Abstract
Introduction
The emergence of COVID-19 caused a sudden, unexpected disruption in the clinical training experiences of nurse trainees at the US Department of Veterans Affairs (VA), the largest clinical training setting in the US for nurses.
Purpose
To understand associations between COVID-19 and nurse trainees’ satisfaction with their training experiences and the likelihood that they would consider future VA employment.
Methods
A cross-sectional design was used to assess 7,890 nurse responses from the VA's Trainee Satisfaction Survey for academic years 2018–2021.
Results
After the pandemic, trainees reported decreased training satisfaction (95.06% vs. 93.46%; P = .0028). Willingness to consider future VA employment was unchanged. Patient case mix, the onboarding process, and challenges with other staff were the most common reasons for dissatisfaction.
Conclusion
Nurse trainees expressed a small but statistically significant degree of dissatisfaction with their clinical learning environment during this study period but their willingness to seek employment with the VA remained high.
Introduction
The current and projected nursing shortage in the United States (Juraschek et al., 2019) underscores the importance of understanding how nurse trainees have been impacted by the COVID-19 pandemic. Representing the next generation of nurses, how they have been impacted may prove to be vital for decades to come.
Onset of the COVID-19 Pandemic
The arrival of the highly infectious virus created a significant challenge for undergraduate and postgraduate nurse trainees who were in the midst of satisfying their clinical requirements (Dewart et al., 2020; Emory et al., 2021; Smiley et al., 2023). Acute and long-term care facilities as well as public health departments were forced to make tough decisions about tolerable risk for nurse trainees, patients, and their own nursing staff. Some temporarily canceled their clinical placements (Blevins, 2021; Chan et al., 2021; Zerwic et al., 2021). At the same time, schools of nursing temporarily closed in-person learning and transitioned to virtual learning (AACN, 2020; Dewart et al., 2020).
Review of Literature
Changes in the Learning Environment
The learning environment was changing significantly for those who would be clinical preceptors to trainees. More than half of 32,000 nurses who responded to the first of many national surveys reported taking care of patients testing positive or suspected of testing positive for COVID-19 and more than half reported being short or out of personal protective equipment (PPE; ANA, 2020). Three months into the pandemic, 49% of more than 10,000 respondents reported they were providing direct care to COVID positive patients. Just over 50% reported feeling overwhelmed and just over 50% were having difficulty sleeping or sleeping too much (ANF, 2020a). By 9 months, 66% of more than 12,000 respondents reported providing direct care to COVID positive patients. 64% were feeling overwhelmed and 67% were having difficulty sleeping or sleeping too much (ANF, 2020b). One year into the pandemic, more than 80% of 22,000 respondents reported guidance to reuse N95 respirators (ANF, 2021). A majority reported feeling stressed, frustrated, exhausted, overwhelmed, anxious, and overworked. The mental health strain was most difficult for nurses 34 years and younger, with 51% feeling not or not at all emotionally healthy and 52% having experienced an extremely stressful, disturbing, or traumatic event. At least 200,000 experienced nurses left the workforce between 2020 and 2022 (Smiley et al., 2023).
Nursing Shortage
A shortage of nurses has been an established concern for more than two decades. A detailed integrative literature review identified major contributors: an aging nursing workforce, declining nursing school enrollment, a changing work climate, and the poor image of nursing (Janiszewski Goodin, 2003). It has been expected that a population cohort of persons over 65 years, known as the Baby Boomers, would live longer, double in size and need geriatric care to manage multiple conditions such as obesity, diabetes, and arthritis (AHA, 2007; Rosseter, 2017). A large portion of this aging cohort includes nurses who are already starting to retire and will eventually leave an estimated gap as high as one million nurses by 2030 (AHA, 2007).
Finding solutions for the nursing shortage is complicated for a variety of reasons, one of which is restricted enrollments that slow the rate of graduating new nurse candidates. Enrollments are primarily restricted by the lack of clinical accommodations and a national faculty shortage (Keaton, 2021). Schools participating in the most recent National League for Nursing Faculty Census Survey of Schools of Nursing cited a few reasons for their difficulties in hiring new faculty: not enough qualified candidates, not able to offer competitive salaries, jobs less attractive than other jobs, and budget constraints (Mazinga, 2022).
From the faculty's perspective, a national survey of 3,556 nursing faculty teaching in undergraduate, Master's, and doctoral programs showed that 68% were experiencing a moderate level of burnout and 16.9% were experiencing a high level of burnout (Zangaro et al., 2023). Scores for exhaustion, disengagement, and overall burnout were found to be highest for the following groups: 35–54 years old, in current institution for 6–15 years, working as an assistant or an associate professor or holding either a Doctor of Nursing Practice (DNP) or a Doctor of Philosophy in Nursing (PhD). Contributing factors for burnout included the amount of workload, demands to obtain funding for research, investment in mentoring students, pressure to publish, pressure to participate in committee and community service, and difficulty finding balance between work and family. More than half of the samples were interested in accepting an early retirement and almost half indicated they were planning to retire within 10 years.
Practical factors can also influence the supply of nurses. Trainees have the choice of taking numerous different educational pathways to licensure (e.g., Diploma, Associate, Baccalaureate, etc.) and currently there is a shortage of baccalaureate prepared nurses who would most likely seek a higher degree and become faculty (IOM, 2011; Wakefield et al., 2021). Issues retaining newly licensed nurses have also emerged (Rosseter, 2017).
While much has been done to address the anticipated shortfall of nurses, recent evidence indicates younger nurses have been disproportionally impacted by the COVID-19 pandemic and staffing shortages have reached critical levels (ANA, 2022). Given the nuances of building and maintaining a nursing workforce to meet the expected need, it is vital to understand the satisfaction and employment intentions of nurse trainees.
Objective
There are two objectives for this national sample of nurse trainees. The first is to understand nurse trainees’ satisfaction with the Department of Veterans Affairs (VA) clinical learning environment (e.g., number and diversity of patients seen, spectrum of patient problems, time for working with patients and learning). The second objective is to understand how nurse trainees are considering future VA employment before and during the COVID-19 pandemic.
Methods
The study team analyzed responses from the VA Trainee Satisfaction Survey (TSS) conducted by the Office of Academic Affiliations (OAA) over three academic years spanning July 2018 to June 2021 to observe how the COVID-19 pandemic may have impacted nurse trainee experience. To assess trainee satisfaction, OAA developed the VA Trainee Satisfaction Survey TSS, which may be completed throughout the academic year. The TSS measures satisfaction with the VA clinical training experience, identifies areas for improvement in the learning environment, and provides a national performance metric for the VA's educational mission. All nurse trainees who have completed a clinical practicum at VA are encouraged to complete the TSS. At the end of their VA rotation, trainees are emailed a link requesting that they complete the survey online.
Design
This is a cross-sectional study in which TSS responses for three academic years were collected from August 3, 2018 to July 30, 2021 from all 156 VA facilities across the country. This manuscript presents data about nurse trainees and is a subset of a larger study of various VA health professions trainees. Additional information regarding the methodology is detailed in a prior study of physician trainees (Northcraft et al., 2022).
Survey Instrument
Outcomes assessed with the survey questions included the trainee's satisfaction with the VA onboarding/in-processing experience, clinical faculty/preceptors, the clinical learning environment, the working environment, and the physical learning environment. Trainees were also asked about the likelihood they would consider future VA employment, as well as demographic information including clinical training program, facility name, and education. See Appendix A for survey questions.
Sample
A total of 9,020 nurse trainees responded to the TSS indicating they received training at 156 VA facilities in academic years 2018–2019 (July 1, 2018–June 30, 2019), 2019–2020 (July 1, 2019–June 30, 2020), and 2020–2021 (July 1, 2020–July 30, 2021). Given the educational pathway of trainees, the sample is separated into two groups: Group A consists of those who are seeking Diploma (Pre-Baccalaureate), Associate Degree, or Baccalaureate Degree. Group B consists of those who are seeking Master's, Post-Master's, or Doctoral degrees. Trainees satisfying requirements to become a nurses’ aide or licensed vocational/practical nurse have been excluded from this sample.
Ethical Considerations
This project was reviewed by the US Department of Veterans Affairs Office of Academic Affiliation and deemed to qualify as a quality improvement study, as it was designed for internal purposes and did not meet criteria to be considered research (i.e., it was not designed to produce generalizable knowledge). Access to the data was granted by a formal data use agreement. The conditions of the agreement prohibit publication of quotes to maintain confidentiality and anonymity as promised at the time of data collection. This project did not require review by an Institutional Review Board as a research activity as it was approved as a quality improvement project by the Department of Veterans Affairs, Greater Los Angeles Institutional Review Board, #1767580-1. As such, informed consent was waived by the Department of Veterans Affairs, Greater Los Angeles Institutional Review Board due to minimal risk to subjects.
Measures
For the purposes of this study, “pre-pandemic” is defined as responses collected before February 29, 2020 and “pandemic” is defined as responses collected after April 1, 2020. Due to the uncertainty of the training period for which the respondent was providing information, responses from the month of March 2020 have been excluded from the current analyses.
To measure satisfaction with the training experience, responses to the survey question “Overall, how satisfied are you with your VA training experience?” were collapsed into satisfied (satisfied/very satisfied) and dissatisfied (dissatisfied/very dissatisfied). To measure the likelihood to consider future VA employment, responses to the survey question “As a result of your training experience, how likely would you be to consider a future employment opportunity at a VA medical facility?” was collapsed into likely (likely/very likely) and unlikely (unlikely/very unlikely).
The TSS also includes other satisfaction measures that focus specifically on the onboarding experience, clinical faculty/preceptors, the clinical learning environment, the physical environment, the working environment, and respect at work. For these questions and only if a respondent chooses “very dissatisfied” or “dissatisfied,” the survey provides the option to specify the cause of dissatisfaction in an open-ended format.
Statistical Analyses
Two separate logistic regressions were conducted to test the association between pandemic group, nursing group, and a pandemic group-by-nursing group interaction term for the two outcome variables: Overall satisfaction and likelihood of future VA employment. Margin commands were used to calculate the probability of reporting satisfied/very satisfied and likely/very likely for each group and the 95% confidence intervals. STATA SE version 17 was used for the analyses.
Reasons for Dissatisfaction, Rapid Coding Process
All four team members (AD, AG, JB, HN) analyzed qualitative data based on the narrative survey feedback from VA nurse trainees regarding the reasons of dissatisfaction. The research team used a rapid coding process (Gale et al., 2019; Taylor et al., 2018). JB team member was responsible for identifying COVID-related causes of dissatisfaction by searching for keywords such as “COVID,” “pandemic,” “virus,” “PPE,” “social distanc*,” “mask,” “N95,” “vaccin*,” “sanitizer” in the narrative responses. A review of the narrative comments identified key issues and initial subject categories, codes, and definitions based on the survey questions. JB and AG were responsible for an independent review of the codes to assign each narrative a code(s). All team members met to discuss any discrepancies and completed final assignment of code(s) to each narrative.
Results
Overall Satisfaction and Likelihood of Future Employment
Response Rate and Sample
62,638 nursing trainees received training at a VA facility in academic years 2018–2019, 2019–2020, and 2020–2021 (OAA, 2021). Across these three academic years, 9,020 nursing trainees responded to the TSS (14.4% response rate). As stated above, 1,139 responses from nurses’ aide, licensed vocational/practical nurse were excluded from the final sample. See Figure 1 for the distribution of nurse trainees in each subgroup.
Revision.
Overall Satisfaction and Likelihood of Future Employment
Overall, nursing trainees reported decreased satisfaction with their training experience once the COVID-19 pandemic began (95.06% v. 93.46%; P = .0028; 95% CI −0.03 to −0.01). The COVID-19 pandemic did not have an association with nursing trainees’ willingness to consider future VA employment (P > .05). There was no effect of nursing group on outcome variables. See group differences in Table 1.
Logistic Regression Predicting Overall Satisfaction and Likelihood of Nurses Considering Future VA Employment by Group.
Note. Group A = Trainees seeking a Diploma (Pre-Baccalaureate), Associate Degree, or Baccalaureate Degree. Group B = Trainees seeking a Masters, Post-Masters, or Doctoral degree.
Reasons for Dissatisfaction
Of the 9,020 VA nursing trainees that responded to the survey, 1,122 provided reasons for dissatisfaction with their VA training experience that contained keywords associated with COVID. Out of the 6,253 VA nurse trainees seeking Diploma (Pre-Baccalaureate), Associate Degree, or Baccalaureate Degree that responded to the survey, 796 provided reasons for dissatisfaction with their VA training experience, 38 of which contained keywords associated with COVID. Out of the 1,603 VA nurse trainees seeking Master's, Post-Master's, or Doctoral degrees that responded to the survey, 257 provided reasons for dissatisfaction with their VA training experience, 15 of which contained keywords associated with COVID. Because the survey includes an open-ended response option, one person could have provided more than one reason for dissatisfaction. We identified eight common reasons based on the review of trainees’ narrative feedback (See Table 2). Thirty-two responses were about lack of patient volume and diversity due to COVID limitations that, in their view, negatively impacted their clinical learning experience. For example, multiple trainees mentioned limited patient interactions which lead to fewer opportunities for learning. They also noted the similar demographics and health issues that the patients had. Twenty-three responses were about onboarding challenges in getting VA badges or computer access that were augmented by the pandemic. One trainee said the clinical training was only 3 weeks, but the onboarding process comprised most of that time. Seventeen responses were about disrespectful staff, lack of teamwork, feeling unwelcome, feeling like they were in the way, and not feeling like they were part of the team. Eleven responses were about limited access to workspace, functional computers, or cameras for video appointments. Nine responses were about lack of communication and feedback from nurse managers and clinical faculty. Eight responses were about being dissatisfied with the lack of housekeeping or rooms that lacked cleanliness. Four responses were about lack of PPE and supplies that seemed essential during the pandemic. Finally, one response was about an unnamed reason related to COVID-19.
Reasons for Nurse Trainee Dissatisfaction During the Pandemic.
Open-ended response option within the survey allowed for one respondent to report more than one reason for dissatisfaction.
Discussion
Results from this survey provide a helpful perspective as the VA is both the largest employer of nursing personnel (ONS, 2023) and the largest provider of health professions training (ONS, 2022) in the US. VA provides the opportunity for nurse trainees to satisfy clinical requirements for Diploma, Associate, Baccalaureate, Master's, and Doctoral programs. Education for health professionals within the VA is led by OAA. In collaboration with schools of nursing across the nation, OAA supports the clinical learning of more than 25,000 nurse trainees annually. Because of VA's broad educational reach, COVID-19's impact on nurse trainees could extend across the US healthcare system.
Satisfaction
Results from this study show both nurse trainee groups had a statistically significant degree of dissatisfaction with their clinical learning environment during this study period. However, it is noteworthy that while statistically significant, the degree of dissatisfaction observed is less than might be expected given the degree of disruption caused by the pandemic.
Access to patient volume and diversity of case mix was cited most often in qualitative data as reasons for dissatisfaction for both groups of nurses. In large part, this lack of access could be explained by the VA observing 42% fewer inpatient admissions during the first 6 weeks of the pandemic (Baum and Schwartz, 2020), which was consistent with many hospitals across the country. Although VA responded by increasing video connection with Veterans in all Veterans Affairs Medical Centers at least twofold (Jacobs et al., 2022) and distributed tablets for video connection to more than 850 inpatient settings and more than 7,000 high risk Veterans with access needs, adoption was difficult for some medical centers, especially those with less video connection experience and poor broadband coverage (Heyworth et al., 2020). VA provider and patient groups also varied regarding their use and preference for telephone versus video-based care (Der-Martirosian et al., 2022, Heyworth et al., 2020).
Onboarding served as the second most common reason for dissatisfaction for both groups, and most of the qualitative comments reflected preexisting challenges around lengthy onboarding processes which were possibly exacerbated during the pandemic. Challenges related to other staff ranked as the third most common reason for dissatisfaction. Despite turning to contract healthcare workers and bypassing some of the normal hiring and onboarding procedures as cases of COVID increased, some VA employee representatives reported that employees were worn out and unable to make up for staffing shortages and the growing number of sick employees (Katz, 2020). Notwithstanding the pandemic, the clinical learning environment is known to be stressful and its impact on student performance and matriculation cannot be understated (Singer et al., 2022). Especially for undergraduate nursing students, impressions are formed, and professional socialization is shaped during the early learning experiences (Leighton et al., 2021). This is when students acclimate to unit culture, the clinical educator, unit census, and patient type.
Other national surveys collected during the same phases of the pandemic provide both similar and contrasting findings. A national survey of students posed to graduate during the initial months of the pandemic provided descriptions such as abrupt and ubiquitous change, uncertainty, emotional and mental turmoil, fear, and worries (Feeg et al., 2021). Despite their experiences, some reported finding silver linings and found motivation for staying positive while 82% said they felt okay about working with patients diagnosed with COVID-19 as long as they had the proper PPE, instruction, and supervision.
Six months into the pandemic, Emory et al. collected data from nursing students in five regions across the US and 80% reported changes in clinical learning (Emory et al., 2021).
Although respondents were not specifically asked about satisfaction with their clinical environment, more than half agreed the changes would affect their success on licensure and certification exams and over half agreed the changes would affect their ability to provide quality of patient care. Half of narrative responses specific to teaching/learning included the words fear, anxious, anxiety, afraid, concern(ed), worried, worry, and scared or scary.
Undergraduate trainees were concerned about missing in-person clinical experiences, passing licensure examinations, and feeling less prepared for practice (Dewart et al., 2020; Emory et al., 2021; Feeg et al., 2021). Advanced practice trainees found themselves navigating the sudden closure or suspension of clinical agreements they had personally arranged, and some were asked to increase hours providing patient care in lieu of academic endeavors (Copeland, 2020; Fauteux, 2022; O’Keefe & Auffermann, 2022).
Willingness to Seek Employment
Despite the increase in dissatisfaction, the authors also find it interesting that we did not observe significant changes within the quantitative data regarding trainees’ willingness to seek employment from the VA for either group. Respondents were not prompted to provide a narrative response for this survey item and therefore a future study is required to understand the factors influencing their response. It is possible these students were left with a sense of loyalty to the VA for keeping its commitment to them as trainees. Otherwise, finding non-VA clinical placements for nursing students has been challenging because of the worsening nursing shortage, an aging nursing workforce, campaigns to promote the nursing profession, an increase in nursing applicants, a shortage of educators and not enough clinical sites with preceptors available to train students (Copeland, 2020).
A comparison of our results with other studies suggests a consistent story related to the various satisfaction survey items. A stressful learning environment, evidence of resiliency, fears related to the virus, and yet we find no reported or observed evidence that the clinical preceptorship was compromised. Our results for seeking employment could also be considered similar to other studies in that the comments of concern were about obstacles preventing or delaying progression to the role of a newly licensed nurse.
Strengths and Limitations
The primary limitations with this study design are that the open-ended questions were only asked of those who expressed dissatisfaction. The survey does not include demographic data and therefore there may be differences in the mix of respondents who completed their training prior to the pandemic and during the pandemic. We focused on pandemic related keywords to limit the potential to inappropriately code responses as pandemic-related, but in doing so we may have missed responses describing stress and feelings of burnout that did not specifically include words such as “pandemic” and “COVID.” A low response rate represents an additional limitation. Responses from those who responded to the survey may be different from those who did not complete the survey. The response rate for the TSS was consistently low before and during the pandemic, suggesting that the pandemic likely did not create a systemic response bias. Nonetheless, the data set is still a large national sample.
Implications for Practice
While this sample is exclusive to VA, VA and non-VA hospitals were facing similar challenges from COVID-19 during the study time period. Accordingly, given the large number of nurses who receive some training at VA, these observations may provide insight into the experience of nurses more broadly and how the abrupt changes caused by the pandemic might have influenced nurse trainee satisfaction with the clinical learning environment and willingness to seek first employment opportunities.
Although the drop in satisfaction was small, the authors would advise that the measures be studied over time given the long-term impacts of the pandemic. A small difference could have a consequential impact on the VA, given the VA is the largest employer of nurses in the nation (ONS, 2023). It is possible that the effects will become evident as time passes and studying licensure results is a relevant research question to consider (Emory et al., 2021). Given the nursing shortage and the swelling of the over 65 population, following this cohort of trainees to understand their employment behaviors will serve as vital information. As Emory et al. point out, the effects of a pandemic on students have never been studied.
Conclusion
While our findings are somewhat expected considering the difficult working conditions during the pandemic, it is encouraging that the effects were not greater given the current nursing shortage and the predicted national crisis (Buerhaus et al., 2017). Nurse trainees expressed a small but statistically significant degree of dissatisfaction with their clinical learning environment during this study period but their willingness to seek employment with the VA remained high. Future studies should examine whether the desire for future employment holds in other healthcare settings. Furthermore, although our findings suggest that current trainees may continue to seek work as nurses, the observed decrease in satisfaction, in combination with the nursing shortage, warrants future study to ascertain whether the overall impact of the pandemic remains limited on the trainees as they move into future careers as nurses.
Footnotes
Acknowledgements
This material is based upon work supported by the United States Department of Veterans Affairs, Veterans Health Administration, Office of Patient Care Services. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. The authors wish to thank Nancy Harada, PhD, PT, VA Office of Academic Affiliations, for her perspectives regarding the study.
Authors’ Contribution
All authors made substantial contribution to the conception and design of this study, analysis, and interpretation of the data. HN and AG drafted the manuscript or revised it critically for important intellectual content. All authors approved the final version of the publication. All authors agreed to be held accountable for all aspects of the work. HN performed the quantitative analysis, and G and JB performed the qualitative analysis, while AG supervised the study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Statement
This project was reviewed by the US Department of Veterans Affairs Office of Academic Affiliation and deemed to qualify as a quality improvement study, as it was designed for internal purposes and did not meet criteria to be considered research (i.e., it was not designed to produce generalizable knowledge). Access to the data was granted by a formal data use agreement. The conditions of the agreement prohibit publication of quotes to maintain confidentiality and anonymity as promised at the time of data collection. This project did not require review by an Institutional Review Board as a research activity as it was approved as a quality improvement project by the Department of Veterans Affairs, Greater Los Angeles Institutional Review Board, #1767580-1. As such, informed consent was waived by the Department of Veterans Affairs, Greater Los Angeles Institutional Review Board due to minimal risk to subjects.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This material is based upon work supported by the United States Department of Veterans Affairs, Veterans Health Administration, Office of Patient Care Services.
