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-->Citation: Cohen D, Crabtree B. "Qualitative Research Guidelines Project." July 2006.
Examining the world through qualitative inquiry
This week’s guest blogger is Kyu Ha Choi, who is a Ph.D. candidate in the Sport Management and Policy program in the Department of Kinesiology at the University of Georgia, Athens, GA, USA. His research focuses on sport event management with emphasis on the development of sport along with qualitative research methods.
Screencast on reflective journals in qualitative research
I initially had three questions that pertain to the concept of reflective journals in relation to qualitative research. Those three questions were: (1) what is the reflective journal in qualitative research? (2) why do we implement reflective journals in our research? and (3) what are the outcomes of employing reflective journals in research? In response to these questions, the objectives of this essay are to understand the concept of reflective journals within qualitative research and to understand why reflective journals are implemented in qualitative research. This essay has been written for any researcher, but especially novice researchers who are not very familiar with or have a limited knowledge of reflective journals in qualitative research and how they might incorporate them in their research. This essay will help researchers learn about the possible outcomes of employing reflective journals and outline some challenging issues of using reflective journals in research.
The reflective journal in qualitative research is a written record by the researchers themselves and is written throughout the research process. A reflective journal includes the details of what the researchers did, thought, and felt while analyzing the data. Then, the rationale behind those thoughts and percepts are recorded. According to Russell and Kelly (2002), keeping self-reflective journals during the analysis process is a strategy that facilitates reflexivity by using the researchers’ journals to examine “personal assumptions and goals” and to clarify “individual belief systems and subjectivities” (p. 2). By doing so, keeping reflective journals consciously acknowledges the values and experiences of the researchers rather than attempting to control their values through methods. In other words, the reflective practice encourages researchers to talk about the presuppositions, experiences, and actions and rationales behind them during the research process. In this regard, reflective journals are increasingly becoming visible within qualitative research.
As for the attributes of reflective writing, the fact that the reflective journal is written in the first-person point of view makes the writing fundamentally subjective. Through writing in the first-person point of view, the centrality of the researcher is acknowledged. Also, self-awareness and an internal dialogue that help in analyzing important issues in the research are supported. In this regard, Jasper (2005) noted that “the purpose of reflective writing is learning which will precipitate some form of action or change in behaviour… is to facilitate the researcher’s discovery and provide a verifiable audit-trail of the research process.” (p. 250) Reflective writing also develops critical thinking by enhancing higher-level conceptual skills. This development is supported because writing down ideas urges the author or researcher to develop and rationalize, which motivate the author to acquire new knowledge that is associated with the research. Finally, reflective writing, along with critical thinking, enables researchers to broaden their perspectives and discover new thoughts and research practices.
Reflective journals as data mainly fall into two categories. First, the products of reflective writing can be used as primary data. Autobiographies, journals, and logs are examples of the case in which reflective writing is employed as the primary data. Reflective writing as the primary data source is well-established in qualitative research, especially in the field of nursing and education. This essay focuses on reflective journals as the secondary data category, including field notes with reflection-on-action that includes insights and references to other data sources. Smith (1999) highlighted in his study that written reflections on one’s own feelings create an audit trail of one’s reasoning, thus contributing to the trustworthiness of the findings by supporting the researcher’s subjectivity.
One of the main reasons why the qualitative researcher maintains a reflective journal is to achieve a rigorous research process. Issues of rigor in qualitative research refer to the trustworthiness of the study (Guba & Lincoln, 1985), and some attributes of rigor include credibility, dependability, and transferability. According to Jasper (2005), reflective journal writing allows researchers to own centrality of their research process, which contributes to the legitimacy of the knowledge claims. Also, reflective journal writing provides an audit trail which clearly indicates the procedural steps that enhance the transparency of process. Moreover, a reflective journal is particularly useful when things did not happen as planned and as one’s thinking changes.
The primary purpose of using reflective journals is to enable researchers to explicitly map their role as researchers. By allowing the subjectivity of the researchers, reflective journals record one’s experiences, thoughts, opinions, and feelings and make them an acknowledged part within the data analysis and interpretation processes. By doing so, researchers can make a vague and unorganized research process more visible not only for themselves but also for their readers. Also, use of reflective journals affects the research process by changing the research design or approach if necessary. Last, but not least, as previously mentioned, use of reflective journals provides an audit trail of the research design, which enhances the transparency of the research process.
Despite the positive potential outcomes from using reflective journals, several challenging issues are associated with reflective journal writing. One potential issue is on ethical grounds in which confidentiality is hard to account for when reflective writing is practiced poorly. Another noticeable issue is hindsight bias. The practice of reflective journal writing may cause hindsight bias which happens when researchers know the outcome of their research in advance and consequently judge that outcome as more likely if they had not known that outcome knowledge (Rehm & Gadenne, 2013). As a result, researchers must overcome several issues in order to conduct a rigorous and reliable reflective journal writing that contributes positively to the research process.
Use of the reflective journal may seem a bit bothersome and time-consuming to some researchers. However, this practice certainly helps qualitative researchers to have a central role in a research process and enhances the transparency of the research process. I am certain that reflective journals are worthy of the required time, and we should make reflective journaling a priority in any type of research.
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Jasper, M. A. (2005). Using reflective writing within research. Journal of Research in Nursing , 10 (3), 247-260.
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Ortlipp, M. (2008). Keeping and using reflective journals in the qualitative research process. The Qualitative Report , 13 (4), 695-705.
Rehm, J. T., & Gadenne, V. (2013). Intuitive predictions and professional forecasts: Cognitive processes and social consequences (Vol. 20). Elsevier.
Russell, G. M., & Kelly, N. H. (2002, September). Research as interacting dialogic processes: Implications for reflexivity. In Forum Qualitative Sozialforschung/Forum: Qualitative Social Research (Vol. 3, No. 3).
Smith, B. A. (1999). Ethical and methodologic benefits of using a reflexive journal in hermeneutic‐phenomenologic research. Image: The Journal of Nursing Scholarship , 31 (4), 359-363.
Kathy Roulston is a professor in the Qualitative Research program in the Department of Lifelong Education, Administration and Policy at the University of Georgia, Athens, GA, USA. She teaches qualitative research methods, and has written on qualitative interviewing. https://orcid.org/0000-0002-9429-2694 Kathryn J. Roulston on ResearchGate My books include: Interviewing: A guide to theory and practice, see: https://us.sagepub.com/en-us/nam/interviewing/book272521 Interactional studies of qualitative interviews. See: https://benjamins.com/catalog/z.220 View all posts by qualpage
A discussion of qualitative & quantitative research design, reflections from the field: questions to stimulate reflexivity among qualitative researchers.
The outcomes from a qualitative study are only as good as the data the researcher returns from the field. And one of the biggest threats to the quality of the research data is the ever-present yet rarely examined assumptions and prejudices inadvertently contributed by the researcher.
This is why personal reflection is an important part of qualitative research design. To motivate and capture this reflection, the earlier RDR article discusses the use of a reflexive journal or diary by which the researcher provides a subjective account of each research event with details of the influences that may have affected results. The journal “sensitizes the [researcher] to his or her prejudices and subjectivities, while more fully informing the researcher on the impact of these influences on the credibility of the research outcomes.”
But what exactly are the particular questions the researcher should be addressing in this journal? That is, what exactly is the researcher reflecting on ? A reflexive exercise that is totally open and non-directional can be good, but it is also useful to consider particular questions that help stimulate reflective thoughts. Here are a few key questions for the researcher’s reflexive journal:
Broad Takeaways from the Research Event (e.g., the IDI, the focus group, the observation)
Specific Reflections on the Experience
¹Compared to quantitative research.
Image captured from: http://photography.nationalgeographic.com/photography/photos/patterns-nature-reflections/#/sandhill-cranes-sartore_1516_600x450.jpg
In school, I was trained to see reflexivity as an important part of the research process. Yet, as a researcher in business, it’s not something that we ever really have time for – I think because it’s not seen as directly useful for the bottom line or the design of products or experiences (even though such reflections can shape research design and analysis, and therefore results.)
Reflexivity is definitely integral to community research, and inherent in approaches such as community based participatory research (CBPR). Interesting comment in above article about ’emotional connections’. Perhaps an unavoidable symptom of the blurred boundaries that emerge in this type of research. Is this an ethical issue? Read what some researchers have said about their experience of ethics in CBPR at http://cbprethics.wordpress.com .
Reblogged this on Qualitative PhD Research and commented: I wonder – how soon do Doctoral Researchers start practicing reflexivity? Is it something that your Supervisor flagged as important? Do researchers ‘dipping their toes’ in qualitative research take on reflexive practice?
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Author contributions, acknowledgements, conflict of interest statement.
Vanessa Er, Mary Crowder, Eleanor Holding, Nicholas Woodrow, Naomi Griffin, Carolyn Summerbell, Matt Egan, Hannah Fairbrother, Young people’s views and experience of diet-related inequalities in England (UK): a qualitative study, Health Promotion International , Volume 39, Issue 4, August 2024, daae107, https://doi.org/10.1093/heapro/daae107
Inequalities in diets contribute to overall inequalities in health. Economic inequality and inequalities in access to healthy food are key drivers of poor diet and ill health among young people (YP). Despite mounting evidence of structural barriers to healthy eating, less is known about how YP view and experience these inequalities where they live, and how to address them. To explore YP’s perspectives on the drivers of diet-related health inequalities, we conducted three interlinked focus groups with YP aged 13–21 years from six youth groups across three geographical areas in England. We analysed the data inductively and deductively using reflexive thematic analysis and generated themes by examining how social structure, context and agency interact and impact YP’s diet. YP were aware of how inequalities in employment conditions impact their families’ income and ability to eat a healthy diet. They cited the high availability of hot food takeaways in their local areas as a significant barrier to healthy eating but did not support closing or restricting these outlets. They held strong views on policies to tackle diet inequality and showed a nuanced understanding of the strengths and limitations of universal and targeted approaches. Our study showed that YP have an awareness and understanding of food as important in relation to health, and of diet-related inequalities. However, further efforts are needed to shape and promote policies that resonate with YP and address both their health and wider social concerns.
Our study recognizes that young people have an awareness and understanding of food as important in relation to health, and of diet-related inequalities.
Young people have a nuanced appreciation of bounded agency: that is, the way social, cultural and economic factors shape individual food choices and practices.
Young people are potential sources of support for health equity strategies that include social determinist approaches.
Further efforts are needed to shape and promote policies that resonate with young people and reflect and address both their health and wider social concerns.
Inequalities in diets contribute to overall inequalities in health ( The Parliamentary Office of Science and Technology, 2022 ). Improvements in diets can improve population-wide health and reduce wider health inequalities. Poor diet in childhood and adolescence tracks into adulthood ( Hovdenak et al. , 2019 ; Appannah et al. , 2021 ) and is associated with lower health-related quality of life ( Wu et al. , 2019 ) and higher risk of chronic diseases, such as cardiovascular disease ( Daniels et al. , 2011 ), diabetes ( Lascar et al. , 2018 ) and some cancers ( World Cancer Research Fund and American Institute for Cancer Research, 2018 ). According to the Global Burden of Disease dashboard, poor diet was the cause of 7.9 million deaths worldwide in 2019, accounting for 14% of all deaths ( Global Burden of Disease Collaborative Network, 2020 ).
One of the main drivers for poor dietary quality is economic inequality and the relatively high cost of eating a healthy diet. According to the Food and Agriculture Organization’s (FAO) report on ‘The State of Food Security and Nutrition in the World’, more than 3.1 billion people across the world could not afford a healthy diet in 2021 ( Food and Agriculture Organization et al. , 2023 ). In the UK, The Food Foundation reported an increase in the proportion of food insecure households with children, from 12.2% in 2022 to 24.4% in 2023 ( The Food Foundation, 2023 ). Additionally, healthy nutritious food was two times more expensive than unhealthy products. Young people (YP) from disadvantaged backgrounds are more likely to experience food insecurity ( O’Connell et al. , 2019 ), which has worsened since the COVID-19 pandemic and the cost-of-living crisis. Studies conducted in England have shown that YP from socioeconomically disadvantaged backgrounds are more likely to have poor diets ( Johnson et al. , 2018 ; Public Health England and Food Standards Agency, 2021 ). The 2020–21 UK National Diet and Nutrition Survey revealed higher consumption of sugar-sweetened beverages and energy-dense food, and lower consumption of fruits and vegetables among the most socioeconomically deprived YP ( Public Health England and Food Standards Agency, 2021 ). Furthermore, the latest statistics from the UK National Child Measurement Programme revealed that children aged 10–11 years living in the most deprived areas were more than twice as likely to be categorized as obese, based on body mass index, compared to those living in the least deprived areas (31.3% vs. 13.5%) ( Office for National Statistics, 2022 ).
Another driver of YP’s diet is the neighbourhood food environment. There is consistent evidence showing a high density of fast-food and takeaway outlets in socioeconomically deprived areas and areas with a high concentration of ethnic minority population ( Fleischhacker et al. , 2011 ; Molaodi et al. , 2012 ; Thornton et al. , 2016 ; Public Health England, 2018 ; Sanchez-Vaznaugh et al. , 2019 ). This means greater availability of, and access to unhealthy food, as these outlets tend to sell relatively cheap, energy-dense and nutrient-poor food ( Jaworowska et al. , 2014 ; Huang et al. , 2022 ; Rinaldi et al. , 2022 ). The inequalities also extend to unhealthy food advertising where YP from ethnic minority and socioeconomically disadvantaged backgrounds are disproportionately targeted where they live, as well as online ( Backholer et al. , 2021 ). In the UK, children living in low-income households are more likely to eat takeaway meals at home, and those who consume takeaways more frequently have poorer diets ( Adams et al. , 2015 ; Taher et al. , 2019 ). The density of takeaway outlets across England increases each year ( MRC Epidemiology Unit, University of Cambridge, 2019 ). A study of takeaway outlets in Norfolk, UK revealed that the density of takeaway outlets grew between 1990 and 2008, and the increase in the number of outlets was higher in the most deprived areas compared to the least deprived, with this widening over time (3.5 times higher in 2008 vs. 2.8 times higher in 1990) ( Maguire et al. , 2015 ). There is emerging evidence of socioeconomic patterning in online access to takeaway outlets too. A recent study by Keeble et al. (2021) found that the percentage of registered food outlets on an online food delivery service in the most deprived areas was approximately two times greater than in the least deprived areas in the UK.
Despite mounting evidence of the structural barriers to eating a healthy diet, such as economic inequalities and the food environment, less is known about how YP view and experience these inequalities where they live, or how to address them. There have been two previous systematic reviews and a scoping review of YP’s views on healthy eating, all focusing on body size (e.g. obesity, body shape and weight) rather than health or health inequalities per se . One review included 11- to 16-year-olds ( Shepherd et al. , 2006 ); another 12- to 18-year-olds ( Rees et al. , 2014 ) and the third 18- to 24-year-olds ( Munt et al. , 2017 ). None of these reviews presented detailed analysis focused on health inequalities, as the reviewers noted that included studies typically reported few details on equity dimensions. The reviews by Shepherd et al. (2006) and Rees et al. (2014) found that YP tended not to frame food as a health issue. Rather they tended to view food in terms of what they liked and disliked.
The case has been made that low agency population interventions, such as free school meals (FSMs), advertising restrictions of foods high in fat, salt and sugar (HFSS) and restrictions of takeaway outlets, are effective and equitable ways to reduce poor diet in the population ( Adams et al. , 2016 ). However, research literature is sparse on YP’s views of such interventions, or their views on alternative (high agency) education interventions or the relative merits of targeted and population-level approaches. In England, the FSM ( Department for Education, 2018 ) and holiday activities and food programmes ( Department for Education, 2022 ) provide healthy food to school-aged children from low-income backgrounds, but there is no provision for older YP (e.g. aged 18–24) from similar backgrounds. Currently, there is a restriction on broadcast advertising for HFSS foods, but only for those aimed at children ( UK Advertising Standards Authority, 2024 ). The existing planning policy only restricts the opening of new takeaway outlets ( Keeble et al. , 2019 ), which has been perceived as less useful in areas that already have a high density of takeaway outlets.
To address the gap in the literature, our study was guided by the following questions:
What is YP’s understanding and experience of diet-related health inequalities?
What are the drivers of diet-related health inequalities where YP live?
What are YP’s views on addressing diet-related health inequalities where they live?
The research in this article drew on data from a wider study exploring YP’s perceptions of what influences their opportunities to be healthy within their local area and their understanding of health inequalities ( Fairbrother et al. , 2022 ). The philosophical underpinning of our approach is critical realism. We view health inequalities as real (they exist independently of human practices and awareness) while acknowledging the role of human practices, perspectives and social context in shaping how we know about health inequalities. In other words, our knowledge of health inequalities is subjective and incomplete. Our approach was critical in orientation ( Braun and Clarke, 2024 ) in that, we sought to unpack and interrogate participants’ accounts to provide causal explanations of health inequalities and make recommendations that are relevant and beneficial to YP. We conducted a qualitative study to understand YP’s perceptions and experiences of health inequalities, with a focus on explaining the causal mechanisms of health inequalities.
As a team of public health researchers, our work is rooted in explaining and addressing health inequalities. Based on our knowledge of the literature, we assumed that YP have a more individualistic explanation of the causes of, and solutions to health inequalities. We believe that YP have a right to good health and they should be supported to live to their fullest potential. We made a conscious effort to include disadvantaged and marginalized voices. However, we recognized the power imbalance as we are older, well-educated and ‘relatively advantaged’ (though this term masks some variation in the research team, such as variation in social backgrounds, job security, housing security and other intersecting equity dimensions). Therefore, we took a participatory approach to research in our attempt to balance power dynamics and meaningfully include YP of disadvantaged backgrounds in discussions on health inequalities. Engaging in a process of reflexivity, we acknowledge that our analysis is informed by our prior understandings of health equity, including pre-held assumptions that social determinants, as described by Marmot et al. (2020) , are particularly important for both explaining and tackling health inequalities. We acknowledge that our research findings extend from our subjective experience of the research, influenced by our social and professional backgrounds, and our particular interactions with the YP who participated.
We recruited YP aged 13–21 years through six youth groups across three geographical areas in England; London, South Yorkshire and North East. Our original sampling frame targeted YP living in areas with contrasting levels of deprivation and geography (e.g. rural and urban). This was hampered by the COVID-19 pandemic, so we recruited YP from youth groups with whom we had established relationships, all of which were located in areas in the most deprived quintile based on the 2019 English indices of multiple deprivation. Furthermore, while we initially aimed to work with YP aged 13–17 years, we took an inclusive approach as some of our youth groups also included YP over 18.
We conducted a series of three interlinked focus groups with YP from each of the six youth groups between February 2021 and June 2021, resulting in a total of 18 focus group sessions. The focus groups were planned to be in-person, but we switched to an online format for all but three sessions with one youth group in the North East due to the UK’s lockdown and social distancing restrictions during the COVID-19 pandemic.
Session 1 used a participatory concept mapping activity ( Jessiman et al. , 2021 ) to explore perceptions of what influences YP’s opportunities to be healthy in their local area. Session 2 examined YP’s understanding of health inequalities through prompted discussion of selected health-related news headlines, including FSMs, fast food and advertising of less healthy food. Session 3 focused on YP’s priorities for change to improve health in their area.
Facilitators used a topic guide (see Supplementary Material ) that had been piloted with youth organizations to aid discussions. At least two researchers facilitated each focus group, accompanied by a youth worker for safeguarding purposes and to support YP if required ( Woodrow et al. , 2022 ). Focus groups lasted between 90 and 100 minutes and were audio-recorded with consent. Participants also provided information on ethnicity, age and residential postcode (used to determine area deprivation level). We gave participants £20 vouchers at the end of each focus group as a token of appreciation for their time.
The study has ethics approval from the School of Health and Related Research (SCHARR) Ethics Committee at the University of Sheffield (ref: 037145). All participants provided written consent. For participants under the age of 16 years, opt-in consent was also obtained from parents/guardians.
Prior to analysis, audio recordings were transcribed verbatim and anonymized by approved transcription services. The research in this article drew on data from a wider study exploring YP’s perceptions of what influences their opportunities to be healthy within their local area and their understanding of health inequalities ( Fairbrother et al. , 2022 ). Here, we only include discussions about food as data. We analysed the data using reflective thematic analysis ( Braun and Clarke, 2022 ) as it is theoretically flexible and fits with a critical realist approach. Using this approach, we examined the mechanisms and structures that give rise to diet-related inequalities by focusing on participants’ accounts and situating them within the contexts (realities) that participants live in. This requires continual reflexivity and critical engagement with the data and the analytical process.
V.E. and M.C. read the transcripts and applied a mix of semantic (surface meaning) and latent coding (underlying meaning), aided by a qualitative analysis software, NVivo 12. During the coding process, V.E. and M.C. met regularly to discuss the meaning of the data to ensure reflexivity and expand the interpretation of the data. We analysed the data deductively by using two frameworks as a lens to make sense of the data: Smith and Anderson’s (2018) framework for lay perspectives of socioeconomic health inequalities, and Pearce et al.’s (2019) conceptual model of pathways to inequalities in child health. We combined it with inductive analysis as we were open to the possibility that the data may not fit these frameworks.
Upon reflection, we decided that Giddens’s (1989) structuration theory which posits social practices as an interplay between agency and social structure, was a better fit for the data and used it to inform the conceptualization of themes. We focused on how diet-related inequalities were produced, by contextualizing YP’s eating practices and interactions with their local food environment, and connecting it with the social history and structure of the area where they live. The themes were further developed by V.E. and M.C. alongside discussions with C.S. and H.F. to ensure the themes capture the central meanings and patterns identified from the data and answer the research questions. V.E. wrote a narrative for each theme, with the scope of each theme being iteratively defined and refined with inputs from M.C., C.S., M.E. and H.F.
Our final sample consisted of 42 YP aged 13–21 living in urban and rural areas, and of different genders and ethnicity (see Table 1 ).
Participant characteristics
. | London ( = 13) . | South Yorkshire ( = 14) . | North East ( = 15) . |
---|---|---|---|
16–21 | 15–17 | 13–20 | |
) | |||
Female | 10 | 6 | 2 |
Male | 3 | 7 | 9 |
Non-binary | – | – | 2 |
Gender-fluid | – | 1 | – |
Trans male | – | – | 2 |
) | |||
White British | 1 | 14 | 15 |
Asian/Asian British | 6 | – | – |
Black/Black British | 3 | – | – |
Mixed/Multiple ethnic group | 2 | – | – |
Chinese | 1 | – | – |
. | London ( = 13) . | South Yorkshire ( = 14) . | North East ( = 15) . |
---|---|---|---|
16–21 | 15–17 | 13–20 | |
) | |||
Female | 10 | 6 | 2 |
Male | 3 | 7 | 9 |
Non-binary | – | – | 2 |
Gender-fluid | – | 1 | – |
Trans male | – | – | 2 |
) | |||
White British | 1 | 14 | 15 |
Asian/Asian British | 6 | – | – |
Black/Black British | 3 | – | – |
Mixed/Multiple ethnic group | 2 | – | – |
Chinese | 1 | – | – |
The YP in this study perceived eating a healthy diet as unattainable due to intersecting inequalities that manifested in their daily food practices and environment. YP’s agency to eat healthily was constrained by structural inequalities, mainly economic inequality and low availability and access to healthy food in deprived areas. We identified three key themes: (i) impact of economic inequality on family food practices, (ii) availability and access to hot food takeaways in areas of high deprivation and (iii) making healthy food more accessible to families.
(i) Perceived impacts of economic inequality on family food practices
This theme captures YP’s understanding of economic inequality. They viewed economic inequality through a ‘place’ lens, whereby some regions or neighbouring local areas in the UK were viewed as more economically disadvantaged than others. A recurring view suggested a mechanism whereby places with economic problems had poorer employment opportunities for YP and their parents. This in turn led to two types of barriers to healthy eating. Firstly, low incomes—YP believed that healthy foods tend to be more expensive than unhealthy food and that low-income families may have to choose between healthy diets and other essentials such as heating and school uniforms. Secondly, YP perceived that for many low-income families, there is less opportunity to prepare healthy meals at home due to a lack of time as a result of working long hours and/or multiple jobs.
Though YP acknowledged the importance of nutrition knowledge and cooking skills for healthy eating, they were acutely aware of how family income (or lack of it) restricted their ability to have an adequate and healthy diet.
I see it sort of like if you have a run down job, you don’t have as much pay to pay for the food. Meanwhile, if you have a high job and you have the high society, you have more pay, therefore you’re able to take on more food. Which brings in the inequality with food discussed tonight. (North East Group 2, Session 2)
There was a common perception among YP that unhealthy food is cheap while healthy food (described mainly as fresh fruits and vegetables) is expensive and thus unattainable on a low income.
things like salads they’re expensive man, like five, six quid then the opposite of that, like portion of chips is like a quid…Even the prices of fruit and veg, I don’t know why they price up a bit too much. (London Group 1, Session 1) I’d say so because like there’s a lot of income inequality where we are especially, so a lot of like poorer households find it hard to buy the more healthy stuff. They tend to be more expensive, especially in supermarkets… (South Yorkshire Group 2, Session 1)
YP also knew of low-income families having to prioritize household bills and expenses over food. A few spoke from experience about their parents having to spend less on food to pay for essentials such as school uniforms. The need to make trade-offs came to the fore while discussing the impact of the COVID-19 pandemic. YP noted that some in their community could hardly afford to pay utility bills and were thus unable to store and/or cook fresh food, resorting to the convenience of fast-food or hot food takeaways.
I think, with fast food, it doesn’t need to be maintained in a sense, so like, let’s say you can’t afford electricity bills, you can’t afford to keep your fridge running, or something. Buying healthy stuff isn’t, it’s not going to last, so just buying fast food, might be cheese and everything, is like OK, I’ve bought it, I can eat it, through it in a day, like it’s finished. (London Group 1, Session 2) …that goes back to the budgeting thing. Some people, especially people who don’t necessarily have a lot of money might want to spend less on food and more on making sure that their child has the right stuff for school. (South Yorkshire Group 1, Session 1)
While YP made direct reference to low income as a barrier to healthy eating, they also demonstrated an in-depth understanding of inequalities in employment conditions faced by those working in low-paid jobs, and how that negatively impacts one’s ability to eat a healthy diet. They pointed out that those in low-paid jobs often lack time to prepare and cook meals as they tend to work long hours or multiple jobs. The North-South (England) divide in economic opportunities was regularly brought up by YPs from the North East. According to one YP, movement restrictions during the COVID-19 pandemic further highlighted the inequalities experienced by those in low-paid jobs (e.g. bus drivers and delivery drivers) as they were less able to work from home.
We did talk a bit about how people in the North, the sort of jobs that we have, it’s less likely that you’ll be able to work from home. So if you are working from home – which predominantly, especially if you’re in the South because a lot of the economies, they’re very knowledge-based – you can afford to do that sort of thing from home…So they have certainly got more time and more time that they can dedicate to something like cooking. (North East Group 1, Session 2)
(ii) Availability and access to hot food takeaways in areas of high deprivation
This theme describes how YP felt physically surrounded by hot food takeaways in their local neighbourhood, and digitally surrounded via food delivery apps. They showed an understanding of how different elements of underserved communities intersect to encourage negative health practices.
YP cited the high density of hot food takeaways in their local area and a lack of food retail shops selling affordable and healthy options as barriers to healthy eating. As a YP related:
I wanted to talk about like fast food joints, like in [Name of location] like there’s a lot of like fried chicken shops, a lot of like and they’ve renamed themselves to grills…like to get like more consumer support. And basically like, what I was saying was like it makes it harder for me. (London Group 2, Session 1).
In terms of family food practices, the constant exposure to hot food takeaway was perceived as offering easy access to food for those whose home situations made it challenging to prepare home-cooked meals. For example, YP described how parents in low-income families worked long hours, leading YP and their families to take the ‘easier option’ of purchasing and consuming readily available hot food takeaways. Even though they were aware that hot food takeaways are unhealthy, they felt that they had to choose convenience over the nutritional quality of their meals.
Because it could be quite a busy job that involves travel where they’d be an air hostess or a conductor for a train. It just might take a lot of time away from their family, so that has to force them to do – in a way – irrational things. Such as constantly sending a fast food order instead of healthy objects. (North East Group 2, Session 2) Like if you come from a lower, like a poor area, maybe – like I knew someone who his mum would give him a quid and he’d go to the shop and just buy something and have it for his tea and he’d be out all night until like 10. His upbringings, obviously it’s not going to be the same as someone who has home-cooked meals every night that are prepared with nutritional value in mind. (South Yorkshire Group 2, Session 3)
YP also talked about how the high availability of cheap and ‘tasty’ hot food takeaways, particularly around the school vicinity, made it convenient for YP to purchase and consume them. It was clear during the discussions that hot food takeaway outlets had become part of the social fabric of local life even though YP were critical of the ubiquitousness of these outlets where they live. They were considered by some YP as the ‘place to go’ after school as there was not much to do for YP in their local area, which also highlighted the lack of services and facilities that cater to youths in areas of high deprivation. Inadvertently, YPs socialized at hot food takeaway outlets and ended up consuming food deemed to be less healthy despite their intentions.
When probed about the high density of hot food takeaways, a YP highlighted the complex interdependency of individual and structural factors that affect one’s ability to eat healthily. Specifically, they explained that demand for cheap and quick meals resulted in the opening of hot food takeaway outlets, which in turn created high visibility and high consumption. This then reinforced the need for more outlets. In contrast, the cycle could be broken or disrupted by the lower demand for ‘cheap’ hot food takeaways in more affluent neighbourhoods.
And then I guess because I think, like, yeah, if you’re in an area where demand is higher you’re going to have more takeaway so then if you’ve got more takeaway then that’s, kind of, what you see most of the time then you’re going to end up going to those takeaways more maybe. And seeing that, like, seeing it as more of an option compared to in a wealthier area where if at first you’re not, like, if there isn’t too much demand for fast food in wealthier areas then the takeaways aren’t really going to go there and then, because, like, and it is then, it is also easier to just go to the supermarket and, like, get stuff. (London Group 2, Session 3)
YP’s narratives also suggested that hot food takeaways have a prominent online presence in their everyday lives. They related their experience of being inundated with advertising of HFSS sold by hot food takeaways in their local area when using food delivery applications, and though healthier options were available, they were more expensive and deemed unaffordable.
…there’s about, I think it’s about 20 on my app just around me, because I live near a load of take aways. (South Yorkshire Group 1, Session 2) …and like delivery companies, some of them actually offer the, the opportunity to like buy healthier options. Some of them do salads and all sort of meals that are meant to be healthier. But it’s like those options are very expensive, compared to the junk food, so called junk food options. So it still leaves you with no choice than to go for the junk food rather than the healthier option. (London Group 1, Session 2)
(iii) Making healthy food more accessible to families
This theme presents YP’s views on public policies or interventions to address inequalities in accessing healthy food. YP had strong views on policies to tackle food inequality and showed a nuanced understanding of the strengths and limitations of universal and targeted approaches. Discussions about interventions, especially those targeted at low-income families were strongly tied to the stigma of poverty. YP in general were not in favour of a targeted FSM approach as they perceived it to be stigmatizing. As recounted by a participant: ‘ There’s an element of shame to it as to whether or not you will accept for yourself that you need that help, feeding your kids and feeding your family’ (North East Group 1, Session 2) .
Although YP from low-income families who were eligible for FSM appreciated the assistance from the government, their accounts of receiving FSM referred to shame and centred on who was ‘poor enough’ to receive government assistance. One YP felt guilty for receiving FSM because their parents held ‘decent’ jobs (i.e. perceived to be well-paid) with full-time employment, and did not consider themselves to be impoverished.
My mum’s a teacher and my dad works at the NHS, but a couple of years ago we were eligible for free school meals because it was something like me mum wasn’t earning enough so we therefore qualified. We felt kind of guilty, like we were robbing it from someone… because there are literally people on it who are choosing between feeding the kids at lunch or clothes for school uniform. (South Yorkshire Group 1, Session 2)
One focus group referred to food voucher schemes, of the kind administered by some schools during the COVID-19 epidemic. Vouchers were seen as a way of giving families a way to decide how best to meet dietary needs and food preferences. This came up while discussing FSM provision during the COVID-19 pandemic, whereby most schools provided food parcels to students. There were strong criticisms of the quality of food parcels as the items were not nutritious and were overpriced. In contrast, another YP who received food vouchers shared how that gave her family the freedom to purchase food according to their needs, and thus they were able to maximize the value of the vouchers:
So for instance, I get them (food vouchers) and we go shopping every month so we just save up all the vouchers and spend it on different places…We get tinned vegetables, like peas and carrots and that, but we don’t really like fresh veg or owt like that because it runs out of date really quickly. There’s no point really getting it. (South Yorkshire Group 1, Session 2)
Most YP demonstrated empathy for those who were perceived to be worst off, for example, those who had to use food banks. Alongside feelings of shame and guilt for receiving FSM, YP shared concerns about the proliferation of food banks in their area and the stigma associated with going to one, particularly the fear of parents being blamed for their inability to provide food for their children. YP’s empathy also extended to local business owners. Although they recognized the adverse impact of hot food takeaways, YP did not want these outlets to be closed or restricted by local authorities—a planning policy that can be introduced by local authorities to limit the number of hot food takeaways, especially within the school vicinity. They expressed concern about the potential loss of income for the businesses and more importantly, loss of employment for workers at the outlets. In terms of supporting customer choice, YP often framed this as wishing to see healthier food options at local outlets as this is where they felt the choice was limited. Incentivizing customers to purchase healthier meals through a loyalty scheme was one of the examples given by YP.
And, I don’t know, I was thinking incentives so, like, in a fast food chain, because you can’t shut them and you don’t really want to disturb their business, but if there was something, like, if you buy a certain number of the healthier meals and you get one of the less healthy meals for free or something, kind of, like a loyalty card…because I don’t think awareness alone necessarily helps because I think people are generally aware but it’s a case of actually, like, putting that into action and I think that can be quite tricky. (London Group 2, Session 3)
This article examines YP’s views on and experiences of inequalities in relation to their access to healthy food and diets. While previous studies have explored YP’s views of healthy eating ( Shepherd et al. , 2006 ; Rees et al. , 2014 ; Munt et al. , 2017 ), there is little evidence on YP’s views of how inequalities in healthy eating occur and how to address them.
The YP we spoke to viewed inequalities in food and health partly in terms of how different people were more or less likely to consume healthy food (with fast food often used by participants as an archetypal ‘unhealthy’ food type). YP discussed inequalities in more explicit food poverty terms: showing awareness that some individuals and families struggle to afford sufficient food. Low income, coupled with the high cost of healthier food products, was singled out as a significant barrier to eating a healthy diet by YP. This is supported by analyses of food costs in the USA, UK and Europe ( Kern et al. , 2017 ; Penne and Goedemé, 2021 ; The Food Foundation, 2023 ), which demonstrated that the cost of healthier food products was higher than less healthy products (two times more in the UK). Furthermore, one in five households in the UK would have to spend almost half of their disposable income to achieve a healthy diet, leaving little for other expenditures ( The Food Foundation, 2023 ). YP also linked low income to inequality in employment opportunities, specifically low access to, and availability of higher paying jobs where they live, and its impact on their diet. This was raised by participants in all three study sites, but more prominently in the North East of England, which has one of the highest rates of unemployment and proportion of benefit claimants ( Office for National Statistics, 2023b ), and the lowest average weekly salary in England ( Office for National Statistics, 2023a ).
We found that YP in our study had a less individualistic understanding of inequality than was suggested in the literature ( Backett-Milburn et al. , 2003 ; Vromen et al. , 2015 ; L’Hôte et al. , 2018 ; Smith and Anderson, 2018 ). While acknowledging the importance of dietary knowledge and cooking skills, our study participants showed an understanding of how structural inequalities impact their ability to acquire and consume a healthy diet. For example, YP were able to articulate the reinforcing connection between availability (supply) and purchase (demand) of hot food takeaways in their local area, which in turn made it easier for them to consume energy-dense and nutrient-poor food. The literature supports YP’s view that disparities in both physical and online food availability reinforce area inequalities. The high density of affordable but less healthy hot food takeaway outlets in deprived areas, both physically and online, has been well-documented ( Fleischhacker et al. , 2011 ; Maguire et al. , 2015 ; Keeble et al. , 2021 ). There is also evidence that it is often the same communities who experience both low income and high exposure to fast-food takeaway in the UK. Burgoine et al. (2018) , for example, demonstrating the double burden of low income and exposure to fast-food takeaway and its impact, found that the lowest income combined with the highest fast-food outlet proportion was associated with greater odds of obesity (odds ratio = 2.43, 95% confidence intervals: 2.09, 2.84). Another study in the UK found that within 4 years of Gateshead Council’s ban on planning permission for fast-food outlets, there was a 13.88% reduction in the proportion of fast-food outlets compared to five other local authorities in the North East of England which did not implement the ban ( Brown et al. , 2022 ). The ban was associated with a decrease in the prevalence of overweight and obesity among children in year 6, living in areas that have a high density of fast-food outlets ( Xiang et al. , 2022 ). This further demonstrates that obesity (as measured by body mass index) is a manifestation of social inequalities in health.
Previous reviews have found that health tends to be deprioritized in YP’s accounts of food, body shape and weight. The previous evidence suggests that YP focus instead on what they like and dislike, particularly on social factors such as social norms and peer expectations relating to body shape, and the social isolation that may result from not living up to those norms ( Shepherd et al. , 2006 ; Rees et al. , 2014 ; Munt et al. , 2017 ). The previous reviews have little to say on health inequalities, perhaps reflecting YP’s apparent lack of interest in health per se . However, some reviewers pointed out that many authors of included studies neglected to provide data on health equity dimensions. In contrast, many of the YP we spoke to were willing to discuss food in relation to health and health inequalities. Possibly, this is because we (the researchers) made our interest in health inequalities known to participants, in contrast to some previously published studies where the researcher's interest in health inequalities may not have been apparent. However, we think it reasonable to hypothesize that health and inequalities may have been more present in YP’s minds at the time of our data collection, given that it occurred during the COVID-19 pandemic. The study also took place in an era where food poverty and food charity (such as food banks) have become more prominent in UK discourse ( The Food Foundation, 2023 ).
Whilst we present YP’s interest in health inequality as a finding from our study, we are careful not to exaggerate the point. The YP we spoke to were also capable of discussing food availability and access in more social terms. For example, participants viewed fast-food chains as places where YP can socialize with friends. This is consistent with findings from a qualitative study of local (adults) perceptions and experiences of chicken shops in a deprived area in East London, which found the shops described as a part of everyday life and valued community spaces ( Thompson et al. , 2018 ). Some participants of our study even felt protective towards local businesses, not wishing to see them shut down. YP’s attitudes towards measures intended to address food poverty were also shaped by more than food considerations. The thought of using welfare or charity was associated by some YP with stigma—and also guilt that seeking help to obtain food could prevent assistance from going to someone with a greater need. These attitudes present insights into what YP regard as social responsibility: supporting local businesses (even unhealthy ones), and assuming that charity and welfare are finite resources best targeted at those in greatest need.
YP’s attitude to universalism was complex. Some appeared to support universal approaches, for example, universal FSMs as a means of reducing stigma. Some wanted further intervention from the government to extend the FSM funding to include after-school and holiday meals. This is in line with the findings of two studies with YP in the UK ( Fairbrother et al. , 2012 ; Knight et al. , 2018 ) which emphasized government and corporate responsibility for ensuring adequate nutrition and a healthy diet is affordable for families. However, other studies on the public’s attitudes towards inequalities have revealed a reticence towards government intervention and a preference for educational (information) and individual behavioural change interventions instead ( Backett-Milburn et al. , 2003 ; Vromen et al. , 2015 ; Smith and Anderson, 2018 ). A comparison study of YP’s view on inequality in the USA, UK and Australia, also found most participants focused on individualized (agency) explanations of, and solutions for inequalities, with little critical engagement of the structural causes of inequalities ( Vromen et al. , 2015 ).
Our findings show YP have a nuanced appreciation of bounded agency: that is, the way social, cultural and economic factors shape individual choice and practices. However, public health policymakers might view some of the YP’s views with mixed feelings. On the one hand, there is evidence of YP’s understanding of health inequalities, and social determinants, and a clear desire for improvement. On the other hand, this section of the public holds views on social responsibility that do not all fit neatly within the kind of universalist and regulatory approaches to health equity that many UK public health practitioners have long espoused ( Bambra et al. , 2011 ; L’Hôte et al. , 2018 ; Marmot et al. , 2020 ). We found evidence of common ground between YP and public health viewpoints, but further bridging work between the public health community and the public is still required.
We believe that our study can contribute to a re-imagining and updating of the evidence base about YP’s views about food and inequalities. In contrast with previous evidence, this re-imagining recognizes that YP have an awareness and understanding of food as important in relation to health, and of diet-related inequalities—including considerations of both individual behaviour and social determinants. While different findings between studies may reflect methodological differences, there are also plausible reasons for hypothesizing that times have changed, and that YP’s views have changed with them. This hypothesis should be explored further in future research.
We recruited YP living in areas of high deprivation. Using a place lens coupled with participatory concept mapping was an accessible way of eliciting YP’s views on diet-related health inequalities. It made tangible the structural inequalities that manifest in everyday life and impact YP’s ability to eat a healthy diet. It also allowed us to explore YP’s diet in multiple aspects of their life and a range of settings, including school, home and community.
Though our study showed that YP’s agency of purchasing and consuming a healthy diet was constrained by individual and area-level economic inequalities, we were unable to explore how that differs by levels of autonomy and agency. A Lancet series on dietary intake among adolescents (aged 10–24 years) emphasized the need to view adolescents as unique; each with different development trajectories within diverse sociocultural contexts ( Neufeld et al. , 2022 ), rather than being defined by age only. Most of our participants still lived at home and thus conversations about food centred around school meals and hot food takeaways. However, a few participants who had more independence and agency felt that they were being forgotten and not supported by existing policies to obtain and consume a healthy diet. In two of the three study sites, all participants were white British. Although these areas have a high proportion of White population, we may have obtained more diverse views if we had included YP of different ethnicity. There were mentions of value for money as a key factor influencing food purchases in our study. A deeper exploration would enhance our understanding of what value for money means to YP, and its implications.
Individual and area-level economic inequalities constrain YP’s ability to eat a healthy diet. The YP we spoke to appeared to be aware of this. We hypothesize that this awareness may reflect changing contextual factors such as the experience of the COVID-19 pandemic and widely discussed concerns about food poverty. YP are potential sources of support for health equity strategies that include social determinist approaches. However, it would be a mistake to assume this support can be relied on without further efforts to shape and promote policies that resonate with YP and address both their health and wider social concerns.
H.F., C.S. and M.E. conceived the study. V.E., M.C., E.H., N.W. and N.G. collected and analysed the data. V.E. wrote the first draft. All interpreted the data, edited and reviewed drafts and approved the final version of the manuscript.
We would like to thank the young people and the youth organizations who took part in the study. Thanks also to Phillippa Kyle and Nicky Knights for their contribution to data collection and analysis.
This study was funded by the National Institute for Health and Care Research (NIHR) School for Public Health Research (SPHR) (Grant Reference Number PD-SPH-2015). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
We do not have any conflict of interest. The funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript or in the decision to publish the results.
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Puvaneswari kanagaraj.
1 Department of Nursing, College of Applied Medical Sciences, University of Bisha, Bisha, Kingdom of Saudi Arabia
2 Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Al Khoudh, Muscat, Sultanate of Oman
3 Narayana Multi Specialty Hospital, Kolkata, West Bengal, India
* Current address: Durgapur City Hospital and Clinic Pvt. Limited, Durgapur, West Bengal, India.
4 Faculty of Nursing, Zagazig University, Zagazig, Egypt
Supplemental material, sj-docx-1-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing
Supplemental material, sj-docx-2-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing
The COVID-19 outbreak disrupted the nursing education across the world. The nursing students faced many challenges in their learning process.
The study explored the experiences and challenges faced by nursing students who had virtual education in India.
The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases. Phase 1: Qualitative data were collected using direct focus group interview with 18 students. Phase 2: Quantitative data were collected from 477 students using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. The analysis was done using the descriptive and inferential statistics and thematic analysis.
Phase 1: The analyzed data produced seven themes and 10 sub-themes; (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. Phase 2: Majority of the students (54.71%) experienced high-level challenges with the nursing education during pandemic. The overall mean and SD of all the domain-wise challenges were 103.39 + 7.11 with the range from 30 to 150. The mean and SD with educational challenges were (20.27 + 3.04), environmental challenges (6.92 + 1.66), communication challenges (17.61 + 4.01), technical challenges (17.39 + 3.75), evaluation challenges (7.09 + 1.94), physical and mental challenges (20.47 + 4.33), career challenges (7.06 + 1.91), and financial challenges (6.61 + 2.1). The demographic variable gender ( P = 0.045) showed a statistically significant association with the challenges.
Considering the experiences and challenges faced by the nursing students, the nursing administrators shall design educational strategies to mitigate these challenges in nursing education during a pandemic.
Virtual nursing education offers flexibility in teaching and learning, self-paced learning opportunity, lower the costs, career advancement, comfortable learning environment, more opportunities for participation, easier to track documentation and improves skills in technology. Therefore, the challenges in virtual nursing education should be lessened to have successful teaching learning experiences.
The world faced unprecedented challenges during COVID-19 global pandemic ( World Health Organization, 2020 ). The pandemic changed the lives of people at different levels. Additionally, social distancing shaped the social relationship and behavior ( Kaveh et al., 2022 ). COVID-19 significantly strained the healthcare system. In addition, it affected the education in academic institutions and universities to a greater extent ( Dewart et al., 2020 ). As a preventive and control measure, all the schools, colleges, and universities were closed ( Mustafa, 2020 ). In April 2020, 94% of learners worldwide were affected by the pandemic, representing 1.58 billion children and youth in 200 countries ( De Giusti, 2020 ). Likewise, nursing education has undergone many radical changes both in developed and developing countries. The situation affected the learning opportunities of nursing students as their clinical placements were suspended and the face-to-face teaching moved into online teaching. Additionally, the pre-clinical activities such as laboratory and simulation-based teaching were affected due to social and organizational restrictions to limit unnecessary access and contact with others ( Tomietto et al., 2020 ).
To continue the teaching–learning activity, the academic institutions adopted various digital platforms including Zoom, Google meet, WebEx, Udemy, Edmodo, Google classroom, etc. ( Mishra et al., 2020 ). Moreover, web-based conferences were routinely organized by educational institutions during this pandemic ( Kaware, 2022 ). In addition, educational institutions have placed greater emphasis on ERP systems, library modules, fee modules, and examination modules. The virtual learning enhanced the comfort, accessibility, and encouraged remote learning ( Mukhtar et al., 2020 ). Similarly, the learners found it easy to access the online material, were able to record meetings and sessions and retrieve information ( Alsayed & Althaqafi, 2022 ). The faculty and students expressed that online education is useful during the COVID-19 pandemic; it was convenient, flexible, cost low, and encouraged self-learning ( Almahasees et al., 2021 ). Likewise, online education improved the flexibility, ability to teach large classes, increased interaction between the teachers and students and increased learning opportunities for the learners ( Hako, 2021 ). Ultimately, these educational technologies have had significant positive impact on the learning of the students. Additionally, it paves the way toward the blending of technology synchronously or asynchronously into education ( Thaheem et al., 2022 ).
Although online education was beneficial to both the teachers and learners, it posed various challenges to the faculty and students ( Nimavat et al., 2021 ). Poor student attendance, loneliness, issues with internet connectivity and lack of information and technology skills were reported as challenges of online education ( Hako, 2021 ). The faculty and students indicated that efficacy of online teaching and learning is less effective than face–face teaching and learning. Moreover, online learning is ineffective for deaf and hard of hearing students. Likewise, online education is linked to lack of interaction and motivation, data privacy and security and technical issues ( Almahasees & Amin, 2021 ; Alsayed & Althaqafi, 2022 ). Furthermore, online education was inefficient in terms of maintaining academic integrity ( Mukhtar et al., 2020 ). The teachers reported difficulties in motivating the students without visual connection during online teaching ( Moustakas & Robrade, 2022 ). Also, Atout et al., (2022) reported lack of resources for the clinical learning, distracting home environment and challenging evaluation of learners as the barriers for virtual learning.
The challenges faced by the instructors includes transitional difficulties from offline to online teaching, communication barriers, changes in the teaching style and additional time and resources for preparation of teaching. The institutions experienced challenges such as need for additional training for faculty and students, technical and multimedia support, online counselling sessions for teachers and the need to have technical troubleshooting team. Students experienced challenges related to having technical skills to learn online, lack of readiness, network and speed issues, and lack of identity, interaction and participation. There were challenges related to content such as development of new material, regular assignments, multimedia tools, and checking assignments and sharing regular feedback with the students. Technological challenges included device suitability, network stability and speed, tools of conferencing software for online teaching and ease of use. Lastly, the motivational factors included lack of sense of job security, non-availability of salary on time, and lack of family support, mental and emotional support from colleagues and higher authorities ( Siddiquei & Kathpal, 2021 ).
To enhance the online teaching and learning, technical aptitude enhancement, resource management and utilization, time management, control over the learning environment and help seeking are essential ( Barrot et al., 2021 ). Furthermore, formal training for the teachers, and enhancement of psychosocial wellbeing of both the learners and teachers are necessary to curb the feelings of loneliness and isolation. Moreover, the nature of the problems related to the shift from face to face to online learning should be identified to combat these challenges ( Hako, 2021 ). In India, both the undergraduate and postgraduate students were badly affected during the COVID-19 pandemic and experienced many challenges with online education ( Joshi et al., 2020 ; Kamal & Illiyan, 2021 ; Muthuprasad et al., 2021 ; Pandit & Agrawal, 2022 ; Rannaware et al., 2022 ; Sengupta, 2022 ). However, very few studies explored the challenges encountered by the nursing students during the online learning ( Gaur et al., 2020a ; George et al., 2022 ; Kanagaraj et al., 2022 ; Lata & Kudi, 2022 ). Therefore, the authors decided to understand the experiences and challenges encountered by nursing students in their nursing education during the COVID-19 pandemic. We believe that the study finding will be beneficial to the educational authorities, curriculum developers, and policy makers to design appropriate measures and strategies to enhance effective learning both in nursing education and practice.
An exploratory sequential mixed-methods design was utilized in this study. The study integrated qualitative data into quantitative data to understand the experiences and challenges experienced by nursing students’ during the pandemic.
The study was conducted among nursing students of Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India. These colleges initiated virtual classes from April 2020. Therefore, these colleges were selected as settings for the study.
The target population of the study included both Diploma and BSN students. The accessible population included both Diploma and BSN students studying in Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India.
Three nursing colleges were conveniently selected for the study. In Phase 1, the researchers used purposive sampling technique to collect the qualitative data from six students in each college (Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India). The data collection was done face to face. Thus, in total, 18 students participated in the focused group interview during phase I. For Phase 2, the sample size calculation was done based on the previous cross-sectional study ( Thapa et al., 2021 ). Having the expected proportion of challenges experienced by nursing students as 15%, with 95% confidence interval, and with the precision, the minimum required sample size was 400. In total, all the three nursing colleges had 654 students. Convenient sampling technique was used to collect the data in phase II.
The study included nursing students who were enrolled for Diploma and BSN program, exposed to online learning, and second, third, and fourth year nursing students. The study excluded those who were not willing to participate, and first year nursing students as they had limited exposure to the virtual theory and clinical classes, which may give a limited and inaccurate data. Considering the inclusion and exclusion criteria, 477 students participated in the study.
The instruments used in the study were prepared by the researchers of the study. The qualitative data collected during the first phase of the study was utilized in preparing the tool used for the quantitative phase of the study. It included four parts namely demographic variables, background variables, open-ended questions to explore the participant's experiences and challenges and Likert scale to assess the challenges.
Part 1 included the demographic variables of the participants including age, gender, course of study, year of study, residence, and place of attending online classes.
Part 2 comprised of the background variables such as gadgets used for attending online classes, source of internet, mode of theory classes taken during the last 6 months, mode of practical training, methods of teaching theory classes, audio visual aids used, and the virtual platform used.
Part 3 consisted of a questionnaire related to students’ experiences and challenges. It included 15 open-ended questions related to the aspects of theoretical learning, practical learning, study materials, teaching methodology, evaluation process, issues related to physical and mental health, issues related to technology and issues related to finance.
Lastly, Part 4 included a Likert scale on challenges having 30 questions with eight domains; educational challenges (six items), environmental challenges (two items), communication challenges (five items), technical challenges (five items), evaluation challenges (two items), physical challenges (six items), career challenges (two items), and financial challenges (two items). Dimensions were evaluated using 5-point Likert scale varying from strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5). The total score ranges from 30 to 150. The domain-wise challenges were interpreted as 1–50 = low challenges, 51–100 = moderate challenges, 101–150 = high challenges. The instrument was prepared in English and no translations were done.
Content validity was obtained from eight experts in the field of nursing education. The calculated content validity index was 0.80. Pilot study was conducted with 10% of the study participants (42 students) to test the reliability of the tool before administering to the main study participants. Using Cronbach's alpha (inter-item reliability), the internal consistency assessed was 0.89, which is highly reliable. The participants participated in the pilot study were excluded from the main study.
Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022) and Institutional review board. After getting the ethical approvals, formal permission was obtained from the Head of Nursing colleges to collect data. The researchers explained the purpose of the study to the participants involved in both quantitative and qualitative data collection. The participants were informed that their participation in the study was voluntary. Since the participants were not forced to participate in the study, they were given the freedom to withdraw from the study at any time without any penalty. The participants signed the informed consent and responded to all the questions and returned the completed questionnaire. All the audio recordings were coded and password protected. It was explained to the participants that they were not exposed to any kind of risk. To keep the data anonymous, no identifying information was collected from the participants. The researchers maintained confidentiality of information throughout the study period. All the collected data were stored in a password protected file. Only, the investigators of the study had access to the data.
In Phase I of the study, three focus groups were selected using purposive sampling technique. Each group included six participants with a total of 18 nursing students. After getting the consent, the participants shared their experiences and challenges faced during their educational training in the pandemic. The interviews were conducted from 25/2/2022 to 25/3/2022 and each interview lasted for 1.30 h to 2 h. The first and third authors conducted the interview. The first author is a PhD and the third author is a BSN holder. The first author is an assistant professor and the third author is a staff nurse. Both of them were females. Both of them were trained in qualitative data collection. The researchers established rapport with the study participants. The researcher used 15 open-ended probing questions and the participants were given the freedom to express additional views and comments. All the interviews were conducted in person in the college and audio recorded with their consent. Focus group discussions were continued till the data saturation occurred. The transcripts were returned to the participants for their correction.
In Phase II, the quantitative data were collected using convenient sampling technique. The total number of students participated in the study were 477. The questionnaires were transferred to Google forms and were circulated to the students after explaining the objectives and getting the informed consent. The quantitative data were collected from 11/04/2022 to 20 /04/2022. The response rate was 72.9% (477) which included Narayana Hrudayalaya College of nursing (88 participants), Koshy's College of nursing (235 participants) and Kirubanidhi College of nursing (154 participants).
The data were analyzed using thematic analysis. The collected data were transcribed and analyzed using Braun and Clarke's thematic analysis. Reflexive thematic analysis was performed in this study ( Clarke & Braun, 2017 ).
The quantitative data were analyzed using descriptive and inferential statistics using SPSS version 22.
To ensure credibility of the data, the researcher strongly engaged with the focused group interviews by means of observation, documentation, and taking notes. Dependability was achieved through reviews and comments given by the research guide, who is the second author of the study who has full knowledge of the study design and methodology. The data collected from participants and the findings could be applicable to other contexts, situations, times, and populations and the study setting. It ensures transferability.
The researcher adhered to rigor by carefully collecting data via audio recordings and by taking field notes. Each focus group interview was transcribed immediately after the interview. The transcripts were given to the participants for cross-checking and approval. In addition to ensuring rigor through trustworthiness criteria, the authors followed mixed-methods research legitimation criteria by ensuring design quality, design suitability, within design consistency, design fidelity, and analytic adequacy ( Teddlie & Tashakkori, 2009 ).
Trustworthiness was established by using an unbiased approach in selecting the participants and by participant's being honest, clearly recorded, and accurately presented inputs. The transcriptions, coding, and themes–subthemes were discussed by the research team for their verification. Then based on the themes and subthemes the quantitative questionnaire was created by the researchers.
Table 1 shows the frequency and percentage distribution of background variables of 18 participants who shared their experiences and challenges faced during their educational training in the pandemic. Table 2 shows the frequency and percentage distribution of participants’ background variables.
Frequency and Percentage Distribution of Demographic Variables of Nursing Students.
S. no | Demographic variables | Qualitative data | Quantitative data | ||
---|---|---|---|---|---|
Frequency | Frequency | ||||
Phase 1 ( = 18) | Percentage | Phase II ( = 477) | Percentage | ||
18–23 years | 16 | 88.9 | 432 | 90.6 | |
23–29 years | 2 | 11.1 | 45 | 9.4 | |
Gender | |||||
Male | 4 | 22.2 | 111 | 23.3 | |
Female | 14 | 77.8 | 366 | 76.7 | |
Course | |||||
B.Sc. Nursing | 14 | 77.8 | 331 | 69.4 | |
GNM | 4 | 22.2 | 146 | 30.6 | |
Year of study | |||||
Second year | 4 | 22.2 | 226 | 47.4 | |
Third year | 9 | 50 | 226 | 47.4 | |
Fourth year | 5 | 27.8 | 25 | 5.2 | |
Residence | |||||
Urban | 11 | 61.1 | 216 | 45.3 | |
Semi-urban | 2 | 11.1 | 113 | 23.7 | |
Rural | 5 | 27.8 | 148 | 31 | |
From where you attended the online classes most of the time | |||||
Home | 7 | 38.9 | 79 | 16.6 | |
Hostel | 11 | 61.1 | 398 | 83.4 |
Frequency and Percentage Distribution of Baseline Variables of Nursing Students.
S. no | Demographic variables | Qualitative data | Quantitative data | ||
---|---|---|---|---|---|
Frequency | Frequency | ||||
Phase 1 ( = 18) | Percentage | Phase II ( = 477) | Percentage | ||
Gadget used for attending online classes (multiple choice) | |||||
Mobile | 18 | 100 | 469 | 98.3 | |
Laptop | 2 | 11.11 | 52 | 10.9 | |
Tablet | 1 | 5.55 | 13 | 2.7 | |
Desktop | 4 | 0.8 | |||
Source of internet (multiple choice) | |||||
WiFi | 3 | 16.66 | 87 | 18.2 | |
LAN | - | - | 1 | 0.2 | |
Mobile data | 18 | 100 | 451 | 94.5 | |
Mode of theory classes taken for the last 6 months | |||||
Online | 1 | 5.6 | 69 | 14.5 | |
Offline | 5 | 27.7 | 157 | 32.9 | |
Both online and offline | 12 | 66.7 | 251 | 52.6 | |
Mode of the practical training | |||||
Online | 1 | 5.6 | 50 | 10.5 | |
Offline | 7 | 38.9 | 289 | 60.6 | |
Both online and offline | 10 | 55.5 | 138 | 28.9 | |
Methods of teaching used for theory classes (multiple choice) | |||||
Lecture cum discussion | 18 | 100 | 451 | 94.5 | |
Seminar | 1 | 5.55 | 98 | 20.5 | |
Role play | - | - | 38 | 8 | |
AV aids used (multiple options) | |||||
Power point presentation | 17 | 94.4 | 445 | 93.3 | |
Videos | 7 | 38.9 | 218 | 45.7 | |
White / Black board | - | - | 88 | 18.4 | |
Virtual platform used (multiple options) | |||||
Zoom | 8 | 44.4 | 250 | 52.4 | |
Google meet platform | 10 | 55.6 | 286 | 60 | |
Cisco | - | - | 106 | 22.2 | |
Web-ex | 4 | 22.2 | 179 | 37.5 |
In Phase 1, the experiences and challenges experienced by nursing students with their educational training during the pandemic were analyzed using thematic analysis. Table 3 reports seven themes and 10 sub-themes. The themes identified includes: (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. The sub-themes were: (1.1) problems with internet connectivity, (1.2) issues with the digital platform, (2.1) theoretical learning experience-better, (2.2) deficient practical skills, (3.1) physical stress, (3.2) mental stress, (4.1) unfair evaluation and lack of feedback, (5.1) decreased quality of communication, (6.1) very convenient, and (7.1) difficult to concentrate.
Themes and Subthemes of Experiences and Challenges Faced by Nursing Students.
S. no. | Themes | Sub-themes |
---|---|---|
Technical issues—a concern | 1.1. Problems with internet connectivity | |
1.2. Issues with the digital platform | ||
Regular rhythm in educational training—but not complete | 2.1. Theoretical learning experience-Better | |
2.2.Deficient practical skills | ||
Stress and strain | 3.1.Physical stress | |
3.2.Mental stress | ||
Evaluation—a concern | 4.1.Unfair evaluation | |
Communication | 5.1.Decreased quality of communication | |
Comfort zone | 6.1.Very convenient | |
Easy distraction | 7.1.Difficult to concentrate |
Modern technology is progressive in all sectors. With this technology, it was possible to deliver training in all educational sectors including nursing education during COVID-19. Though it was helpful, technical problems interrupted the teaching–learning process. Most of the participants expressed their concern related to technical issues. It includes issues with internet connectivity, and issues with the digital platform.
Constant network issues were an unavoidable fact for many students. Students could not be connected to the virtual class on time due to the internet connectivity issues and they had to miss attending the classes.
“Sometimes it keeps on showing error code and by the time I get connected the class is completed by the faculty” (5A).
Students stated that they faced technical and network issues while attending the classes.
“During online classes, we have faced a lot of technical and network issues” (2A).
In addition, fluctuations in the network connectivity were another technical issue faced by students and it affected the virtual learning of the students.
“I faced fluctuations in my network during a natural calamity in my place so I missed many classes during that time” (13A).
There are various platforms used to deliver online educational training. The participants expressed their difficulties as they had hitches in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning.
Digital platform did not work if the application is not updated on time. This was stated as below;
“If I did not update the app on time, it will not work” (1A).
Students faced problems in joining the virtual platform due to issues with the virtual platform.
“Sometimes I faced problems with joining with the virtual platform” (8A).
Lack of experience in using the virtual platform by both the faculty and student was another challenge stated by the students.
“Had struggle to join the meeting initially for both students and faculties because it was very new to us” (5A).
Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.
“I struggled while submitting the answer sheets /assignment through digital platforms” (4A).
Virtual education is a boon during pandemic. It took the education system in a rhythmic manner. Though the online lectures were beneficial, at times, students faced few challenges.
The students utilized the opportunities to learn from online classes with few challenges in attending online classes.
Commencement of online classes helped the students to have continuity in their studies. As the online classes were started on time immediately, it did not affect their theoretical learning.
“…It was not at all possible for the colleges to continue the offline classes so that the apex body instructed to start with online classes and it's good that we were in touch with our studies” (12A).
Different methods and techniques of teaching adopted during online classes enhanced interest in their learning.
“During online classes teacher used to teach with PPTs, and some good videos to make the session interesting. Sometimes they used to conduct lecture cum discussion. That time I was interested to listen to the class” (15A).
“I was interested to attend the online theory classes when teachers used to take a class by showing some videos related to theory content. It was good” (16A).
Students encountered issues with the storage of study materials as they had minimal storage space in their gadgets.
“Teachers used to send notes in PDF form in the mail or by WhatsApp. When I have storage issues in my gadgets, I deleted the content because of storage issues” (18A).
Practical training is a major part of nursing profession. Students faced many challenges while attending online practical classes.
Most of the students stated that their theoretical learning through virtual mode was excellent. However, students felt that learning practical skills through direct clinical experience is rewarding than learning through virtual platform.
“…theory classes were very good. But in case of practical, like IV infusion, it was very easy to watch the procedure in a virtual platform, but it was very difficult to perform. I feel offline clinical exposure is better than online” (3A).
Students stated that they learnt basic nursing skills through direct clinical experience before the pandemic. However, the students lack confidence in performing the skills that they learnt through videos. The students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning.
“…During my first-year clinical posting, I learnt basic procedure like vital signs checking, wound care, surgical dressing, etc with the direct clinical experience, suddenly everything goes on online, the faculty used to show us best videos. While watching videos I feel I can do. But when it's time to do directly, my hands were shivering and I was not confident. I feel offline exposure is better, we can get more exposure” (1A).
Huge gap in practical learning due to the pandemic affected the learning of the students. Thus, the students did not recommend online learning for learning the skills.
“I did not get adequate practical posting in my first year because of COVID-19. It continued with the second year too. So I have a huge gap with practical learning. For practical learning, online learning is not appropriate” (7A).
Prolonged online training affects the students’ physical as well as mental health. They felt more stressful.
Students experienced physical symptoms such as strain in the eyes, neck pain, back pain and numbness in the legs due to prolonged usage of phone and sitting.
“I have to write my notes by seeing my phone. Every time I need to continuously see my mobile and make notes. It was straining my eyes and stressful for me” (16A).
“While attending online classes I used to keep my video on and listen to the class. Due to prolonged sitting, I have neck pain, eye strain also” (5A).
“I felt back pain and numbness in my leg while attending the online classes with prolonged sitting. I used to walk in between for some time to reduce the numbness” (12A).
Students were anxious, as they could not complete the given tasks in online classes.
“I was anxious because I did not complete my task given in online classes, I was lazy” (4A).
As the students did not get practical experience in the clinical area, their confidence levels were low during the pandemic. Moreover, as the students did not get any opportunity to practice directly in the clinical area during the pandemic, they felt tensed and lacked confidence to directly practice on the patient after the pandemic.
“Due to lack of practice in clinical, my confidence had come down” (8A).
“I felt stressed out when I am thinking about my practical learning. I did not get adequate opportunity to practice” (10A).
“After lockdown when I came in the clinical setting, I was tensed about how I will handle the patient” (15A).
Evaluation is the process of providing feedback to the students to improve themselves. The test, examination, assignment, and evaluation were new for the students and faculty during the pandemic and there were malpractice incidences by the students.
Students felt conducting exam using Google form as useful.
“Some faculties conducted few exams in Google Form, it was good because at that time I studied and attend the exam” (16A).
Malpractice in the online exam could be observed in the students during virtual learning.
“For the online exam, I never used to study because I can copy from PPT, my screenshots, or from Google and score good marks” (2A, 8A, 17A, 18A).
Students stated that they did not get proper feedback on their assignments.
“In my point of view, some faculties did not give us proper feedback on my assignment writing” (6A).
One student stated the unfair evaluation as the students copied scored well.
“I feel very bad when I write without copying and score very less marks; while the students who did malpractice scored well. So the evaluation was going very wrong” (4A).
It is necessary to build proper communication between the teachers and students to continue a smooth training session online. However, students felt that this distance learning created a communication gap between teachers and students.
Limited and disrupted communication with the friends and teachers created distress in the students.
“It was not possible for me to communicate face to face with my friends and teachers during the online classes. It was quite distressing” (1A).
“Online class communication was the major problem. We could not communicate with faculties and peers like offline” (18A).
Students felt that they could not clarify their doubts with the faculty. However, faculty responded to their queries through WhatsApp and social media.
“If it comes to communication, it was very limited… During offline we can directly ask doubts to the faculty, but not now” (2A).
“During the online classes communication was not easy like face to face communication. But teachers were responding by WhatsApp and other social media after class time also” (6A).
Online classes were attended by the students either from hostel or home.
Students felt comfortable staying home and attending online classes.
“It was convenient for me. Because I can stay at home, take care of my family and attend class also” (8A).
“For me, it was convenient, I got more time and can get up late to attend classes” (2A, 3A, 7A).
Students expressed that their transport expenses could be minimized, as they were not required to travel during the pandemic.
“I could save time. Even transport expenses could be minimized” (10A).
Distraction was very high in online classes.
Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings.
“As my internet is on I will get many notifications from other apps during class, it was a distraction for me” (4A, 9A, 11A).
“I attended online classes from my home only. I had disturbance from siblings, during my online classes” (7A, 16A).
Students themselves got distracted as they were using social media in between the online classes.
“I used to browse on Facebook, Instagram, YouTube, etc. during the online classes” (13A).
Table 1 shows the frequency and percentage distribution of participant's demographic variables. Majority (90.6%) of the participants were in the age group between 18 and 23 years. Most of them were females (76.7%). 69.4% of the students were undergraduate (BSN) nursing students, while the rest were in Diploma nursing program. 47.4% of the participants were in their second and 47.4% were in their third year of study. Nearly half (45.3%) were from urban areas and 23.7 were from semi-urban areas, while the remaining (31%) were from rural areas. A large number (83.4%) of students attended the online classes from their hostels.
Table 2 outlines the frequency and percentage distribution of participants’ background variables. The results showed that the majority (98.3%) of the students used mobile phones to attend online classes. Most of them (94.5%) used the mobile data to have the internet connection. Almost half of the participants (52.6%) attended both online and offline classes. More than half (52.6%) of the participants had both online and offline practical exposure, and around 33% had offline clinical exposure. Most of the students (94.5%) attended lecture and discussion sessions. A huge number (93.3%) used power point presentation, and 45.7% of them used videos for teaching. Majority (60%) used Google Meet, while 52.4% used Zoom. The remaining used multiple platforms like Cisco, and Webex.
Figure 1 describes the frequency and percentage of distribution of level of challenges. It was classified as low, moderate, and high level of challenges. Majority of them (54.71%) experienced high-level challenges, 44.6% encountered moderate-level challenges, and the remaining experienced low-level challenges related to their nursing education during the pandemic.
Frequency and Percentage Distribution of Challenges Faced by Nursing Students During Their Educational Training.
The domain-wise challenges with nursing education during pandemic were shown in Table 4 . The eight domains included educational challenges, environmental challenges, communication challenges, technical challenges, evaluation challenges, physical and mental challenges, career challenges, and financial challenges. The mean and standard deviations for educational challenges is (20.27 ± 3.04), environmental challenges (6.92 ± 1.66), communication challenges (17.61 ± 4.01), technical challenges (17.39 ± 3.75), evaluation challenges (7.09 ± 1.94), physical and mental challenges (20.47 ± 4.33), career challenges (7.06 ± 1.91), and financial challenges (6.61 ± 2.1). The overall mean and S.D. of all the domain was 103.39 ± 1 7.11 with the range from 30 to 150.
Assessment of Mean and Standard Deviation of Domain-Wise Challenges Faced by the Nursing Students n = 477.
S. no | Domain-wise challenges | Mean | Standard deviation | Range |
---|---|---|---|---|
Educational challenges | 20.27 | 3.04 | 6–30 | |
Environmental challenges | 6.92 | 1.66 | 2–10 | |
Communication challenges | 17.61 | 4.01 | 5–25 | |
Technical challenges | 17.39 | 3.75 | 5–25 | |
Evaluation challenges | 7.09 | 1.94 | 2–10 | |
Physical and mental challenges | 20.47 | 4.33 | 6–30 | |
Career challenges | 7.06 | 1.91 | 2–10 | |
Financial challenges | 6.61 | 2.1 | 2–10 | |
Total |
Table 5 displays the item-wise challenges. The results of Educational Challenges indicated that almost 38.57% responded that they lack interest in learning. 15.93% either strongly agreed or agreed that face-to-face learning is very effective than E-learning. A larger portion (78.62%) of participants mentioned that the notes and lectures were inadequate. More than half of the participants (54.3%) agreed that virtual demonstration is not very effective for the practical patient care, and 61.21% mentioned that they lack confidence while taking care of patients. The participants provided similar responses during the qualitative phase of the study. The students lack confidence in performing the skills that they learnt through videos. Similarly, the students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning. However, one third of the respondents (33.75%) expressed that they could learn the modern ways of handling patients through videos.
Item-Wise/Domain-Wise Analysis of Challenges Faced by Nursing Students.
S. no | Items | Strongly agree | Agree | Neutral | Disagree | Strongly disagree | |||||
---|---|---|---|---|---|---|---|---|---|---|---|
f | % | f | % | f | % | F | % | f | % | ||
1 | Lack of interest in learning | 74 | 15.51 | 110 | 23.06 | 214 | 44.86 | 43 | 9.01 | 36 | 7.55 |
2 | Face-to-face learning is more effective than E-learning | 30 | 6.29 | 46 | 9.64 | 140 | 29.35 | 126 | 26.42 | 130 | 27.25 |
3 | Notes/Lecture content are not adequate | 224 | 46.96 | 151 | 31.66 | 72 | 15.09 | 16 | 3.35 | 14 | 2.94 |
4 | Virtual demonstration is not very effective—practical patient care. | 113 | 23.69 | 146 | 30.61 | 155 | 32.49 | 35 | 7.34 | 28 | 5.87 |
5 | Lack of confidence while taking care of patients | 162 | 33.96 | 130 | 27.25 | 117 | 24.53 | 44 | 9.22 | 24 | 5.03 |
6 | Learnt modern ways of handling patients through videos. | 56 | 11.74 | 105 | 22.01 | 185 | 38.78 | 80 | 16.77 | 51 | 10.69 |
7 | Distracted very easily while attending online classes | 142 | 29.77 | 139 | 29.14 | 133 | 27.88 | 38 | 7.97 | 25 | 5.24 |
8 | My environment was very comfortable during pandemic to attend online classes | 85 | 17.82 | 113 | 23.69 | 150 | 31.45 | 77 | 16.14 | 52 | 10.9 |
9 | Difficulty in sharing my view with the teachers | 83 | 17.4 | 141 | 29.56 | 169 | 35.43 | 55 | 11.53 | 29 | 6.08 |
10 | Process of teacher–students interaction became passive. | 74 | 15.51 | 145 | 30.4 | 197 | 41.3 | 48 | 10.06 | 13 | 2.73 |
11 | Socializing with peer groups has decreased | 109 | 22.85 | 167 | 35.01 | 151 | 31.66 | 27 | 5.66 | 23 | 4.82 |
12 | Experience of loneliness without interacting much with peer groups. | 115 | 24.11 | 155 | 32.49 | 151 | 31.66 | 32 | 6.71 | 24 | 5.03 |
13 | Missed interaction with my seniors/college mates | 94 | 19.71 | 138 | 28.93 | 167 | 35.01 | 43 | 9.01 | 35 | 7.34 |
14 | Uncertain internet connection interrupts the learning process. | 70 | 14.68 | 140 | 29.35 | 174 | 36.48 | 63 | 13.21 | 30 | 6.29 |
15 | Teachers had difficulty in using technical aspects of the online platforms. | 69 | 14.47 | 109 | 22.85 | 143 | 29.98 | 87 | 18.24 | 69 | 14.47 |
16 | Good internet connection was there at my place. | 140 | 29.35 | 148 | 31.03 | 125 | 26.21 | 38 | 7.97 | 26 | 5.45 |
17 | Faced technical issues with learning platform /device. | 114 | 23.9 | 151 | 31.66 | 146 | 30.61 | 37 | 7.76 | 29 | 6.08 |
18 | Difficulty while submitting the answer sheets /assignment through digital platforms | 140 | 29.35 | 144 | 30.19 | 122 | 25.58 | 44 | 9.22 | 27 | 5.66 |
19 | Online evaluation may create irrational discrimination between students. | 99 | 20.75 | 145 | 30.4 | 168 | 35.22 | 39 | 8.18 | 26 | 5.45 |
20 | Evaluation/test conducted online was unfair | 121 | 25.37 | 127 | 26.62 | 158 | 33.12 | 39 | 8.18 | 32 | 6.71 |
21 | Experience of physical strain like headache, backache, neck pain, eye strain | 147 | 30.82 | 149 | 31.24 | 158 | 23.27 | 43 | 9.01 | 27 | 5.66 |
22 | I did not feel much mental stress | 47 | 9.85 | 92 | 19.29 | 165 | 34.59 | 106 | 22.22 | 67 | 14.05 |
23 | Developed insomnia | 88 | 18.45 | 137 | 28.72 | 162 | 33.96 | 54 | 11.32 | 36 | 7.55 |
24 | Addicted to phone due to prolonged using of phone other than learning purpose. | 96 | 20.13 | 127 | 26.62 | 149 | 31.24 | 64 | 13.42 | 41 | 8.6 |
25 | Regular life style has changed | 125 | 26.21 | 146 | 30.61 | 148 | 31.03 | 38 | 7.97 | 20 | 4.19 |
26 | Worry about online teaching applications that lack proper security system | 99 | 20.75 | 131 | 27.46 | 160 | 33.54 | 55 | 11.53 | 32 | 6.71 |
27 | Virtual practical training will affect my career as a registered nurse. | 115 | 24.11 | 154 | 32.29 | 151 | 31.66 | 38 | 7.97 | 19 | 3.98 |
28 | I may not be able to work as a skillful nurse | 91 | 19.08 | 143 | 29.98 | 152 | 31.87 | 56 | 11.74 | 35 | 7.34 |
29 | Extra money for my expenses for good internet package | 149 | 31.24 | 128 | 26.83 | 126 | 26.42 | 40 | 8.39 | 34 | 7.13 |
30 | Bought a new laptop/mobile/electric gadgets to attend virtual classes. | 89 | 18.66 | 94 | 19.71 | 111 | 23.27 | 68 | 14.26 | 115 | 24.11 |
With regard to Environmental challenges , 41.51% expressed that they were comfortable with their home or hostel environment to attend online classes. However, more than half (58.91%) said that they were easily distracted while attending classes. Similar findings were seen in the qualitative phase of the study. Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings. Further, the students were distracted as they were using social media during the online class.
In terms of Communication challenges , almost half of them (46.96%) expressed that they had difficulty in sharing their view with the teachers, and 45.91% said that teacher–student interaction was passive. More than half (57.86%) of them expressed that peer group socialization has decreased, missed interaction (48.64%) with other college mates/seniors and experienced loneliness (56.6%) without interacting much with peer groups. Similar to these findings in the quantitative phase, in qualitative phase, the students mentioned that limited and disrupted communication with the friends and teachers created distress in the students. Moreover, the students could not clarify their doubts with the faculty.
Regarding Technical challenges , 44.03% had uncertain internet connection that interrupted the learning process. Around 37.32% expressed that the teachers had difficulty in using technical aspects of the online platforms initially. Around 39.63% had internet issues in their place. Almost 55.56% students faced technical issues with learning platform/device and around 59.54% had difficulty while submitting the answer sheets/assignment through digital platforms. Likewise, the qualitative findings revealed that the students faced technical and network issues while attending the classes. In addition, fluctuation in the network connectivity was another technical issue faced by students and it affected virtual learning. The participants expressed their concerns as they had difficulties in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning. Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.
Related to Evaluation challenges , almost half of them (51.15%) mentioned that the online evaluation might create irrational discrimination between students with network issues, and 51.99% of them said that the evaluation/test conducted online was unfair. Consistent findings could be noted during the qualitative phase of study. Students mentioned that malpractice in the online exam occurred and it affected their grades. In addition, students stated that they did not get proper feedback on their assignments.
With respect to Physical and mental challenges , more than half 62.06% experienced physical strain like headache, backache, neck pain, and eye strain, 47.17% experienced insomnia, around 70.86% had mental stress, 46.75% got addicted to phone due to prolonged usage other than for learning purpose, 56.82% mentioned that the regular life style has changed, and lastly 48.21% were worried about the online teaching applications which lack proper security system. Likewise, same results are discovered in the qualitative phase of the study. Students experienced physical symptoms such as strain in the eyes, neck pain, back pain, and numbness in the legs due to prolonged sitting and continuous usage of phone. Additionally, students were anxious, as they could not complete the given tasks in online classes. Further, as the students did not get practical experience in the clinical area, their confidence levels were low and they felt tensed and lacked self-confidence to directly practice on the patients after the pandemic.
In terms of Career challenges , 56.4% agreed that virtual practical training may affect their career as a registered nurse, and 49.06% agreed that they may not be able to work as a skillful nurse with the virtual learning. Regarding Financial challenges , almost 58.07% agreed that extra money was spent for good internet package and 38.37% bought a new laptop/mobile/electric gadget to attend virtual classes.
With regard to association of demographic variables, only gender (χ 2 = 6.218, p = 0.045) has shown statistically significant association with problems or challenges faced by the nursing students during educational training in the pandemic at p < 0.05 level of significance.
During COVID-19 pandemic, face-to-face teaching and learning were converted to virtual learning and the clinical experiences were suspended to protect the students from the pandemic ( Agu et al., 2021 ). The experiences with the online classes were very new for the nursing students. Moreover, the online education became unavoidable and was a good choice for the faculty and students during this pandemic across the world. Even though, the students and teachers had a positive view of the technology, which helped in the teaching–learning process during pandemic, it posted many challenges ( Mousavizadeh, 2022 ).
We conducted a mixed-methods study to explore the experiences and challenges faced by nursing students in their education during COVID-19 in India. The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases; the qualitative data were collected during Phase I using focus group interview with the students. The qualitative data collected during the first phase of the study was utilized in preparing the tool for the quantitative phase of the study. The quantitative data were collected using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. During Phase 1, the analyzed data produced seven themes and 10 sub-themes on the challenges. These themes produced during the qualitative phase further explained the challenges experienced by the nursing students in their education during COVID-19 pandemic in the quantitative phase.
Learning motivation encourages learners’ activities and directs and maintains their progress, allowing students to immerse themselves in learning ( Kim, 2020 ). However, virtual learning decreased students’ attention and interest in classes, which then decreased their motivation to learn ( Morfaki & Skotis, 2022 ). Likewise, in the current study most of the students expressed that they lost interest in their learning. Student's interest is very important for academic achievement, so different methods of teaching and learning need to be adopted in future to improve the learning among students during online education ( Mousavizadeh, 2022 ).
During COVID-19 pandemic, the medical and nursing institutions used learning management systems (LMS) and uploaded various reading materials, videos, quizzes, and presentations to encourage the engagement of students in asynchronous learning activities. In addition, online discussion forums were created to facilitate the virtual learning process ( Atwa et al., 2022 ). Some students preferred online learning as it provides structured learning materials and enables studying from home at their own pace and convenience ( Paechter et al., 2010 ; Zheng et al., 2021 ). However, most of the students in different studies conducted across the world preferred face-to-face learning for acquiring motor skills, for establishing interpersonal relationships, and for achieving student learning outcomes ( Arias et al., 2018 ; Faidley, 2021 ; Ramani & Deo, 2021 ; Lim et al., 2021 ). Similarly, Muthuprasad et al. (2021) advocated that the online mode of learning may not be a viable option for practical/skill-oriented courses and therefore hybrid/blended curriculum involving both face to face and online modes of learning shall be adopted by the institutions.
The faculty used different methods of teaching and audio visual aids to enhance the teaching–learning process during the pandemic ( Reimers et al., 2020 ). However, students in the present study mentioned that the notes/lecture content were inadequate. Similar findings were reported in other studies that the quality and effectiveness of lecture were low; and inconsistencies were observed in some professor's lecture during COVID-19 ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ). This warrants the educational institutions to monitor the quality of teaching delivered by the faculty to their students during this pandemic. In addition, the faculty should take self-initiatives for the professional empowerment ( Osmanovic Zajic et al., 2022 ).
The professional preparation of nurses involves many hours of practical and theoretical classes which is conducted face to face, which gives a real learning experience ( Dziurka et al., 2022 ). However, COVID-19 pandemic caused alterations, restrictions, limited clinical placements and simulation training in the campus ( Rohde et al., 2022 ). Thus, many nursing institutions adopted virtual theoretical and practical learning modes. Various studies across the world including the present study reported that virtual practical learning was inappropriate and ineffective in doing practical skills. Additionally, the nursing students lack confidence in taking care of the patients as they did not have hands on training ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Gheshlagh et al., 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ; Wajid & Gedik, 2022 ). Therefore, in addition to direct face-to-face practical training in the clinical areas, more nursing simulations, virtual reality, artificial intelligence and telenursing should be utilized to enhance the practical learning of nursing students ( Dziurka et al., 2022 ).
Student engagement during the virtual classes are very essential. The students are expected to actively participate, show positive conduct, self-regulated, display deep learning and understanding, and should demonstrate positive reactions to the learning environment, peers, and teachers ( Bond et al., 2020 ). However, students in the current study and many other studies were distracted very easily while attending online classes, which limited their learning during pandemic ( Bergdahl, 2022 ; Farrell & Brunton, 2020 ; Fazza & Mahgoub, 2021 ; Hollister et al., 2022 ). Therefore, more peer-to-peer conversations and faculty–student exchanges are recommended to enhance the engagement and learning during the pandemic.
Effective communication between the educator and the students enhances the learning experience and creates a positive learning environment. In addition, it improves the exchange of ideas, knowledge, and thought to fulfill the purpose of teaching and learning. However, ineffective communication creates frustration, impaired interpersonal relationships, and lack of motivation ( Alawamleh e al., 2020 ). In consistent to this study, the present participants had difficulty in sharing their view with the teachers, could not socialize with peer groups, and experienced loneliness. Furthermore, studies reported that impaired communication during online learning creates uncertainties and insufficiencies in learning ( Cengiz et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ). Thus, effective communication with the students should be streamlined for successful virtual learning ( Mukasa et al., 2021 ).
Online education can be effectively integrated in the nursing curriculum as it guarantees effective problem-based learning. However, the nursing colleges were not adequately prepared to effectively utilize the online teaching and learning in developing and under developed countries ( Molefe & Mabunda, 2022 ). Technical aptitude was lacking among the faculty and students, which posed various challenges ( Barrot et al., 2021 ). Moreover, technical challenges limited the satisfaction of students and faculty toward online teaching and learning ( Mahyoob, 2020 ). Furthermore, failure of internet services, website failures, problems in logging into the site disrupted the teaching–learning process during the pandemic ( Fuchs, 2022 ; Gaur et al., 2020b ). Similar to these studies, the present study participants mentioned that they experienced uncertain internet connection, faced technical issues with learning platform/device, and had difficulty while submitting the answer sheets /assignment through digital platforms. In addition, the teachers had difficulty in using technical aspects of the online platforms. This calls for improving the instructional design and pedagogical methods by training the faculty and students to utilize the digital platforms effectively, which might improve the motivation and engagement of faculty and students during the online education ( Aivaz & Teodorescu, 2022 ).
Significant changes in the teaching and learning during the pandemic created profound opportunities and threats. Stakeholders and students reported that the evaluation during online learning was biased and ineffective ( Krishnamurthy, 2020 ) and experienced uncertainty toward the examination ( Idris et al., 2021 ). Besides, online learning affects the test scores and grades, student outcomes, attitude, and overall satisfaction with learning ( Szopiński & Bachnik, 2022 ). In the same way, the students in the current study mentioned that the online evaluation created irrational discrimination between students and the evaluation conducted online was unfair. Therefore, standard setting in the evaluation is an essential step considering the learners and educator's perspective, which would improve the teaching–learning process ( Wasfy et al., 2021 ).
COVID-19 pandemic disproportionately affected the physical and mental health of students ( Ro et al., 2021 ). Students missed eating, did not participate in extracurricular activities, and experienced computer-related physical stress ( Idris et al., 2021 ). Likewise, students experienced increased stress due to homework, social isolation and lack of social interactions ( Rao & Rao, 2021 ). In congruent with these study findings, the participants in the present study experienced headache, backache, neck pain, eye strain, insomnia, and mental stress. The authors recommend addressing the physical and mental health issues of the students by promoting the utilization of physical, emotional, and mental health support programs ( Idris et al., 2021 ).
COVID-19 pandemic impacted the career preference, career perspective, and ideal workplace ( Wang et al., 2022 ). In the same way, the students struggled with the career decision-making process during the pandemic ( Jemini-Gashi & Kadriu, 2022 ). Likewise, working students lost their jobs, which affected their lives, studies, and health ( Tsurugano et al., 2021 ). In line with these studies, students of the present study expressed that virtual practical training will affect their career as a registered nurse and they may not be able to work as a skillful nurse. This calls for the initiation of a structured and well-designed practical training program for the nursing students in the hospitals before their placement as a registered nurse in the clinical practice.
The pandemic put a number of students under financial strain, which severely affected their mental well-being ( Negash et al., 2021 ). Similarly, the university students were disproportionately affected by the economic consequences of the pandemic, which escalated the economic uncertainty ( Gewalt et al., 2022 ). The students who lost their economic resources during pandemic experienced higher prevalence of depressive symptoms ( Tancredi et al., 2022 ). Participants in the current study mentioned that they had to spend extra money for good internet package and bought a new laptop/mobile /electric gadget to attend virtual classes, which increased their economic burden. To counterbalance these economic challenges, financial aid schemes for students need to be made available to relieve distress and allow students to focus on their studies ( Gewalt et al., 2022 ).
The study findings are limited to only few nursing colleges in India. Therefore, the study findings may not be generalizable to other states of India. As the study population was not selected through probability sampling strategy, the representativeness of samples might be lacking in the current study. Moreover, the study instruments were prepared by the investigators of the study that did not undergo rigorous standardization process, which might limit the strength of the study. Based on the study findings, the institutions where the study was conducted should design strategies to mitigate the challenges to have effective teaching and learning.
Virtual nursing education can be improved by refining the content and delivery methods, training of nursing faculty to use online educational strategies, and by reducing the technical and environmental barriers. Hybrid and blended teaching–learning strategies may further improve the learning among nursing students.
Virtual education can be very successful if we address the challenges and experiences of the students by performing appropriate groundwork by upgrading the required hardware and software, teaching how to use the facilities, and developing innovative teaching techniques and standard protocols for virtual education.
Acknowledgments.
The authors thank the students and faculty members who participated in this study. The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program. The authors would like to acknowledge the nursing students who have participated in the study. Special thanks to the administrators and faculty members of the institutions for their motivation and support during data collection.
Author Contributions: PK designed and conducted the study and wrote the initial draft of the manuscript. JA edited and added additional content and refined the manuscript. AP collected the data. SM edited the manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Approval: Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022).
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program.
ORCID iDs: Judie Arulappan https://orcid.org/0000-0003-2788-2755
Shimmaa Mansour Moustafa Mohammed https://orcid.org/0000-0002-2956-610X
Supplemental Material: Supplemental material for this article is available online.
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