By Ryan Basen

As COVID-19 surges in the U.S., nursing students are still being encouraged to join the front lines, though some program leaders aren't going along.

Back in June, it was reported that in official guidelines, nursing leaders encouraged students to enter clinical settings, in contrast to guidance for medical students from the Association of American Medical Colleges at that time (it now supports clinical rotations). Many in both nursing and hospital leadership continue to advocate for that plan.

But in late July, a new guidance written for the American Association of Colleges of Nursing (AACN) by Tener Goodwin Veenema, PhD, of Johns Hopkins University, was more cautious about recommending that nursing students participate in COVID-19 care.

"It may be advisable, in the interest of student safety, to limit student direct care of known or suspected cases of COVID-19 infection until better epidemiologic data are available," the guidance states. "For now, other than limiting direct care of COVID-19 patients, clinical students should continue their roles as part of the care team."

What has resulted is variation in policies at nursing programs and their clinical partners, and in support from nursing leadership.

"It's a better approach for students if they get to finish their studies," which would include clinical experience, said AACN board chair Susan Bakewell-Sachs, PhD.

Many students indeed want to train clinically now, and many hospital administrators favor that approach: "Clinical settings realize they need the next workforce coming forward and want them to be as prepared as possible, so trying to get them back into clinical is essential," said Donna Meyer, MSN, CEO of the Organization for Associate Degree Nursing (OADN).

Veenema did not return requests for comment for this story.

Nurses in Demand

The pandemic has worsened in many areas since those July guidelines were published, and some nursing schools are already helping students become "workforce extenders," as students are described in the AACN guidance.

Nursing students at Ohio University's Zanesville campus, for instance, had their clinical time expedited in order to graduate in October, in the middle of the academic term. They then accepted positions with Genesis Hospital, according to the Zanesville Times Recorder.

Administrators for the Ballad Health system in northeastern Tennessee and southwest Virginia plan to address their surge in part by enlisting nursing students, according to the Bristol Herald Courier.

Other systems could soon follow, as the COVID-19 surge has hit the nursing workforce especially hard. Many nurses have retired or left clinical settings to work in safer, less traumatic settings.

But questions have arisen as to whether nursing students would be adequately prepared to replace them.

A Johns Hopkins Center for Health Security report published in June noted that concepts in public health emergency response and disease surveillance and containment strategies are "frequently absent" from nursing education. It also stated that graduates "enter the profession already lacking critical knowledge to keep themselves and their patients safe."

Veenema was the lead author on that report.

Up to the Programs?

At the same time, other nursing programs and the medical institutions they work with have continued to limit or ban student clinical training.

Some programs make it difficult for students to participate by requiring them to quarantine if they travel interstate, said Diane Mancino, EdD, RN, executive director of the National Student Nurses Association (NSNA), while some medical centers have limited or banned students specifically because they fear another COVID-19 surge. Some academic leaders have moved training from clinical to simulation settings because their clinical partners lacked adequate PPE.

The norm nationally is "not consistent; that's the problem," Mancino said. "You can understand why. Each circumstance could be a little different."

Support for the July AACN guidelines has been inconsistent too. Leaders of OADN and the National Organization for Nurse Practitioner Faculties say they support the guidelines, but neither organization has officially endorsed them or updated their published guidance. Indeed, OADN has produced a template for its members to write letters to clinical partners advocating participation. The letter is posted to an online resources page.

The NSNA sticks by its own guidance from March, which states that students should be able to learn in clinical settings as long as "proper training, health, and safety can be maintained."

Mancino said NSNA has not updated its guidance because nationally the pandemic landscape has not changed much since the spring.

The National Council of State Boards of Nursing still supports a March policy brief signed by many nursing student organizations -- including AANC, OADN, and NASN -- which called participating in care on the COVID-19 front lines an "unparalleled opportunity."

Bakewell-Sachs noted she wanted to speak for herself, not AACN: "There is a reason nursing as a profession is licensed under public safety in the states," she said. "I support making sure nursing students are safe over letting them just finish [school]."