The impact of COVID‐19 on work, training and well‐being experiences of nursing associates in England: A cross‐sectional survey

Abstract Aim To explore how the COVID‐19 pandemic affected nursing associate work, training and well‐being experiences. Design Cross‐sectional survey. Methods A survey of trainee and newly qualified nursing associates was completed in July 2020. Closed responses were analysed using descriptive statistics with inferential comparisons made between community and secondary care settings. Open questions were analysed thematically. Results Sixty‐four participants responded. Over half (53.2%) experienced an increased workload with 24.2% reporting extensions in their role. One third (32.3%) were redeployed, and a quarter (24.2%) did not feel safety concerns were adequately addressed when raised. Those working in the community reported significantly more concerns about staffing (p = .03), working overtime (p = .03), missed care (p = .02) and safety (p = .04). Despite this, many (75.8%) participants felt able to provide the same standards of care. Several spoke about enhanced teamwork, and the majority (96.8%) were not looking to leave their post.

healthcare services worldwide, with concerns amongst healthcare professionals about increased workload, adjusted working practices, and risk of exposure to themselves and their families, leading to workforce shortages and burnout (Azzopardi-Muscat, 2020;Heath et al., 2020).
Healthcare workers caring for patients with COVID-19 are at higher risk of contracting the virus than the general population (Salas-Vallina et al., 2020;Shah et al., 2020), with Black, Asian and minority ethnic (BAME) individuals at particularly high risk (Moorthy & Sankar, 2020;Salisbury, 2020). A study by Shah et al. (2020) in Scotland found that the risk of hospital admission due to  was threefold for healthcare workers and twofold for members of their households. Furthermore, 17.2% of all admissions due to COVID-19 were healthcare workers or their households (Shah et al., 2020).
Concerns amongst healthcare workers are exacerbated by shortages of personal protective equipment (PPE) (Bielicki et al., 2020;Newman, 2020) and psychological distress (Heath et al., 2020;Moorthy & Sankar, 2020). Studies of previous respiratory pandemics have also noted concerns about PPE and infectivity (Koh et al., 2012;Lam & Hung, 2013). The impact of the pandemic on frontline staff is clear to those in senior management. A survey of 199 hospital executive directors across England revealed that 99% are concerned about staff burnout following the first wave of COVID-19 (NHS providers, 2020), with fears of an impending "perfect storm" of workforce shortages, staff burnout and the second wave of coronavirus.
A narrative review of similar outbreaks (SARS-1 and Ebola) by Heath et al., (2020) identified several strategies to reduce the psychological impact on the healthcare workforce. For example, selfcare, a supportive workplace culture, adequate PPE and appropriate training when redeployed to other areas. They concluded that effective leadership, resilience training and psychological first aid could help counter psychological distress for healthcare workers during a pandemic. Similarly, Mills et al. (2020) advise that, in order to respond to a crisis such as a pandemic, workforce well-being and resilience depend on self-care and staff support through compassionate leadership. The importance of supportive leadership was revealed in a survey in Hubei China, which found that nurses were more likely to volunteer to care for COVID-19 patients if they were provided with adequate training and psychological support (Gan et al., 2020).
The impact of effective leadership was also highlighted in a study of healthcare leaders in Spain, where rates of COVID-19 in the workforce appeared lower in settings with a high level of trust and information sharing (Salas-Vallina et al., 2020).
Improving recruitment and retention has been a UK healthcare workforce priority for some time (NHS Improvement, 2019).
Previous studies have identified reasons for student nurse attrition and nurse dissatisfaction. Student nurse attrition is due to lack of support, unmet expectations and financial concerns (Health Education England, 2018). Furthermore, nurses have reported feeling demoralized from a perceived lack of support and staff shortages (Senek et al., 2020). Future key priorities for the workforce are to improve the experience of providing care, including prioritizing mental health and psychosocial support (Azzopardi-Muscat, 2020).
Organizations have also been prompted to consider how best to protect healthcare workers and their families to maintain services and reduce community transmission of COVID-19 (Moorthy et al., 2020;Shah et al., 2020).
While previous work on the effect of COVID-19 on the nursing workforce is clearly important, little is yet known about how COVID-19 has affected nursing associates in relation to their work, training and well-being. This study focusses on how the pandemic is being experienced by this new occupational group during the first wave of the pandemic.

| Research question
How is COVID-19 affecting the work, training and well-being experiences of nursing associates?

| Design
The study used a cross-sectional survey design with closed and open questions to examine how COVID-19 is affecting the work, training and well-being experiences of trainee nursing associates (TNAs).

| Methods
A purposive sample of TNAs across England was recruited to a longitudinal cohort study in 2019. Recruitment was facilitated through university email lists; course leaders in seven Higher Education Institutions (HEIs) across England were contacted via email and asked to disseminate information about the study to their TNA student groups. Social media twitter posts were also used to recruit TNAs to this cohort. The HEIs were purposively chosen to provide geographical spread across England and diversity in approach to NA training, thereby helping reduce bias that might come from a limited geographical sample or from a single HEI establishment. Social media recruitment further extended this geographical and training diversity.
In July 2020, a specific survey on COVID-19 was distributed to this established cohort of 121 TNAs. Informed by issues of concern emerging in the literature on respiratory pandemics, and contemporary concerns reported in the nursing press and highlighted by

| E THI C S
Research Ethics Committee approval was gained from the University of Sheffield Research Ethics Committee (reference 026355). A link to the information sheet was included in the email sent out by the HEIs and in the social media advert, with a further link to the consent form on the information sheet. Informed consent was gained from participants prior to survey completion.

| Rigour
A number of strategies were used to ensure rigour. Twice-weekly meetings were held between the first three authors throughout the study to critically consider issues, and research team meetings were held to facilitate additional reflection and input at key points (e.g. commenting on design, on survey questions and assisting with theme development). Colleagues external to the project but involved with NA training were consulted at various stages to help sense check: recruitment processes, survey questions and emerging findings. Data collection involved data source triangulation (from several HEIs and via social media). Coding, theme development and integration and interpretation of data were checked independently and collaboratively by the research team (see analysis section).
We have used the "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) reporting guideline for crosssectional studies (von-Elm et al., 2007).

| Analysis
Two researchers analysed the quantitative data (TR and MS).
Descriptive statistics have been used to present participant demographics. Descriptive and inferential (Chi square) statistics were used to analyse the quantitative measures. For the purpose of this paper, we divided participants into those who worked in (primarily hospital-based) acute care contexts (n = 22, 35%) and those who worked in community contexts (n = 40, 65%). Two participants did not provide sufficient information to locate them in either of these contexts and have therefore been removed for the quantitative analysis (though their responses remain included in the qualitative analysis). Differences and similarities in the quantitative measures for participants working in the acute and community sector are considered given the potential for different experiences of COVID-19 in these two settings. SPSS 25 software was used to support this stage of analysis.
Answers to open ended questions have been analysed thematically using the six steps outlined by Braun and Clarke (2006). Initial coding was undertaken independently by the first author (RK) and sections of this checked SR. Further coding, categorizing and initial theme development was completed collaboratively by these three co-authors and then final themes refined in discussion with the whole research team. Quirkos © computer assisted qualitative data analysis software (CAQDAS) version 2.3.1 was used to manage the qualitative data.
The closed and open question design was used to facilitate the development of both data patterns and in-depth insights into the experiences of COVID-19 on this sub-section of the healthcare workforce. Data were integrated through iterative consideration of both data sets collectively by four members of the research team (RK, SR, TR and MS) in order to generate the critical discussion.

| RE SULTS
There were 64 responses to the survey, a response rate of 53%.

BOX 1 Survey Question Domains
A total of 44 (71%) participants said they cared directly for patients with COVID-19. While 40 (64.5%) participants felt they had sufficient PPE, only 33 (53.2%) felt staff had received enough training. These figures were similar across both acute and community settings. While approximately half of the participants (54.8%) felt adequately prepared in terms of staff numbers, there was a significant difference (p = .03) between those in community care (45%) and those in acute care settings (72.7%). It is possible that these challenges about staffing led to 28 (45.2%) participants reporting working more overtime than normal and 32 (51.6%) not having enough time to get work done. Staff in community settings reported working significantly more overtime (55%) than those in acute settings (27.3%) (p = .03). Significantly more staff in community settings reported not having sufficient time to complete tasks (62.5%) compared to acute settings (31.8%) (p = .02).
Of the participants, 39 (62.9%) stated that COVID-19 had affected their job role. A question about whether workload had increased, stayed the same or decreased was asked (not presented in the table as it does not have a binary outcome measure). The majority, 43 (69.4%), did notice a change in their workload with 33 (53.2%) experiencing an increase in workload and 9 (14%) a reduction.
Fifteen participants (24.2%) had extended their role beyond their normal scope of practice. Additional analysis showed that amongst those who had extended their role only eight were given additional training while five said that training would have been helpful and two that additional training was not required. Twenty (32.3%) had been moved to a different workplace. While 56 (90.3%) felt able to raise concerns with their employer, only 47 (75.8%) felt that appropriate action was taken when they raised concerns. None of these issues around job role showed significant differences between the acute and community sector participants.
Linked to this, 20 (32.3%) participants felt that COVID-19 risk could have been reduced, although this did not quite reach the level of significance between community settings (40%) and acute settings (18.2%) (p = .07).
Despite these challenges, 47 (75.8%) participants reported still being able to provide the same standard of care and 60 (96.8%) did not want to leave their training/job. Both of those that stated they did wish to leave worked in a community setting.

| Qualitative themes
Three themes were developed from the open questions relating to the impact of COVID-19 on working practices, training and development, and well-being experiences.

| Impact of COVID-19 on working practices
Participants responded to the service demands caused by the pandemic. They broadened their scope of practice to care for very unwell patients, worked in new areas through redeployment, drew on experiential knowledge, demonstrated knowledge translation and met the extra demands caused by staff shortages: The role of the ward I was on changed but I was able to use my knowledge from previous placements to help and assist on the ward which meant stepping up.

TNA 4
While some reported these experiences of "stepping up," others reported the reverse, an enforced move back into healthcare assistant roles: Staff members being moved and leaving ward staff short so you're fulfilling a health care support worker role.

TNA 13
As highlighted earlier, many participants noted changes to their workload. Those that reported an increased workload described a number of reasons for this. Staff shortages (including increased sickness absence), time associated with wearing personal protective

TNA 19
The TNA/NAs adapted their role to meet the needs of healthcare services during the pandemic, such as substituting for staff shortages through redeployment, taking on cleaning responsibilities to improve infection prevention and control, and providing significant emotional care (as well as physical care) to patients.

| Impact of COVID-19 on training and development
The COVID-19 pandemic significantly affected participant experi-

TNA 37
Some trainees were unable to develop skills essential to their generic role. For those whose placements continued, staff were often too busy to supervise the development of clinical skills and patient contact was limited: The registered nurses were too busy to give me learning opportunities so I wasn't able to perform any clinical tasks.

TNA 34
Greatly reduced patient contact to zero.

TNA 30
University delivery of the academic aspect of training was moved to remote learning which some trainees found difficult: University has been difficult as I learn best in a faceto-face environment with my cohort and peers, Zoom lectures are just not the same.

TNA 19
Trainees clearly valued the face-to-face weekly university teaching and the associated peer support from other TNAs. They missed this contact with their peers and, to some extent, their lecturers. This coincided with feeling more isolated in their clinical settings, due to infection control procedures and redeployment: Patients relied on us to be their support, we were alone and so were they.

| Impact of COVID-19 on well-being
As noted earlier, the majority of participants stated that they felt safe at work. This, however, masks a number of concerns affecting the well-being of participants. These include burden of workload, uncertainties attached to being moved to new areas, the disappointment in suspension or reduction of training, the worry of keeping up to date with policy changes, unreliable guidance on and provision of PPE, and associated anxieties around protecting themselves, their families and patients from infection. These all contributed to feelings of stress and fear.
There was widespread confusion early in the pandemic caused by ever-changing guidance about the correct use of personal protective equipment (PPE): Initially we were told we only needed to use PPE with confirmed cases. As the virus progressed it became apparent this was not the case, however by then it was too late and we had either been exposed and become ill, or had carried the virus to other patients.

NA 3
Furthermore, some felt that colleagues were not adhering to guidelines, and there was a general fear of the unknown. While the majority felt able to raise concerns about this and other risks to staff and patients, many did not feel that appropriate action was taken when concerns were raised leaving them feeling isolated and vulnerable:

NA 14
There were some factors that helped provide a counter-balance to these fears and anxieties and helped foster elements of positive wellbeing during these challenging circumstances. The pride in their work noted in the previous section was one such element. Improved teamwork and bonding, feeling that they had an important role to play, were also important positive factors mentioned by several participants: Although it was difficult we still pulled together as a team, supporting each other and the young people […] I think as a team we are able to acknowledge that the reason we work so well is that everyone has a part to play.

TNA 37
Overall, the effect of COVID-19 on well-being was therefore mixed, with TNAs/NAs demonstrating a high degree of stress, fear and anxiety while also reporting opportunities for increased pride and sense of connection with colleagues and patients.

| D ISCUSS I ON
Integrating closed and open questions provided a depth of insight into the experiences of the participants. In exploring how COVID-19 influences the work, training and well-being of nursing associates, this study highlights several important issues. With the few exceptions noted that showed statistical significance, it is clear that these issues were largely present for TNAs/NAs across both acute and community contexts. These issues, and differences across these two contexts, are discussed below.
First, staff shortages, time-consuming infection control procedures and caring for patients with higher acuity have increased the workload for many. This resulted in some extending their scope of practice, working more overtime than normal and yet still reporting insufficient time to get necessary work completed. These latter two were particularly noticeable in the community sector where the withdrawal of face-to-face care by other services and hurried hospital discharges have added to community nursing pressures during the COVID-19 crisis (Green et al., 2020). For those whose workload reduced during the pandemic, there was frustration that their skills were not being fully used in supporting care. This has significance as helping colleagues is recognized as a motivator for commencing NA training (Coghill, 2018;King et al., 2020). Future research could consider developing redeployment models that aim to maximize skill utilization.
Second, previous work has shown that during the development and implementation of this new, second level, nursing associate qualification, students and staff often feel in a liminal space with role and task boundaries often being unclear (Davey, 2019;King et al., 2020).   and in relation to "worker" versus "learner" perceptions (Coghill, 2018). These have been compounded by COVID-19. The training of new NAs is seen to be crucial in meeting future healthcare service demands (Health Education England, 2015); therefore, a pause in training as a result of the pandemic has implications for this policy. Furthermore, participants described feeling isolated from their peers as a result of remote university learning. This has relevance as previous work highlights the significance of peer support to trainee NAs as they seek to develop a shared occupational identity (Coghill, 2018;King et al., 2020).
Fourth, the COVID-19 situation took its toll on the well-being of this group. Fear about catching and transmitting the virus to family members, noted in previous viral, respiratory pandemics (Koh et al., 2012;Lam & Hung, 2013), were compounded by the stress and anxiety of inadequate PPE provision and, for some, by a perceived lack of action being taken when safety issues were raised. Some of these safety fears were greater in the community sector compared to acute care settings. As others have noted (Green et al., 2020), in the early stages of the pandemic the discharge of patients, with often unknown COVID-19 status, increased workload and risk anxieties for those working in this sector. Our findings support this, with insufficient staffing and higher levels of missed care (despite higher levels of overtime) being present for community sector participants.
These are important issues given that missed care and failure to have safety concerns actioned are two of the main determinants of job dissatisfaction for nurses with a potential impact on intention to leave (Senek et al., 2020). Further strategies to improve the wellbeing of this workforce in the context of COVID-19 could include prioritizing mental health support (Azzopardi-Muscat, 2020).
Finally, the majority of participants felt able to retain the same standards of care. Many felt proud of the contribution they were making and reported enhanced feelings of cohesion and teamwork.

| Limitations
The majority of TNAs/NAs who completed this survey were female and white British. Future recruitment to TNA/NA workforce studies should aim to increase the diversity of participants. A further limitation was the response rate of 53%. This can be partly explained by the fact that, despite a request for more permanent contact details, on joining the cohort study in 2019, some participants only provided university email addresses some of which were no longer in use for the 2020 period of data collection. Finally, this limited response rate means the inferential analysis was most likely underpowered.
However, we believe these results still give indication as to where future policy and research might focus.

| CON CLUS ION
As a new role in the healthcare workforce, nursing associates already face significant challenges which have been exacerbated by . Despite changes in working practices, interrupted training and development, and fear of exposure to COVID-19, participants strived to provide excellent care and support for their patients and colleagues, sometimes at personal cost. Future strategies to assist NAs as COVID-19 continues should focus on protecting their development, utilizing their skills in appropriate ways, ensuring adequate support for psychological well-being and safety and emphasizing their value in the wider healthcare team.

ACK N OWLED G EM ENT
The authors would like to thank all of those who participated in this study.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to declare.

AUTH O R CO NTR I B UTI O N S
All authors have met the following criteria for authorship: Have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data;Been involved in drafting the manuscript or revising it critically for important intellectual content;Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; andAgreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

E TH I C A L S TATEM ENT
Research Ethics Committee approval was gained from the University of Sheffield Research Ethics Committee (reference 026355). A link to the information sheet was included in the email sent out by the HEIs and in the social media advert, with a further link to the consent form on the information sheet. Informed consent was gained from participants prior to survey completion.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.