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Unlike medical students who were strongly encouraged to sit out of COVID-19 care, nursing students have largely had to decide for themselves whether they would join the front lines, MedPage Today has found.

National associations have generally balked at officially advising on whether students should be assigned to clinical settings -- but some have issued guiding documents that encourage clinics to keep students away from COVID-19 patients while hinting that they may be needed.

The (NSNA), for instance, signed off on a guiding document that called the pandemic "an unparalleled opportunity for nursing students to assist the nation in a time of crisis."

This national guidance ; it seems to counter by the American Association for Medical Colleges (AAMC), which "strongly suggest that medical students not be involved in any direct patient care activities" unless there is a "critical need locally."

Nursing education leaders defended themselves, citing nursing's loose national organization, nursing students' knowledge of preventing infection transmission, and a professional culture that demands risk.

"It's always been for nurses that you don't know what you are walking into," said Beverly Malone, PhD, CEO of the National League for Nursing (NLN). "That's part of being a nurse."

'Students Are a Valuable Resource'

Nursing students must accumulate a certain number of clinical hours to graduate and be professionally certified. Programs are offering virtual simulations during the pandemic to foster their education, but the in-clinic hours are still usually required. "There's nothing like working directly with a patient," Malone said.

Students working in clinics are not receiving hazard pay or medical benefits from their educational institutions or sites -- not even, in some cases, while they are permitted to receive academic credit or cover the cost of their own care should they become sick.

"If a student is exposed to anything, they will have to go to employee health and will have to cover the cost," one program director wrote in an email to students.

Donna Meyer, MSN, CEO of the Organization for Associate Degree Nursing (OADN), said nursing students "are a valuable resource and can assist staff as needed. That's why having them get credit for clinic time is a great idea."

That was one of many ideas hatched by the national associations, including the NLN, the OADN, the American Association of Colleges of Nursing (AACN), and the National Organization of Nurse Practitioner Faculties (NONPF).

from the NLN and National Council of State Boards of Nursing (NCSBN) advised: "Please remember that students should not be categorized as 'visitors' to the practice facilities, but rather as health care personnel. Therefore... students will be able to continue in their clinical experiences."

a professor of nursing and public health at Johns Hopkins University in Baltimore, noted that in the absence of adequate data on transmissibility, morbidity and mortality, nursing students should not care directly for COVID-19 patients but should otherwise "continue their roles as part of the care team."

dated March 26 -- which was endorsed by NLN, OADN, AACN, NSNA and the American Nurses Association -- said that student participation is "voluntary" but also called the pandemic an "unparalleled opportunity for nursing students to assist the nation in a time of crisis and learn the principles of population health and emergency management."

"It is an unparalleled opportunity. We've never been confronted like this in 100 years," Meyer said. Students "have knowledge and we were in a time of crisis."

, "It is recommended that student clinical placements that require the use of PPE should be deferred in order to protect the nation's supply of PPE," while also adding: "Pandemic contingency staffing plans may include the potential use of nursing students."

According to AACN, that statement was prepared by Veenema, with AAMC input.

The NONPF and Association of Faculties of Pediatric Nurse Practitioners co-issued during the pandemic, along with the AACN. It said nurse practitioner students must still complete 500 clinical hours during their entire program course -- because 500 is the minimum programs require, said Mary Beth Bigley, DrPH, CEO of NONPF. Telehealth work can be included. Some academic programs, which had required up to 750 hours, now must permit students to compensate for the hours beyond 500 with simulated exercises.

"Certainly students can go to faculty or their academic institution and request not to be in a clinical site if they felt that uncomfortable," Bigley said. "I don't think any school made students go into clinical."

"There's not a dean or director who is going to send students into an unsafe environment," Meyer said. "That's a priority."

Nursing students learn early in their curriculum how to avoid infection, leaders said. Bigley, a nurse practitioner, recalls learning early in her training how to stay safe. But, she added, "nobody becomes an expert in a technique until you do it a while. They're [students] still novices at it."

"It's a balance, isn't it? In terms of how do I offer that student the best learning opportunity and at the same time make sure that student has as much of a safe learning environment as possible," Malone said. "Nursing is dangerous, did you know that? Whether there is a virus or not ... we are always right there." Students don't need to be in clinic to face COVID-19, she said, noting they could also encounter it at home or the beach.

Regarding the policy brief, Malone called it an attempt at collaboration. "How does one keep the pipeline of students going if we don't have a positive relationship between the academy and practice?" she posited. "It becomes even more important these days."

In any event, it was the NCSBN that led on the brief, Meyer said.

Guidance Influenced by Hospitals?

A nurse educator who asked to remain anonymous "completely agreed" with the medical college association's strong suggestion at first and insists the AACN and AAMC "were aligned in the information they provided." But the AACN is "not in a position to issue guidelines," the educator said, adding that the nurse education organizations were hampered by an unclear risk profile for the disease early in the pandemic.

The AACN did not respond to requests for comment.

Douglas Davis, a past president of NSNA, called the policy brief "a completely different tone ... towards protection or even addressing the potential protection for students than the AAMC is taking for medical students. It reinforces the longstanding attitude that nurses are seen as expendable."

"It just feeds into this vicious circle that we are seen as labor," said Davis, who called himself "lucky" because the clinical partner for his school (University of North Florida) banned nursing students for the last few months. "It shows me there is not really concern for our safety."

The guidance likely was influenced by hospitals, said a nursing student who wished to remain anonymous. The student cited a program director's email: "[H]ospitals have enacted some changes that you all need to be aware of. These changes are not only for summer clinical, but probably will be in place for fall." One change: Students will be required to sign a waiver.

The NSNA offered in late March: "NSNA recommends that students do not care directly for patients diagnosed with or under investigation for COVID-19. Students must be fully informed of the risks associated with the possible care of COVID-19 patients. ... Students must be instructed in the proper use of [PPE]."

Contacted by MedPage Today, NSNA officials referred questions to A.J. Cook, who served as its interim president from January to April. Cook, a University of Nevada-Las Vegas student, answered questions via email.

The association added its statement to complement the policy brief after meeting for several days, "with review from industry professionals," Cook wrote.

NSNA "positions emphasized student safety that also helped support alternative educational opportunities," he added. "The health and safety of nursing students should come first. If the health and safety of nursing students cannot be guaranteed due to lack of adequate training or PPE supplies then alternative educational opportunities should be provided. ... If proper training, health, and safety can be maintained, students should be afforded an opportunity where they have the option to learn in a setting that is their right as a student."

When asked for his thoughts on the policy brief's assertion that the pandemic presents "an unparalleled opportunity for nursing students to assist the nation," Cook replied: "NSNA supports both nursing students and will advocate for patients."

'Striking Absence' of Preparedness

As pandemic conditions morph and differ by region, nursing education leaders say they are adapting guidance and being proactive.

A Johns Hopkins Center for Health Security subtitled "Early Lessons from COVID-19" questions how prepared nursing students -- and professional nurses -- were for clinical settings.

"Studies evaluating curricular content in U.S. schools of nursing reveal a striking absence of healthcare emergency preparedness content and little evidence that the few students who do receive healthcare emergency preparedness instruction achieve competency in these skills," wrote authors led by Veenema, a visiting professor with the Center.

"What is frequently absent is education around concepts in public health emergency response, disease surveillance and containment strategies, and mass vaccination operations ... and instruction regarding the proper selection and use of PPE. Thus, new graduates enter the profession already lacking critical knowledge to keep themselves and their patients safe."

Ultimately, going into clinic during the pandemic "is really their decision. I think that's a hard one for every nurse," Malone said. Professionals have told her of their fears. "But it's a choice," she added, "for all of us."

In the mean time OADN is working with clinics to assure future COVID-19-compliance, Meyer said, and developing new guidelines for the fall semester -- assembling a 12-member task force to help.

The task force currently does not feature any students.

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