Disturbances of nursing students in internship during emerging disease COVID‐19 pandemic: A qualitative study

Abstract

Aim

The aim of the study was to examine the experiences of nursing students in internship during the COVID‐19 pandemic.

Design

A qualitative study.

Methods

Purposeful sampling was conducted among undergraduate nursing students at Tabriz School of Nursing in November 2021. Students participated in 14 in‐depth open‐ended interviews and stated their experiences and opinions on internships during the COVID epidemic until full data saturation. Data analysis was performed using the conventional content analysis method. This study followed the Standards for Reporting Qualitative Research (SRQR) checklist.

Results

Findings were extracted and classified into five main categories, including a lack of facilities and equipment, psychological disturbances, physical risk, disturbances in education and learning activities and movement to continue clinical learning in the situation.

Conclusion

Nursing students in clinical training during the COVID epidemic have experienced physical and mental health issues, as well as educational challenges. During an infectious disease epidemic period, education administrators should adopt appropriate strategies to protect students' health and facilitate their educational and learning activities.

1. INTRODUCTION

The COVID‐19 virus epidemic was first reported in Wuhan (China) in December 2019 (Shoja et al., 2020). After the rapid spread of the disease around the world, which has infected millions of people, the World Health Organization (WHO) declared the disease a pandemic in March 2020 (Poupin et al., 2021). More than seven million have been infected in Iran, of whom 140,000 have lost their lives to this virus so far (WHO, 2021). The number of infections and deaths is still rising every day. This emerging disease has created social and health crises that directly affect healthcare systems around the world. The greater risk of transmission of the disease to healthcare workers, particularly frontline nurses, has put additional stress and psychological strain on them (Garcia‐Castrillo et al., 2020). In the study by Saffar et al. (2020) Nurses reported their experiences and concerns about their self‐care when caring for patients with COVID.

During the pandemic, one of the key challenges in healthcare systems has been to provide specialized human resources, and in some cases even the capacities of nursing students have been utilized. These students reported that nursing was associated with high levels of stress and that they needed to learn more about illness and psychological support to adapt to prevailing conditions (Casafont et al., 2021). In a similar case, nursing students accepted this task with courage and compassion (Leigh et al., 2020). According to the policy of the Ministry of Health and Treatment of Iran during the COVID‐19 epidemic, nursing students have not been employed as nurses, but they have participated in voluntary and limited activities such as public health education and prevention (Ministry of Health and Medical Education, 2021). However, educators and students of medical sciences, especially nursing students, may be exposed to the virus in various fields during the epidemic and in the course of clinical education and patient care. However, little information is available on the rate of their exposure to the disease. Based on the researchers' observations, some of them have been exposed to and infected with the virus since the beginning of the COVID‐19 disease outbreak.

Social restrictions such as bans on close gatherings, travel and school closures, as well as the use of various protective equipment such as masks and disinfectants to prevent the spread of the disease, led to many changes in people's lifestyles. These changes can cause various problems for students, such as B. Stress, anxiety, fear and worry, loneliness, fatigue, depression, impairment in learning and the educational process (Garboczy et al., 2021; Goni‐Fuste et al., 2021; Haslam, 2021; Kochuvilayil et al., 2021; Masha'al et al., 2020; Monforte‐Royo & Fuster, 2020; Swift et al., 2020), Etc.

In a study of 50 first‐year nursing students during the first half of the COVID‐19 epidemic, students reported difficulty concentrating, feelings of anxiety, fear of the disease and health concerns from relatives or friends. Most students expressed concern about their academic performance (Fitzgerald & Konrad, 2021). The results of another study conducted on 662 nursing students between April and May 2020 showed that they experienced moderate stress during the COVID‐19 epidemic based on age, gender and some other variables (Aslan & Pekince, 2021). The results of a study in the Netherlands also showed that, in addition to stress and anxiety, the pandemic is also affecting the mental health of nursing students, including depression and their eating habits (Kalkan et al., 2021). Various types of mental disruptions in nursing students have been reported in China due to the COVID‐19 epidemic (Li et al., 2021).

Therefore, more research is needed in this area and many important challenges need to be continuously monitored and addressed by the relevant authorities. In this regard, the present qualitative study is conducted using the content analysis approach to examine and explain the experiences of nursing students with internships during the COVID‐19 pandemic as their most challenging educational phase at the X… University of Medical Sciences. The results and the detailed and rich information obtained from them can guide educational planners and educators.

2. METHODS

2.1. Design and research environment

This study is a qualitative content analysis using a conventional approach (Graneheim & Lundman) conducted in 2021 at the Tabriz University of Medical Sciences. Content analysis is a suitable method to obtain and analyse rich data from participants. It is a research method for analysing and interpreting textual data. It involves the systematic identification, coding and categorization of patterns and themes within the data to gain insights into the underlying meanings and participants' experiences. This method is commonly used in social science research to analyse interviews, focus groups, surveys and other forms of qualitative data. Qualitative content analysis is a flexible and adaptable approach that can be used to examine a wide variety of research questions and topics.

The Tabriz School of Nursing and Midwifery, the first nursing training institute in Iran, was established in 1917. In 1976, the old nursing education system was revised, and a new academic education system replaced the previous one. Today the faculty has 650 students in BSc programmes in all three majors of Nursing, Midwifery and Surgical Technicians. Of these, 96 students are senior nursing students. In 1996, the faculty became the first in …X… to admit nursing students to the Ph.D. programme. Today, this faculty has 28 students in the Nursing PhD programme and 298 students in MSc programmes.

2.2. Sampling and participants

The study population consisted of nursing students. The sampling was carried out by targeted sampling. In doing so, the researcher looks for people who have rich experience with the phenomena and who have the ability and willingness to express them. Accordingly, 14 senior nursing students met the inclusion criteria and were interviewed to reach a full saturation level, in other words, lack of information and new code. Inclusion criteria were final year nursing student (B.Sc.), at least one semester of internship experience during the COVID‐19 pandemic, and satisfaction with participation in the study.

2.3. Data collection method

After obtaining the necessary approvals to conduct the study, the first investigator, who was one of the clinical educators of the students, explained the objectives of the study with reference to the students and obtained their written consent to participate in the research. The time and place of interviewing them was also determined. For data collection, face‐to‐face, in‐depth and unstructured interviews with open‐ended questions were conducted. The most important and in‐depth questions the students were asked in the interviews were: What do you think of clinical internships during the COVID‐19 pandemic? What do you feel positive or negative or concerned about in clinical internships during the COVID‐19 pandemic? What triggers these feelings in you? What are you doing to improve your feelings? Or should you do it? How one? And under what circumstances? What do you think? Why? Explain more, you could give an example so I understand what you mean. Do you mean this…?

In order to obtain valid data and focus on the research questions, the interview process was started with the main questions and recorded with the necessary approval. The interview sessions were arranged in a room with adequate conditions in the hospital and lasted 20 to 45 min. It was done individually in a private and quiet space. During the interview, the researcher encouraged participants to freely express their views and experiences, and in this process and to understand the depth of the topic, in‐depth and exploratory questions were asked based on the nature of the answer to each question. During the interview, participants' non‐verbal data such as tone of voice, hand and body movements, gestures and facial manifestations were also recorded. After careful listening several times, interviews were transcribed into text and then analysed. To validate the research data and results, the first researcher, as a clinical educator, prepared field notes containing faculty educational announcements, unexpected educational events and events in the clinical educational process during the pandemic.

2.4. Data analysis

For data analysis, qualitative content analysis with the conventional approach (Graneheim & Lundman) was used. Its' steps include the construction of the units of analysis, construction of codes of meaning, condensation, extracting codes and categorization (subcategories, categories, and the main categories). In qualitative research, data analysis occurs parallel to data collection. In this study, each interview was considered as a unit of analysis, and its unit of meaning consists of words, sentences or paragraphs that contain aspects that are related in content and context (Mazhari & Khoshnood, 2021).

In order to immerse themselves into the data and understand it in depth in order to extract themes, the audio file of each of the recorded individual interviews was first listened to extensively several times at the earliest opportunity and in less than 24 h and translated into a handwritten text. The text has been adapted to the original audio version after several in‐depth reviews. Then, by examining the notes, handwritings, and experiences, an attempt was made to ascertain their superficial and inner elements. Then the text was divided into units of meaning. In the next step, the units of meaning were condensed while retaining the core. The condensed units of meaning were then labelled with a code. Similar codes have been merged and classified. The classes were named based on an inclusive idea to form subcategories. Finally, by trying to make the codes of each subcategory more homogenous and merging them together, the data are grouped into the more general and abstract main categories (major categories and themes). To ensure that a particular component or dimension is not far from the researcher's point of view, the researcher again referred to the interviews and extracted codes.

To confirm data trustworthiness, accuracy, and correctness, Goba and Lincoln's four concepts of credibility, transferability, dependability and confirmability were established and achieved. Credibility means confidence in the ‘truth’ of the findings. For this purpose, first researcher Spent sufficient time in the field and observed the research phenomenon. An attempt was made to select students with different experiences and to continue sampling until full data saturation. The text of the interview and the extracted codes were also presented to the participants and confirmed after verification. Transferability shows that the findings have applicability in other contexts. In order to increase the transferability of the data, the study method and characteristics of the participants were described in sufficient details. Dependability shows that the findings are consistent and could be repeated. To check dependability, the research method was reviewed by the 23 faculty members and necessary corrections were made. Finally, for confirmability, an attempt was made to hold the interview sessions on time to avoid extending interview or data collection time as much as possible, and all participants were interviewed on a topic.

2.5. Ethical considerations

This study was approved to conduct by the Ethics Committee of Tabriz University of Medical Sciences (code: IR.TBZMED.REC.1400.479). We received written consent from all participants. Before signing the written declaration of consent, the students willing to participate in the study were first informed about the study goals and informed about their right to withdraw at any time. They were also ensured that no names or facts were to be stated in the data and it will be confidential.

3. RESULTS

Fourteen nursing students took part in this study (10 students in the 7th semester and four students in the 8th semester). Of these, nine were boys and the rest were girls. The mean age (standard deviation) of the students was 23 (2) years. After analysing the data in 215 primary codes, 32 subcategories, 17 categories and 5 main categories were extracted and classified as follows (Table 1).

TABLE 1.

Categories and main categories related to nursing students' experiences.

	Main category	Category
1	Lack of facilities and equipment	Lack of facilities and equipment
2	Psychological disturbances	Fear and worry about illness
		Depression
		To be blamed
		Unusual family desires
		Disturbance in social interactions
3	Physical risk	High‐risk exposure to disease
		Developing the disease
4	Disturbances in education and learning activities	Avoidance of clinical practice
		Reduction of clinical work opportunities
		Failure in the role of caregiver
		Disturbance in educational activities
		Reduced effective learning communication
		Academic failure
5	Movement to continue clinical learning in situation	Continue to internship in pandemic
		Use e‐learning
		Self‐protection in clinical setting

3.1. Lack of facilities and equipment

Participants in this study experienced a lack of facilities and equipment during the internship, including a lack of personal protective equipment and a lack of educational and welfare facilities. In this regard, the participating students stated: ‘During our internship, it was difficult for us to access personal protective equipment, including masks, gloves, covers, and shields. But hand sanitizers were abundantly available. After talking with faculty officials, the mask was distributed daily to students through the nursing office of the hospital’. (Participant number 3). ‘The library, study hall, and other educational units of the hospital were closed, there was no place in the hospital to study or perform other educational activities’. (Participant number 7). ‘The dining hall was closed, we had to have breakfast on our feet or the hospital grounds and it was both unsanitary and annoying… The students' locker room was not in good clean condition. There were no hand washing and showering facilities to use if necessary’. (Participant number 5).

3.2. Psychological disturbances

From the participants' perspective, their psychological disturbances experiences included fear and worry about illness, depression, blame, unusual family desires and disturbance in social interactions.

3.2.1. Fear and worry about illness

Students cited fear and worry about illness as one of the most prominent experiences with psychological disturbances, including actual fear (of unknown illness), worry about the likelihood of being a carrier, abnormal fear of illness and family Issue. In this regard, the participants commented: ‘I didn't have much information about the corona disease, the treatment was still unknown, some of the patients died, so I was afraid to go to the hospital, because of the possibility of infection and disease’. (Participant number 1). ‘… We were worried about becoming a carrier of the disease, and family members become infected’. (Participant number 2). ‘At the beginning, I had less information about the corona disease, if someone would cough or cough up next to me, I thought she was infected with corona and I was afraid that I would be sick, I was afraid to touch patients and things in the bedside. Until, over time and after learning more about corona disease, these unnecessary fears and worries disappeared’. (Participant number 6).

3.2.2. Depression

Depression was one of the psychological disturbance experiences of students. ‘the situation in the corona had become very dull for me’, they said, ‘the normal course of life was disrupted, I did not enjoy anything, I felt depressed’. (Participant number 14).

3.2.3. Blame

Students reported that they experienced blame during their COVID‐19 internship. In this regard, they stated: ‘Because we had done less clinical work, we were weak in doing some practical nursing skills, for example inserting intravenous pathways, providing cardiac tape, giving medicine, etc., so some trainers blamed the students! They thought we had a learning weakness or what to say we were low on intelligence. We'd be upset, that's not the right judgment! If we were already provided with more clinical opportunities, we wouldn't have that kind of weakness’. (Participant number 7).

3.2.4. Unusual family desires

The family's unusual requests were one of the participants' psychological disturbance experiences. ‘Parents were worried, even sometimes asking not to go to internships or at least be further away from patients’, the students said in their experiences (Participant number 6).

3.2.5. Disturbance in social interactions

Nursing students expressed failure in social interactions from their psychological disturbance experiences, which included avoidance behaviours of others and a reduction in social interactions. The students said, ‘In the family of others, they stood further away from me, so that I would be left alone in one corner, and they thought that because I had worked in the hospital, I might be the vector of the disease’. (Participant 14). ‘ … The situation had become such that to prevent the possible transmission of the disease and to maintain the health of me and others, I preferred to stay at home longer and be less present in a family gathering’. (Participant 2).

3.3. Physical risk

The physical risk was one of the other experiences expressed by the students including the possibility of high‐risk exposure to disease and developing the disease. In this regard, the students stated: ‘At the end of the internship in the new internal ward, indirectly from the talk of physicians and nurses in the ward, we found that the results of one of the hospitalized patients were positive and the other three were suspicious. Although we were observing individual protection precautions, we contacted these patients without knowing about it. We were so worried that we were unaware… On internship days when traveling by bus or taxi, it became impossible to maintain a safe physical distance from others… Sometimes attending the ward and at the patient's bedside, especially in group form, caused a lot of congestion… Even a few students and trainers contracted the coronavirus’. (Participant No. 4).

3.4. Disturbances in training and learning activities

Most students referred to the issue of disturbance in training and learning activities in expressing their experiences. The experiences expressed by students in this field included avoidance of clinical practice, reduction in clinical work opportunities, failure in the role of caregiver, disturbance in educational activities, reduced effective learning communication and academic failure.

3.4.1. Avoiding of clinical practice

Students stated, ‘Early on, due to fears of coronavirus, some students and trainers, especially novice students, were shutting down internships. Sometimes the trainers would not attend the section without the students' knowledge. Sometimes, the trainers did not go to the patient's bedside with the students at all, and in a class in the section, only the contents were explained, and the internship was held theoretically. … There were some students who avoided going to the patients’ bedside. (Participant No. 10).

3.4.2. Reduction of clinical work opportunities

Students stated: ‘… The number of non‐corona patients hospitalized in wards had decreased… On the other hand, the number of internship days had decreased. The opportunities for clinical work for students and learning nursing skills were very low…’ (Participant No. 10).

3.4.3. Failure in the role of caregiver

Students stated: ‘In the early part of the coronavirus outbreak, I could not easily approach patients and provide the necessary care. For example, when the patient asked me for water or something, I was afraid to approach him’. (Participant No. 10).

3.4.4. Disturbance in educational activities

Students stated: ‘As the prevalence of coronavirus increased and decreased in the society, according to the decision of managers, the educational programs of universities and faculties suddenly changed or closed down. This situation was repeated several times. Most theoretical training were held virtually. In these circumstances, there were irregularities in the holding of internships and other training programs. So that the faculty officials could not supervise and manage the situation, it seemed that they had become out of control. In some circumstances, students were confused’. (Participant No. 9).

3.4.5. Reduced effective learning communication

Students stated: ‘… In the section, everyone had to use masks and have a physical distance, so sometimes it became difficult to hear the explanations of the trainers and nurses. … To prevent the accumulation, the presence of trainers at the bedside of patients along with students and providing necessary explanations were less. Clinical teaching was summarized and sometimes lacked the necessary depth and quality’. (Participant No. 9).

3.4.6. Academic failure

Students stated: ‘… The good faculty educational program wasn't progressing, and we were lagging a lot behind… In wards, we did not learn specialized nursing subjects well and learning was superficial. … Therefore, in the evaluation of the mentioned units, we obtained low scores’. (Participant No. 10).

3.5. Movement to continue to clinical learning in situation

Another participant's experience was move to continue clinical learning in situation. ‘When I received more information about the coronavirus disease and the public vaccination was carried out against the disease, over time the conditions became a little normal for me. I continued to internship’, the students said. (Participant No. 6). ‘In the coronavirus outbreak, I have always tried to follow the principles of infection control in clinical settings, before and after nursing procedures, I wash my hands so that it is used to me, and I regularly use masks and hand sanitizers’. (Participant No. 12). ‘ … Most of the theoretical training was held virtually… We experienced good virtual education and related software. A new method was used in nursing education that was not common before’. (Participant No. 11, 13).

4. DISCUSSION

This study was conducted with the participation of nursing students and aimed to examine their experiences of internship during the COVID‐19 pandemic. The results of the data analysis showed that the students had diverse experiences in this area, which often manifests itself as a disturbance. Students have expressed their experiences in five main categories including lack of facilities and equipment, psychological disturbances, physical risk, disturbances in education and learning activities, and movement to continue clinical learning in situation. Of course, each of these main categories has some categories and subcategories. For nursing students, internship is one of the most challenging phases of their education, which deserves more attention in times of epidemics like COVID‐19.

Access to personal protective equipment such as masks and gloves in the hospital was one of the main concerns of the students. It is, therefore, necessary to ensure that they have the necessary facilities and equipment to protect their health from illness and physical hazards so that they can properly carry out their educational and caring responsibilities. Exposure to risk, particularly in clinical settings, can make student nurses victims of infection as well as potential vectors of the disease to a wider population. The results of this study showed that during the epidemic, students faced physical risks ranging from high‐risk exposure to disease to getting it. Therefore, nursing schools and healthcare systems must provide a quality and safe clinical learning environment, teach students the most effective crisis management measures, and continue to protect them. As well, it is necessary to provide students with appropriate facilities such as suitable dressing rooms and educational facilities such as libraries, internet and study halls to facilitate their training and learning activities. In another study, nursing students reported problems related to a lack of access to personal protective equipment such as masks and surgical gloves in hospitals. All students described the spread of false information in social networks and the high‐risk behaviours of the people. Most of them were afraid of infection and were concerned about their family's wellbeing, so they constantly do protective measures. Students recognized their responsibility towards society and the importance and risks of the nursing profession. They also described the negative experiences of public transportation and accommodation in student dormitories (Lovric et al., 2021).

Another experience of nursing students was psychological disturbances. Its different dimensions should be taken into account. They feared and worried about their health and worried about the health problems of their families and other relatives. In addition, the students reported on disturbances in social interaction and depression. Students' views and their reactions to prevailing conditions may differ. These findings were corroborated by other studies suggesting that nursing students faced a variety of mental health issues, including anxiety and worry (Lovric et al., 2021; Swift et al., 2020), stress (Aslan & Pekince, 2021; Casafont et al., 2021), anxiety (Fitzgerald & Konrad, 2021) and depression (Kalkan et al., 2021), during COVID‐19. Therefore, in the event of a crisis from emerging, contagious and dangerous diseases such as COVID‐19, nursing students and their families need more appropriate education and support. Students should be able to speak, and their voices should be heard. College should teach them how to take care of themselves. Their fears and concerns in this regard should be addressed appropriately. To support students and their families, one can avail counselling and psychiatric services that are available at the university or public centres and facilitate their vaccination programme.

With regard to disturbances in teaching and learning activities, the results of the present study showed that with the outbreak of the COVID‐19 crisis, despite extensive activities by different levels of educational management of the university and college to control infection and disease, the whole process of clinical teaching and learning was strongly influenced, and students expressed it in the form of disturbances with different dimensions. This disturbances has caused difficulty in their education and learning process leading to academic failure. The results of a study in Belgium showed that despite the efforts of nursing schools and clinical sites, most students are confused in the face of the COVID‐19 pandemic and have a strong need for preparation, and support from the faculty. This raised concerns about reduced learning opportunities and even fundamental doubts about their choice of nursing (Ulenaers et al., 2021). Lovric et al. (2021) also reported that some nursing students have become unmotivated, impaired concentration and experienced poor memory due to the COVID‐19 crisis, which made learning difficult for them. Nursing students may also experience similar problems during other epidemics, which could have negative consequences for their academic achievement. It seems imperative that for a better control of educational activities in times of crisis, the formation of a crisis management team in the university and its planning is an appropriate solution. The crisis team consists of experienced university and college management and trainers who can develop, practice, implement and support a flexible and appropriate educational programme by dealing with various aspects of the crisis. Establishing such a team in critical situations like COVID‐19 could facilitate and coordinate the educational activities of university leaders, professors and students in educational and clinical settings, greatly reducing challenges and disruptions in the educational process.

In this study, participants reported that they continued clinical learning by raising awareness and information about COVID‐19 and following the public vaccination programme. One of the important points in this category is the efforts of most students to adhere to infection control methods such as personal hygiene and hand washing as basic measures to prevent the disease. In one study, nursing programme applicants reported that the COVID‐19 epidemic and community response to nursing staff efforts positively strengthened their career choices (Swift et al., 2020). On the other hand, although the COVID‐19 pandemic was seen as a challenge for most nursing students, they were less inclined to leave the profession (Duprez et al., 2021). Alshutwi's study showed that the willingness of nursing students to treat patients with COVID‐19 was no less than that of other patients (Alshutwi, 2021).

As well, with the outbreak of the COVID‐19 epidemic and the imposition of physical and social constraints on society, nursing schools used virtual education as an alternative method of teaching a significant portion of theoretical nursing courses. Due to the problems and shortcomings in nursing education, it is better to continue this process under normal circumstances, and nursing schools can use virtual education capacity to achieve some educational goals. However, the results of previous studies have shown that the use of virtual education in nursing is not common under normal circumstances and its development is associated with many challenges (Kokol et al., 2006).

The present study also has some limitations; initially, the interviews were only recorded and analysed in audio and written formats. Although the researchers attempted to record more details about the participants' non‐verbal responses such as body language, emotions and emotional states during the interviews, using a camcorder is more appropriate for this purpose. However, due to potential issues such as morale, security and the unwillingness of the participants to have them filmed during the interview, the filming was not carried out. The second limitation was rooted in the researchers' focus on gathering nursing student experiences of hospital placement and patient care. However, in the COVID‐19 epidemic, nursing students have had different experiences, but other subjects have been avoided due to the lack of available time for interviews. Further detailed studies in this area are important to better understand their experiences. In this study, an attempt was made to plan the interview process in such a way that participants would have as much peace and confidence as possible to learn about their true feelings and experiences. Although the generalization of results is one of the inherent limitations of qualitative studies, examining and recognizing the experiences of nursing students in other colleges strengthens the possibility of generalizing the results.

5. CONCLUSION

The results of this study indicated that the most important key categories related to nursing student internship experiences during the COVID‐19 pandemic can be summarized in the form of five main categories: lack of facilities and equipment, psychological disturbances, physical risk, disturbances in education and learning activities, movement to continue clinical learning in situation. Within the subset of these categories, attention should also be paid to issues such as providing students with personal protective equipment and social services and managing their fears and concerns. It can facilitate teaching and learning activities and improve the quality of the nursing services they provide, while ensuring the health of nursing students and addressing their concerns.

AUTHOR CONTRIBUTIONS

Hossein Feizollahzadeh contributed to study conception and design, data collection, analysis and interpretation of results and draft manuscript preparation.: Hadi Hassankhani contributed to analysis and interpretation of results. Masoomeh Barsaei contributed to draft manuscript preparation. All authors reviewed the results and approved the final version of the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors stipulate that there is no conflict of interest in the present study.

Feizollahzadeh, H. , Hassankhani, H. , & Barsaei, M. (2023). Disturbances of nursing students in internship during emerging disease COVID‐19 pandemic: A qualitative study. Nursing Open, 10, 6197–6204. 10.1002/nop2.1854

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.