4) To protect the confirmability of the results, all 4 researchers were involved at all stages of the analysis. 19
Dependability were inspected by using the 5 stages from Kvale’s method 18 : categorization of meaning, condensation of meaning, structuring of meaning, interpretation of meaning, and ad hoc methods for generating meaning.18,19 The chosen categories appeared from the material; we interpreted the meanings of the findings, which we emphasized and condensed into dimensions with their unique arguments unbroken. Subsequently the results were condensed; we created narratives on every category. In this procedure, the researchers discussed the meaning of the statements to ensure context sensitive interpretation and to understand the statements of sense of the total setting which the statements occurred. 20 Then the results were systematized, condensed, and sorted in preliminary categories.
All authors were female and have extensive experience with qualitative analyses and pre-understanding of the different authors were discussed before making the interview guide and while doing the analyses.
Ethical Considerations
All the participants were fully informed about the purpose and process of the study and gave written consent to participate prior to the focus group discussion. The Norwegian Agency for Shared Services in Education and Research were notified and approved the project (nr. 546312).
Results
We identified 3 main categories: (1) psychosocial learning environment, (2) personal and social challenges, and (3) communication. Table 1 shows the main categories and the subcategories.
Main Findings From the Focus Group Discussion.
Psychosocial Learning Environment
Learning in a Home Environment
The participants perceived digital teaching as both positive and negative for learning. They discussed that digital lectures were more mentally exhausting than on-campus lectures. Some teachers were good at taking frequent breaks while others were not:
“. . .. Because I experience that the sessions get very long, then the teachers often think that it’s okay if we spend another few minutes. But then you are tired. And some teachers are good at it; We have to remember to have short sessions, and frequent breaks. And us students are different too; some students want the lecturer to keep going so that we can finish sooner
It was expressed that in lectures that are already too long, they don’t wish to ask questions that would add even more time to the lecture:
“And then I don’t want to be the one person that start asking. . . that makes the lecture even longer. I can sometimes get annoyed when someone else starts asking so that the lecture gets longer, and that is not good.”
Several participants expressed that they liked digital teaching. They said that they appreciated not having to spend an hour traveling to and from campus, but rather could get up 15 min before the lecture started. Several participants expressed that it was more relaxing learning from home. If they did not think that the lecture was relevant, they could do other things while listening, such as house chores. This was expressed as being an improvement from attending lectures on campus where they felt like they wasted time in lectures that they did not perceive as relevant. One participant described it like this:
“. . . And you don’t have to travel and calculate the travel time. . .. it sucks a bit, because it’s like. . .. it’s fun to be at a lecture too, but its more relaxing to be at home. But I. . . it’s difficult to keep the focus too, because there are so many other things that can distract you.”
The participants brought up that the learning outcomes is lower when learning from home. They do not have the opportunity to ask their fellow students if there is something in lecture they do not understand:
“I notice it, it is a big difference for me, to sit alone at home in front of the screen, compared to sitting in a lecture theatre, where you see everything in front of you and you have fellow students to ask. I have taken it for granted that you can whisper to each other: “What did she mean by that? And then get a quick explanation.”
They also expressed that they miss out on learning from student discussions that normally take place in on-campus lectures. These discussions do not take place in the digital setting:
“So it has influenced my learning outcome at least, that I have been learning alone. And I don’t ask questions in the lecture either.”
Change of Examination Method
Some participants perceived the change from school exams to home exams as stressful. One participant stated that she was under the impression that the home exam was only a copy of the school exam, with the only difference being that they had to do referencing:
“. . .. my experience was that the ordinary school exam was redone into a home exam. Just with “remember to reference at the same time”. That’s what I pictured, so it was a pretty bad experience. I remember that I was shaking for an hour afterwards.”
Several participants found it problematic that they had to sit at home during the exam. They expressed that house mates, family and sick kids made it difficult to concentrate:
“For my part, it is the home situation. I like better to have the exam on campus. I feel that then it is just like “okay, now I’m at school, complete the six hours” and that’s it. Because its like. . . sit at home, and you live with three others, and they have to take into consideration that you sit there. . ..”
One participant expressed it like this:
“I didn’t have my own space, I had to sit in the living room. And of course, if there are others, husband or sick children at home then, it would be a bit stressful.”
To avoid the problem of disturbing family members several participants had planned to sit with fellow students during the exam. When notified by the university that sitting together would be considered cheating, they immediately changed plans and stayed at home. They were worried that they would be accused of cheating if they sat with other students, even if they did not talk to each other during the exam:
“What if. . .. Is it cheating to sit with another student? And I started thinking; Then I can’t do it, even if we don’t cheat, even if we don’t talk”
Clinical Practice
The students participating in the focus group discussion were about to start their clinical practice soon after the initial lockdown and several participants expressed that information regarding their clinical practice were delayed from the university, causing them to stress about whether they would get their placement or not. Some participants started organizing their own clinical practice because of the delay in this information. One participant explained it like this:
“. . . in lockdown, everything was new then, I think that many students felt insecure, and it was a bit stressful, it seemed like. And then it was things related to where we were going to have our clinical practice, I experienced a lot of anxiety in the fellow students then.”
The participants discussed the importance of staying calm when they were uncertain about where they would be placed in clinical practice. One participant stated this:
“I knew that it would work itself out somehow. So I was kind of like. . .. I didn’t do anything about it. So I was waiting. . . on this clinical placement.”
The confusion about clinical practice caused the students a lot of stress and some were scared that their studies would be delayed if they did not sort this out themselves:
“But I stressed a lot about it. . . wanted to get a job just in case, I didn’t want to… get my education delayed.”
Peer Learning
The participants expressed that they missed the interaction in groups that they perceived as important for their learning outcome. The social interaction and the groups discussions with students with different opinions facilitated learning in a way that they could not imitate at home:
“. . . a bit like because of the social, I think during the exam period, we were a group of friends from nursing. . . that got together and worked together. And that does something for learning, it was great that the campus was open.”
“And you learn from each other, we can have different opinions, or points of view, on something nursing related and then we learn from each other.”
The participants highlighted simulation in groups as a teaching method that they missed during the lockdown. One participant stated that she thought simulation was the most useful teaching method on the whole nursing curriculum because they learn from watching each other.
“What I felt that we lost, was the group work, that I think has been very difficult, but also very useful. . … and that we lost the simulations that we started at the beginning of the second year”
It was perceived as important to discuss with fellow students because it makes you remember better. One participant summed it up like this:
“So, it’s quite magical this group thing.”
Personal and Social Challenges
Psychological Distress
Some participants expressed that the sudden closing of society and the university made them anxious and scared of leaving the house. Several participants stated that they found it difficult to leave the house to go to the grocery store or even to just go for a walk. On participant stated:
“I found it difficult to go to the grocery store. . .”
Another participant expressed this:
“You get a bit trapped at home too, at least then, I couldn’t get outside if I didn’t have anything to do there. I don’t like going for a walk for nothing. . . to just go for a walk.”
Social Consequences
The participants missed their fellow students and the social interactions with them outside studying. Many of the students studying nursing, come from other parts of the country and their only social network may be their university friends. Several of the participants in the focus group expressed feeling lonely while the university was closed. One participant said this:
“. . . but at the same time I miss the social interactions. Just meeting my class, being at the lecture theatre with them, and just being there. Even though I didn’t have a huge circle of friends, it was my group I used to hang out with, and it was them I just to be with.”
Another participant put it like this:
“I miss having somewhere to go. I don’t have anyone but myself to think about, so I missed meeting friends at uni, having lunch together, talking in the breaks. Yes, you miss out on the social aspect too.”
Your time as a university student is supposed to be the best and most care-free time of your life, where you create memories that will last a lifetime. The participants felt like they had missed out on creating memories with their fellow students:
“. . .. at the same time I feel that I really miss that we are a group, and just, I don’t know, just having some photographs to look at.”
The social aspects of studying with friends were also discussed. They missed reading and hanging out with fellow students during exam periods. Companionship while studying had a social aspect to it that was perceived as important by the participants.
“. . .It is a bit like the final period of writing the bachelors thesis. I had been sitting at home the whole time. Apart from when we collected data, and then I noticed the difference. When it normally is almost time to submit an assignment, you usually stay at uni late, and maybe you buy candy and soda, and maybe you order pizza together. And it is kind of social too.”
The importance of communication
Information
Communication from the university to the students was perceived to be important as it helped relieve stress caused by lack of knowledge. Most of the participants were happy with the timeliness and amount of information received from the university. One participant stated that if you checked your emails, you got the information you needed. The participants agreed that the information received, were sufficient to keep up with the new rules and changes in teaching methods and clinical practice. One participant expressed that the organization of the online learning portal, Blackboard, could be a bit messy and that different teachers have different ways of organizing the material, leading to difficulties navigating the website. One participant noted:
“. . .the teachers don’t agree on how to sort things which makes it a bit chaotic. But apart from that, I think that the university has been quick to send out information about new things.”
Follow-Up
Another type of communication that was perceived as important by the participants, was the follow-up they received from their teachers. Several participants expressed that they were happy with the follow-up from their teachers, and some had communicated via text messages and emails:
“. . .. I had close contact with my supervisor, and she was very available. I talked to her on her private phone. Or we texted. If something was up.”
Another participant was also happy with the follow-up by the course coordinators of several of the subjects she was taking:
“. . ..I have been in contact with both course coordinators on email. Asked questions and got answers very quickly. Simple and specific, so. . . I think they have been available.”
Discussion
The COVID-19 pandemic led to university closures all over the world and to conversion of all on-campus lectures to home-based learning at all higher learning institutions in Norway. Thus, Norwegian university students faced social isolation as all teaching were done digitally. In this study, we aimed to explore the nursing students experience with studying and learning and the psychological consequences during the period of social isolation of the lock-down period. Our results show that the students have been negatively affected by the social isolation, but also that some aspects, such as digital lectures, is partly considered a positive change. We identified 3 main categories in the results, the psychosocial learning environment, personal and social challenges, and communication.
Psychosocial Learning Environment
The participants perceived the change of learning environment, from campus lectures to digital lectures, from school exam to home exam, and uncertainties about placements in clinical practice as stressful. There was a lot of worries initially, but as they got used to the new learning environment, their worries settled, and they could see some benefits from watching lectures from home. This is in line with a previous study on home-based learning in nursing during the pandemic in Singapore. Similar to the participants in the current study, Hu et al 21 found that the majority of the nursing students were positive in regards to digital lectures and tutorials, they liked the flexibility of the home-based learning which enabled them to plan their studies and to avoid wasting time on lectures they did not find relevant. Even though the students generally liked following lectures from home, they were concerned about having a home exam as a substitute for school exam. They worried about not having the privacy to complete the exam in due time. Many students live in shared accommodation and the potential blurring of public and private space that communal living may involve 22 could also pose obvious practical challenges in relation to getting the privacy needed to undertake home exams.
Even though the students liked the flexibility of learning from home, they missed learning from their peers through group work and simulation. Sociocultural learning theory is based on the concept that learners develop new knowledge and skills by observing and interacting with others in their environment and highlights the importance of social interactions for students. 23 During the period of social isolation, the students did not have the option to learn from their peers which may have influenced their learning process and outcomes. From this, it becomes important that the sociocultural aspect is ensured in digital learning. The students should be given the opportunity to interact in groups during the lecture or in sperate sessions which would ensure that the students still learn from each other.
Our findings also showed that the students found it hard to concentrate for the duration of the digital lecture. Lethargy and eye strain are common complaints when learning digitally 24 and teachers lecturing online should therefore be sure to incorporate shorter and more frequent breaks in a digital lecture than in an on-campus lecture. Another way of increasing the attention of the students could be integration of online quizzes or group discussions as digital lectures often lack interactivity, an important element in effective learning. 25 Additionally, it has been suggested that the duration of digital lectures should not exceed 4 h daily to reduce ocular problems, 26 which may in turn affect their performance as the participants in this study experienced.
Personal and Social Challenges
The students in the current study missed their fellow students and the social interactions from studying together, but also from having lunch or just hanging out, both in and outside the campus. They expressed disappointment about not being able to hang out and create memories with their fellow students. Going to university is for many students a time to be care-free, have fun with friends and to create memories that will last a lifetime. To not be able to meet their fellow students may be particularly challenging for them as their potentially great expectations for having fun with fellow students were not met.
The social isolation caused anxiety for the students in the current study. This is in line with the findings of a recent review that found anxiety to be highly prevalent among university students during the Covid-19 pandemic. 27 Previous studies have also found that university students experienced strong fears that the students themselves or their families would be infected28,29 which aligns with the results of our study where the students experienced fear of leaving the house or going to the grocery store. Previous research have also suggested an association between weak social relations and increased anxiety levels.30,31 Approximately 40% of the Norwegian general population reported to suffer from mild anxiety during the pandemic 32 and Norwegian students have been found to have poorer mental health than the general population. 33 University students may constitute a particularly vulnerable population for mental health problems because of challenges commonly associated with transitions to adulthood and the frequent economic and material difficulties of this population.34,35 The social connection may therefore be particularly critical for this group, and in times of crisis, it may be more important than ever.
Communication
The digital learning portal became more important than ever during the lockdown period and the students in the current study expressed some frustration with how it was organized. Different teachers used it in different ways, and the students sometimes found it hard to navigate the information. Digital learning platforms have been used for many years and have offered many benefits such as flexibility, improved interactions, and better communication between teachers and students.36 -38 However, when using digital learning platforms there may be some difficulties in students’ learning process, such as decreased motivation, delayed feedback or help, or feelings of isolation due to lack of physical presence of classmates. 39 The different organization and use of the digital learning platform between teachers may complicate the information flow, and there seem to be a need for a template on how to organize the information on digital learning platforms.
Apart from the digital information given in the digital learning platform, the students perceived personal communication with their teachers as important. Several students reported to have communicated with their teachers through email and text messages.
Strengths and Limitations
One of the strengths in this study is the selected methodology used to obtain in-depth information about the students’ experiences of being a nursing student during social isolation. By organizing a qualitative focus-group interview and using a semi-structured interview guide, the students were able to use the discussions in the interviews to broaden their perspectives and discuss experiences with each other and supply data on how they experienced the period of social isolation.
The analysis of the data and writing of the paper were conducted by a group of researchers, which also represents a strength to this study by improving the reliability of the data. Dependability and confirmability are major areas when conducting this study. 40 Analyses of the findings were regularly examined among the researchers to verify the dependability of the results.
There are also some limitations in this study, one being the small sample size which led to that data was not fully saturated. 41 Another limitation is that that the data was collected using a virtual meeting point and not face-to-face, but it was important to gather the students experiences close to the period of social isolation. These limitations might damage the transferability of the findings.
Conclusion
This study has shown that the restrictions due to social isolation and pandemic restrictions such as closing of the university campus, has impacted students’ study situation significantly, both psychosocially and academically. The use of virtual technology in teaching may be convenient and efficient, but findings in this study have showed that this may also create challenges in the students’ learning environment. Even if the students in this study appreciated the flexibility of having home lectures, they however experienced concentration problems during digital lectures. If social isolation should be necessary in the future, universities need to use methods such as group discussions, quizzes, and short breaks in the lectures to prevent unnecessary problems among the students.
The participants in this study also described some personal challenges due to the social isolation, such as anxiety or other mental health issues. These are issues that are more difficult to avoid or prevent, but the universities must be better prepared to give students more personal communication, have unformal meetings and provide more information to the students in times of crisis.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
