Abstract
Introduction
There has been unprecedented uncertainty involved in the COVID-19 pandemic, especially for working nurses. Nurses working while attending graduate school faced additional unique challenges including working extended hours while also home-schooling young children, managing a family life while also navigating pandemic-related changes affecting students’ educational paths.
Objectives
The purpose of this study was to explore the lived experiences of working nurses attending graduate school during the COVID-19 pandemic. The central research question was: What is the lived experience of working nurses attending graduate school during COVID-19?
Methods
The exploration of the lived experience of working nurses attending graduate school during a pandemic required a research methodology delving into the meaning of lived experience as it has been lived, temporally, and contextually (during a pandemic). Qualitative hermeneutic phenomenology was used to explore the meaning of lived experience from an interpretational stance.
Results
The overall meaning of the experience was a paradigm shift of existence across the three realms of work, home, and school. The themes associated with the shift were rapid change, uncertainty, fear, and support persons. Stress was a resulting overarching theme.
Conclusions
To support working nurses further their education during times of crisis, nurse leaders and educators should put processes in place to mitigate change and stress through strategic communication and supportive work environments.
Introduction/Background
Working nurses attending graduate school are those seeking to further their education in the form of various degree types including the Master of Science in Nursing (MSN), the Doctor of Nursing Practice (DNP), and the Doctorate in Philosophy (PhD) while also working as Registered Nurses (RNs). Nurses working while attending graduate school during the COVID-19 pandemic faced unprecedented challenges. Because of the nature of the job, even prepandemic, nurses experienced work-related stress (Muhamad Robat et al., 2021). Although nurses’ work environments tend to be stressful, many nurses choose to advance their education via graduate school.
Graduate school has been shown to be stressful, prepandemic. For example, a study conducted by Higgins and Hartgerink (2022) found MSN and DNP students to have experienced stress while in graduate school, including home challenges, decreased self-care, and related decline in overall health status. Similarly, Brown et al. (2016) found students seeking an MSN in a Jamaica school of nursing experienced academic-related stress. Indeed, balancing school, family, life, and financial stressors was challenging for working nurses (Brown et al., 2016; Higgins & Hartgerink, 2022). Managing the existing stressors related to working while attending graduate school was compounded by the COVID-19 pandemic.
Review of the Literature
A literature overview describing the body of knowledge on the effects of COVID-19 on working nurses attending graduate school follows. The databases utilized included the Cumulative Index of Nursing and Allied Health Ultimate and Medline via Medline PubMed. The academic search engine Google Scholar was also utilized. Search terms included nurs*, working, graduate school, PhD/MSN/DNP programs, and COVID-19.
In several studies, the psychosocial effects of the COVID-19 pandemic on populations of frontline working nurses and nurse graduate students have been explored. Frontline nurses in Lebanon caring for COVID-19 patients experienced exhaustion, fear, and stress which resulted in subsequent depression and burnout (Sagherian et al., 2017). Nodine et al. (2021) found stress levels increased during the pandemic among MSN, DNP, and PhD students in the United States. Indeed, the pandemic presented different challenges for nurse graduate students. For example, Family Nurse Practitioner (FNP) graduate students faced barriers due to a lack of clinical placement opportunities resulting in fear and uncertainty about program completion (Link et al., 2021). The abrupt cessation of clinical opportunities greatly contributed to increased stress levels among graduate nursing students (Nodine et al., 2021). Changes in work, clinical, and school schedules increased stress, anxiety, and depression in graduate students of all levels at the Western United States College of Nursing (Rosenthal et al., 2021). To date, research related to the COVID-19 pandemic has either focused on frontline nurses or graduate nursing students. There remains a paucity in the body of knowledge on the experiences of working nurses that were also attending graduate school during a global pandemic (COVID-19). This population of nurses lived a unique experience with related challenges.
Thus, understanding the lived experience of working nurses while attending graduate school during a pandemic is important. Given the projected shortage of nurses, retention of working nurses in graduate programs is societally vital. The Future of Nursing 2020–2030 report recommended nurses acquire higher levels of education (National Academy of Medicine, 2021). The purpose of this study was to explore the lived experiences of working nurses attending graduate school at Texas Schools of Nursing during the COVID-19 pandemic.
Methods
Design
Investigating the experiences of working nurses attending graduate school during a pandemic requires a research methodology delving into the meaning of lived experience as it has been lived, contextually and temporally. Hermeneutic phenomenology is a methodology involving an exploration of the experiential meaning of being in context and time (Heidegger, 1962). The context of the experience is central to the interpretation of the meaning of the experience (Callary et al., 2015).
The interpretive process in hermeneutic phenomenology embraces the researcher's preconceived notions and experience (van Manen, 1990, 2014). Two of the nurse researchers experienced working while also attending graduate school during the COVID-19 pandemic. The researchers reviewed transcripts for communicative validation and verified the overarching themes resonated with their experience. The experience continues to exist and comingle via reflexivity in the interpretive process. Hermeneutic phenomenology is a circular process of reading, reflective writing, and interpretation by means of written and spoken language commonly referred to as the hermeneutic circle (Kafle, 2013; van Manen, 1990, 2014). Understanding of meaning is a co-created process with the textual data and researcher interpretation.
The intent of the interview in hermeneutic phenomenology is an immersion experience for the participant and the researcher to gather written (transcribed) material for developing an understanding of the phenomenon (van Manen, 1990). Thus, a conversational interview was conducted using an interview guide to explore the experience of the participant as it was lived contextually and temporally. The overall interview conversation focused on the question: Can you tell me about your experiences of being a working nurse attending graduate school during COVID-19? Interviews were conducted via video conferencing or telephone and were <60 min in duration. Simple transcription rules were applied via transcription services. Data collection continued until it was determined data saturation had occurred.
Research Question
The central research question was: What is the lived experience of working nurses attending graduate school during COVID-19?
Sample
Participants were recruited using a combination of purposive and snowball sampling strategies. A recruitment email was sent to Deans and Directors of Colleges of Nursing offering graduate programs in the state of Texas. Sampling was limited to the state of Texas because state boards of nursing rules on practice and educational requirements vary from state to state. Telephone screening was conducted with potential participants self-identifying as working RNs attending graduate school. All potential participants (n = 20) agreed to participate, and none withdrew.
Inclusion/Exclusion Criteria
Inclusion criteria were nurses working at least part-time enrolled and attending a graduate program in the state of Texas. Nurses working less than part-time and non-English speaking were excluded.
Institutional Review Board
Institutional Review Board approval was obtained (No. 2020-05-047). Prior to each interview, the purpose of the interview was explained to participants. Verbal informed consent was obtained and documented.
Data Analysis
Data analysis employed hermeneutic phenomenology methods as described by van Manen (1990). Transcripts were verified by reading and listening to the audio-recorded interviews simultaneously. Transcripts were reread, and the overall meaning was interpreted. The NVivo12
Results
Sample Characteristics
There was a total of 20 participants. The average age was 38 (range 25–64). All were female. Sixteen self-identified as White, not of Hispanic origin, two were Hispanic, one was African American, and one was Native American. Sixteen participants’ highest degree was a Baccalaureate of Science in Nursing (BSN) with four holding MSN degrees as the highest degree earned. All participants were attending fully online (n = 11) or hybrid-based (n = 9) content delivery methods. Eighteen were working full-time with two working part-time. Thirteen participants were working in acute care, five in primary care, and two as nurse educators. Participants’ specific demographic data including program type is outlined in Table 1.
Participant demographics.
Note. White = White-not of Hispanic origin; BSN = Baccalaureate of Science in Nursing; DNP = Doctor of Nursing Practice; MSN = Master of Science in Nursing; NP = nursing practitioner. *BSN to a terminal degree program.
Research Question Results
The overall meaning of the experience of working as an RN attending graduate school during the COVID-19 pandemic was a paradigm shift of existence in the realms of work, home, and school. The participants learned to quickly exist in the three realms in the context of the COVID-19 pandemic as it evolved. Themes stemming from the paradigm shift of existence included rapid change, uncertainty, fear, and support persons. Stress was an overarching theme for participants having lived the experience of the shifted realms of work, home, and school. Figure 1 is a contextual graphic representation of the overarching themes.
Representation of findings in the context of Heidegger’s (1962) dasein.
Rapid Change
At work, hospitals changed protocols and procedures without warning based on information as it unfolded from the Centers for Disease Control. Participants were faced with having to disregard everything they knew about best practices. As Participant 6, working on her PhD in Nursing Science and working as a clinical educator explained, It seems like everything we were taught that's good practice, it's flipped. We're putting IV poles out in the hallway, we're wearing masks in the hallway. Everything we knew that was good practice is gone. Yeah, so it's been a little unsettling in that way [P6].
…he [the patient] was having a heart attack… he coughed, and everybody stopped. Normally we’d get ‘em to the cath lab real quick, but had to wait for the COVID swab, which took 8 hours. It's all about caution, which I get, but it's been very difficult, dealing with delays of care like this [P2].
There were also treatment changes as more was learned about the treatment of patients with COVID-19.
… the policies constantly are changing. So keeping up to date with those and all the different treatments that we're trying on these patients are hard to keep up with [P 21].
Rapid change became a constant. Some days nurses were required to reuse personal protective equipment (PPE). Some days, PPE was rationed. Some nurses were subjected to unit structure prejudices regarding PPE. Participant 1 described a situation where a procedure nurse was denied PPE: She would say, “Hey, I need to do this procedure on this COVID-positive patient. I need a mask,” and they would say, “Go to your unit. We don't have masks for you here.” And it was like, “Whoa. Wait, what?” It kind of felt like racism, like it was segregation of, “You don't work on this unit. You don’t get your mask here” [P1].
There were also changes in delegation best practices. As Participant 19, a 39-year-old nurse working on a telemetry unit while pursuing her DNP in education explained: We [nurses] do everything…. We collect the labs, we deliver the meal trays…. empty the trash. It's literally the nurses doing everything for the patients because they want to limit the exposure. The purpose of delegation is so nurses can do more higher-level things for patients. Those higher-level things just aren’t getting done [P19].
The rapid change also occurred in the realm of home life. During the shutdown, RNs with young children had to juggle work-life, which usually consisted of 12-h shift work, while also navigating rapid changes in childcare and school options. Participant 12, a 28-year-old MSN student explained, I really struggled with sending my daughter to [a new] daycare. …because it was somewhere she hadn’t been before. … I felt like I'm giving my child to a stranger…. that was really difficult [P12].
Changes in work–life and home–life were exacerbated by students’ graduate programs implementing changes as well. One participant described an assignment-related change and its repercussions. The course content…changed to do like a COVID based project instead of the original plan. So, since the nursing courses are built off each other, the fact that we didn’t do that content we’re supposed to, now we’re having to try to get caught up. It's been a disservice, that content I was supposed to learn, I never did. But now I'm expected to know it [P10].
Another student described inconsistent communication regarding clinical and progression. … every day we would have like a different update, and it was like a back and forth with like, yes, you’re going to graduate. No, you may not graduate. So, um, that's when it was the most overwhelming [P 18].
Uncertainty
Uncertainty was closely related to rapid change. The theme of uncertainty as it unfolded, intersected across the three realms. As Participant 7, an outpatient clinic nurse working on her MSN in Informatics explained, So, going to school and working at the same time [was] already difficult, but during a pandemic it's been, well, uncertain. You’re having to rearrange things and figure out how you’re going to do things that you already had figured out. Then those plans fall through the cracks, so you have to come up with alternate solutions [P7].
At work, there existed an uncertain potential for furlough and self-quarantine. For example, …some of my other friends in the class were laid off from their positions without compensation. They were scrambling financially [P1].
Participant 16, who described multiple episodes of furlough, spoke of financial uncertainties and paying for school. It was stressful paying for school and [thinking about costs of] the supplies for the next semester while not knowing how much I would get on the next paycheck [P16].
The uncertainty of work transcended the uncertainty of home life. For example, to complicate financial instability, several participants’ spouses lost employment related to the COVID-19 shutdown, which put an additional financial burden on the family. As Participant 4, a 42-year-old female working as a unit manager described, My husband lost his job in January and we were paying cash for my school from his pay… but, to make matters worse, …I didn’t qualify for any of the financial aid whatsoever [P4].
Work uncertainty was closely related to rapid change in the hospital system. Specialty nurses were required to work in different practice areas contributing to the uncertainty.
There's a disruption in the level of comfort. When you’ve been an OB nurse for over 30 years… It's just a different type of nursing, so there's that uncertainty. You just don’t know [P12].
Program completion uncertainties were related to clinical hours attainment. Many facilities stopped allowing students to attend clinical. Participant 21, a nurse pursuing FNP–DNP while working in a pediatric trauma intensive care unit (ICU), described a situation of clinical hours attainment uncertainty: We may take you, we may not, we have to reevaluate things. I’ve had multiple small family clinics tell me no, just out of safety concern. However, I’m getting yeses from clinics that are two or three hours outside of the metroplex who aren’t seeing as many COVID patients. It's very uncertain trying to figure out how to get hours [P21].
For many participants, academic programs contributed to uncertainty. It was clear to participants, schools were doing their best to accommodate their situations and some participants appreciated the changes and the leniency with deadlines; however, some faculty did away with deadlines altogether, which proved challenging for other students. But when they made it to no due dates, …. it really got infinitely harder. Because it was just too much change. …[assignments] just really kind of fell off my radar for a little while. The classes that did not change when assignments were due, and what assignments were due, and how we did it, those were the easiest classes to finish [P4].
The school in this case was trying to be helpful but added to this participant's feelings of uncertainty. Participant 10, in the second semester of her program, described the school as a sort of stability amid uncertainty.
I would say uncertain would be how I would describe the whole thing. Things at work were constantly changing. But my school has stayed pretty stable. So I wouldn’t say I would describe that any differently, but it's just been … I guess, while school is stable, work has been unstable [P10].
In the academic setting, nurse educators as graduate students, faced uncertainty related to transferring their teaching and work to fully online and coordinating alternative clinical situations secondary to hospital systems denying students. As Participant 5, a nurse educator working on a DNP described, … I’m the clinical coordinator. Everything was great until the Friday before they were supposed to start and all the facilities closed access to students. So it has been a constant uncertainty and struggle to have multiple fallback plans or to adjust to this rapidly changing information and situation in each area that I've been working with [P5].
Fear
Participants experienced fear for themselves in contracting COVID-19 and facing the consequences of the potential for becoming very ill and/or death. I have fears for my students, but also for myself. And so, of course it makes me like, oh, I get to go back and do this all again tomorrow. It makes me a little bit, I don’t know. I get the heebie jeebies and wanting not to go back because it's frightening [P6].
Are we doing enough as far as … Have I washed my hands enough? Are we sanitizing enough? Just trying to stay safe and take care of patients safely while not taking this stuff home to our families. It's scary [P19].
Many participants’ facilities faced shortages in PPE which also contributed to their fear. Looking at my nurses, standing there with tears in their eyes, scared to death about walking into these rooms knowing the PPE was not up to standards… We just didn't know. It was terrifying [P4].
Participants, also, of course, feared for their patients. I saw people that were healthy, never had any health problems whatsoever, not as even a child, no asthma, 39, 40 years old, and I didn’t know if they were going to survive. It was really scary, and I was so concerned for my patients [P8]. I got kicked out of my neighborhood gas station when I went in to go get a coffee, because they knew I was a nurse… they asked me to leave and not come back… So even though I'm very proud to be a nurse, I’m a little bit nervous to show it off to anybody else because I don't want to be ridiculed or judged that I might make them sick [P8].
Regarding the school realm, many participants reported fear related to completing their programs. During the COVID-19 shutdown, clinical sites closed to students. Several participants were afraid of not being able to finish their programs of study in a timely manner because of these clinical experience uncertainties.
Support Persons
Having persons of support emerged as essential. Each source of support was separate from each others, but participants identified all as important to their experiences. If the work environment was healthy and included teamwork, the support of the team helped alleviate the stressors. The team environment created a feeling of “being in it together” for the participants. …it's a teamwork mentality. We all work as a team because we can get a patient that's fine one minute, and then 30 min later, they’ve tanked… having the team makes it less stressful, and that's happened a lot with COVID [P18].
… our administration, they were really supportive, and of course we didn’t agree with everything. But that's expected ya know. [They sent]… a kind of a, I guess a little motivational email. And I remember thinking in that moment, how honored I felt to be a part of the solution, because the whole world was impacted, everyone was scared. It was supportive [P11].
Participants tended to have a sense of community with each other and other nurses, in person, but also virtually via social media. Participant 15, a 33-year-old Cardiovascular ICU nurse working toward her FNP spoke of community support in social media venues, … a community of people and I think other nurses are probably finding this in their lives on [social media]. You have this community of people who are all trying to support each other in this environment… And all of those little things sort of add up to this community of people who genuinely care and want to help and that is helpful, even those little things [P 15].
The participants’ schools and faculty also were supportive of well-being awareness extending beyond the goal of student success in academics. Several participants mentioned having faculty support as they navigated existing as a working nurse attending graduate school during a pandemic. [One professor] made me feel okay for how I was feeling. Before that, I thought it was just me not coping well with any of this. So, for her to recognize, for them to be transparent about what was going on there. I could just tell that they were in the same boat with us and really trying. To be like, you're not forgotten about. We hear you; we see you. We know this is hard [P12].
Participant 7 appreciated the flexibility afforded her regarding clinical hours during her MSN in informatics coursework.
… they’ve been very flexible just trying to let us know that they’re working with us and trying to get us through the program. They were trying to get us to different options and different ways that we could come up with those clinical hours so that we could finish the semester. It helps when you’ve got professors and work environment that are willing to help [P7].
Participant 20, a 31-year-old nurse working in a leadership role in the inpatient setting while working on her FNP appreciated the transparency and updates provided by her school and faculty. They really went above and beyond to keep us updated with expectations, what is changing, giving us the extensions, extremely understanding in this situation, and I feel that the [names school] community has adapted in a very positive way [P20].
By far, the participants mostly appreciated the support from their families. As Participant 20 elaborated, … my family and my husband, my parents, they help with childcare. If it hadn’t been for them because my son's school closed, I wouldn’t have had a childcare option. I would have somehow had to find [something]. But I’m just extremely thankful that they were here and they really stepped up. They’ve been helping us tremendously so that we can both continue to work full time, and I can continue to go to school full time [P20].
Participant 15 spoke of maintaining family ties and support via virtual means.
My family has been great, my parents have been extremely supportive. My mom is very high risk for COVID, so we have not been able to see her, but she facetimes me and my kids regularly, and her and my dad always offer they’re just absolute unconditional support, which has been great [P15].
Overall, participants tended to attribute their persistence amid the chaos of the pandemic to their persons of support at work, school, and most importantly home.
Stress
Rapid change, uncertainty, and fear contributed to the theme of stress across all participants in the realms of work, school, and home lives. All participants mentioned high-stress levels regardless of the work setting. Work is very stressful, not just COVID related, but now there's a lack in staffing because some are just leaving the profession, so resources are limited, and work is just overtaxing and stressful [P19].
Participant 6, a nurse educator attending graduate school described, As far as my other life, my teaching life, that got ten times more stressful with having to translate everything to an online format. We had to proctor online. That work part of my life, probably my hours doubled. It was awful, which was a stressor on the graduate school part of life, as well [P6].
Participant 15 described stressors related to homeschooling her 2 children and working on her schoolwork with her husband working from home. …so when I’m home, they’re home… it is nearly impossible to be focused … I’m surprised he hasn’t barged in here already. It's very, very difficult to be left alone, my 12 year old does good, but the four year old is very difficult. And so [for faculty] to set an exam time at 10:00 AM in the middle of the day, when that's me trying to get my kids set up for home school and make sure everybody's had breakfast and changed and whatever. My husband's now working from home, so he needs private time to do his WebEx classes. So I just felt like there was just a very distinct lack of connection between what we were trying to do and what they [the faculty] were trying to do [P15].
Remote proctoring for exams from shared spaces at home was stressful. I’m in my office and you can’t really see it, but there's a bunch of clutter in here because my husband shares it with me and I’ve got kids and their stuff hanging on the walls, and so when I took the practice exam, it flagged my video for too much clutter. And I would have to take down my whole office just to take a test … that's very inconvenient and stressful under the circumstances… [P15].
In the context of working while attending graduate school for these nurses, stress was a theme closely related to and intermingled with the themes of rapid change, uncertainty, and fear.
Discussion
The overall meaning of the experience of working as an RN while also attending graduate school during the COVID-19 pandemic was a paradigm shift of existence, among three realms of work, home, and school. The new existence emerged contextually during the COVID-19 pandemic with its related consequences including shutdown, quarantine, and self-isolation. Themes stemming from the paradigm shift of existence included rapid change, uncertainty, fear, and support persons. Stress was an overarching theme (Figure 1).
The paradigm shift for nurses working during a pandemic while also attending graduate school cannot be discussed exclusively. Temporally and in the context of the COVID-19 pandemic, nurses attending graduate school while working, faced unique challenges transcending all resulting themes. Like nurses not attending graduate school, the nurses in this study dealt with constant practice guidelines changes and home life changes. In addition, they navigated related adjustments in graduate school requirements. Changes led to a great amount of uncertainty and fear resulting in stress. Existing environments of support at work, school, and home helped mitigate stress.
The nurses in this study faced similar practice-related challenges to those already reported in the literature. Participants voiced concern, fear, and uncertainty related to the endless practice and guidelines changes. For example, isolation requirements constantly changed including time spent with COVID-19 patients related to exposure potential (Al Thobaity & Alshammari, 2020; Catania et al., 2021; LoGiudice & Bartos, 2021). Participants feared for themselves, but also, of potentially bringing a deadly virus home to their families and loved ones. Nurses in other countries and settings experienced anxiety and fear of working with a virulent infectious disease and related unknowns (Jang et al., 2022; Sun et al., 2020). Changes in guidelines exacerbated the uncertainty for participants. Nurses reported experiencing confusion and uncertainty regarding working conditions which made providing nursing care challenging (Jang et al., 2022; LoGiudice & Bartos, 2021). The self-isolation uncertainty, resulting in being away from family consequently contributed to uncertainty with home life for participants. Some participants faced financial difficulties because of needing to self-isolate due to exposure, without compensation. Participants expressed frustration in the lack of, or inconsistencies in communication on guidelines. Catania et al. (2021) found nurses, especially critical care nurses felt less autonomous in caring for COVID-19 patients secondary to uncertainties in treatment guidelines, which resulted in decreased confidence. For nurses, lack of information resulted in a marked wariness and concern about practicing outside the bounds of research and evidence (Catania et al., 2021; LoGiudice & Bartos, 2021). Participants expressed frustration with the lack, reuse, and self-disinfection of PPE, staffing shortages, delegation challenges, reassignments, and excessive unpredictable workloads, which contributed to the uncertainty and fear. Nurses in the Catania et al. (2021) study faced similar concerns and frustration regarding the lack of PPE and guidance regarding its use. The frustrations described by the participants in this study have been described in previous pandemic situations as in the H1N1 outbreak in 2009 (Corley et al., 2010). As the American Nurses Association (2020) reported, close to half of the nurses responding to a survey working during COVID-19 attributed their contracting the virus to deficiencies in best practices including reuse of PPE, rationing of PPE, and self-disinfecting of PPE. Similarly, Jin et al. (2020) found the main perceived mode of infection among healthcare workers was the reuse of PPE. In this study, a nurse was refused PPE due to unit-based prejudices. In addition, there existed a complete lack of delegation without adjustment in workload. For example, participants were expected to take on pre-COVID-19 patient–nurse ratios without the usual benefits of delegation secondary to isolation requirements. The participants faced a double standard to deliver high-level care, while also delivering care that under normal circumstances would be delivered by other members of the care team. It was common for all patient-related care, including work done by radiology, nutrition, and other specialties to be conducted solely by the primary nurse, which expectedly resulted in exhaustion and an exacerbation of what was already a stressful care situation (Jang et al., 2022). Participants expressed frustration with reassignment to areas outside of their area of expertise. Specialty nurses were often assigned to areas outside of their clinical expertise (Catania et al., 2021; Kennedy et al., 2022). Nurses reassigned during COVID-19 reported concerns with the scope of practice, team dynamics, and environmental challenges (Kennedy et al., 2022). According to Benner (1984) nurses practicing in an area other than their home unit revert to novice secondary to differences in scope and environment.
In addition to changes occurring in the work realm, changes and uncertainty in graduate school contributed to participants’ fear and stress. Most graduate schools were also forced to implement changes quickly. For the participants, there was uncertainty related to clinical placements. For example, some communications conveyed that clinical would occur as planned, then quickly, new communications stated the opposite. Inconsistent and conflicting communications from graduate school administrators related to progression and graduation trajectories served as a source of frustration for participants. Graduate students experienced stress related to inconsistencies in communications from their graduate programs (Link et al., 2021; Nodine et al., 2021). Students and graduate programs were dealing with practice partners’ needs and were forced to quickly adjust clinical requirements secondary to the pandemic-induced shutdown. Subsequently, participants feared they would not complete program requirements because of the inability to attain the required clinical hours. Program completion fears compounded the existing stress of attending graduate school during a pandemic (Link et al., 2021; Nodine et al., 2021). The uncertainty, fear, and stress were exacerbated by the potential for exposure. In situations when participants were able to attend clinical, they faced the risk of exposure and related exposure consequences: becoming ill, self-isolation, and interruption in clinical progression. In contrast, some participants, specifically those early in their programs with no pending clinical requirements, found school to be stable: an away from the stress of work and even home life which warrants further study. Participants experienced graduate program changes intended to be beneficial, but sometimes had the opposite effect. Most participants appreciated accommodations made to assignment deadlines consistent with the existing literature (Link et al., 2021; Nodine et al., 2021). However, for some participants, no deadlines and uncoordinated curriculum changes led to procrastination and a lack of content needed for subsequent coursework serving as a source of stress. In addition, participants experienced stressors related to examination changes. For example, participants experienced frustration and stress because of technological, changed logistics of remote exam proctoring. Participants were required to quickly adjust to remote exam proctoring including acquiring webcams and technology, taking exams in testing windows, and testing from home with family members present. There is little research on remotely proctored exams (Castaño et al., 2021). However, participants, as graduate students, expressed discontentment with the process and, in addition, thought it demeaning to their integrity. Indeed, Elsalem et al. (2021) found, students prefer other forms of assessment to remote exam proctoring.
The COVID-19 pandemic work and school changes intermingled with participants’ related home life changes. Participants experienced shutdown-related financial burdens including spouse work changes while navigating homeschooling and/or childcare situations. The participants themselves reported being furloughed without pay when required to self-isolate. In addition, spouses were furloughed related to the COVID-19 shutdown exacerbating existing financial stressors for participants. Prepandemic, finances were a concern for graduate students (Nodine et al., 2021). During the pandemic, Nodine et al. (2021) found decreases in household income to exacerbate the existing financial stressors. For participants, there existed frustration with government assistance programs neglecting to consider the unique circumstances of being a nurse working while also attaining higher graduate education. Participants also had concerns regarding going to work when their children were in uncertain childcare situations.
Stress emerged as a main theme stemming from rapid change, uncertainty, and fear. Nurse graduate students experienced “cyclical stress” meaning the experiences of stress resulting from the combination of change, uncertainty, and prioritization exacerbated stress (Link et al., 2021, p. 449). Nurses working with COVID-19 patients experienced psychological ramifications including fear, anxiety, and stress (Catania et al., 2021; Doo et al., 2021; Kennedy et al., 2022). Rosenthal et al. (2021) found health professional graduate students experienced COVID-19-related mental health concerns including depression and related posttraumatic stress. Participants were already coping with the expected stress of working while attending graduate school. The pandemic forced participants to come to a new existence.
However, the stress of the new existence was mitigated by healthy support environments at work, home, and school. At work, team support including a caring environment was cited as a mitigator of stress for nurses (Labrague & De Los Santos, 2020; Sun et al., 2020). Reassigned nurses experienced less stress when they served in a supportive team member role with nurses experienced to care for COVID-19 patients (Catania et al., 2021; Kennedy et al., 2022). Supportive graduate school environments were appreciated by participants. Link et al. (2021) found students to appreciate accommodations, but also faculty engagement and reflection assignments. Having personal support from family and loved ones played a large role in supporting the participants working while in graduate school. Nodine et al. (2021) found home life to be the largest positive change for nurses amid the pandemic. For many participants extended family reached out to assist with childcare, spouses managed and/or shared homeschooling situations, and family connections grew stronger using virtual means.
Strengths and Limitations
The research team consisted of a nursing research scientist and nurse educator with a Doctorate in Philosophy of Nursing Science with an established program of research (interviewer) and two Nurse Educator MSN students (thematic analysis verification), who were living the experience during the study. The was no relationship with study participants other than the interview contact. The research topic was of interest to the researchers as nurse educators which was shared with participants.
The frameworks of Guba and Lincoln (1994), Lincoln and Guba (1984), and van Manen (1990) were utilized to ensure trustworthiness and scientific rigor in this qualitative inquiry. Interpretation and circular writing occurred congruently with data collection until data saturation was deemed achieved. Researcher reflexivity was a strategy employed toward truth and accuracy to the interpretations. Researcher audit trails were utilized to track thematic data analysis.
While several strategies were used to strengthen the trustworthiness of the interpretations, the limitation of this study is transferability. The sample was rather homogenous; therefore, the results are not transferable. Despite these threats, the study findings lend insight into the lived experience of nurses working while also attending graduate school during a global pandemic.
Implications for Practice
The COVID-19 pandemic was and remains an unprecedented time in modern nursing practice and education. Graduate students pursuing higher education while also working as nurses in practice face unique challenges during a crisis. Nurse leaders and educators should create specific predictable communication plans. Communication should be clear and concise. Crises have occurred in the past, including other viral outbreaks and catastrophic events including terrorist attacks, hurricanes, and earthquakes. Nurses, historically, have dealt with new infectious disease outbreaks with unknowns, such as H1N1, Ebola, severe acute respiratory syndrome, and human immunodeficiency viral diseases among others. Lessons have been learned from these experiences and recommendations offered (Corley et al., 2010; Einav et al., 2014). Implementation of lessons learned from these experiences during uncertain times seems to be lacking. Based on the findings in this study, it is essential for nurse leaders and educators to create ways to mitigate change. Change is challenging for many, even in the best circumstances. In fact, nurse theorists and researchers should explore and revise change theory specific to nursing practice. In addition, nurses in practice need reassurance regarding evidence and ethical principles related to social justice while working during times of crisis and uncertainty. During the COVID-19 pandemic, clinical sites shut down to nurse graduate students, which was a missed opportunity for not only learning, but also to support the practice environment in a time of crisis. Nurse leaders and educators should collaborate to maximize such opportunities by offering clinical hours for RN graduate students to support nursing efforts in times of crisis. The participants faced unique financial burdens. Financial aid opportunities were lacking for graduate students and options should be explored. Graduate schools should carefully consider and plan curricular changes including the introduction of new content and technologies during uncertain times. Remote proctoring for exams emerged as a significant source of frustration and stress for participants exacerbated by the related intrusion in their homes and lives. The matter of remote proctoring and alternative assessment methodologies warrants further investigation. The outcomes related to healthy and supportive work environments were supported by this study. Healthy supportive environments across work, school, and home lives were important. Nurse leaders and educators should strive to support nurses working while attending graduate school with healthy environments, while also paying attention to home–life balance needs.
Conclusions
Using hermeneutic phenomenology, this qualitative study sought to interpretively explore lived experiences of working nurses attending graduate school during the COVID-19 pandemic. There existed a paradigm shift of three realms of work, school, and home lives. Navigation of this shift involved coping with rapid change, uncertainty, fear, and related stress. The stress was mitigated by healthy environs across the three realms. Nurse leaders and educators in times of crisis, should reflect on past experiences while collaborating to mitigate change and stress and implement better communication strategies, while also providing supportive environments.
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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Spring 2021 Texas A&M University-Corpus Christi (TAMU-CC), College of Nursing and Health Sciences Research Enhancement Grant, and the TAMU-CC Division of Research and Innovation COVID-19 Just in Time funding program.
