Satisfaction and perceptions with clinical practicum course among graduating nursing students: a mixed methods study

Abstract

Background

To date, limited literature explored graduating nursing students’ satisfaction with different modes of practicum and the perceived impact on their future nursing practice. This study aims to explore the satisfaction and perceptions with clinical practicum course among graduating nursing students in Taiwan through a mixed-methods approach.

Methods

A mixed-methods design comprises a questionnaire and qualitative content analysis. Grade 4 students of 4-year bachelor nursing program of a technological university in the north of Taiwan were recruited by purposive sampling, and it was conducted in May 2022. Students were invited to fill out a 5-point Likert scale to answer questions on their satisfaction with clinical practicum (online/school-based/traditional) and describe their experience and perception of online clinical practicum and school-based clinical practicum. Quantitative data were analysed using mean and standard deviation, and qualitative data were evaluated using content analysis.

Results

A total of 360 nursing students participated. The average scores for overall satisfaction with online, school-based and traditional practicums were 3.08 (± 0.83), 3.44 (± 0.71) and 3.85 (± 0.64), respectively, and those for satisfaction with the attitude of practicum teachers for online, school-based, and traditional practicums were 3.74 (± 0.81), 3.78 (± 0.81) and 3.85 (± 0.67), respectively. Qualitative analysis data consisted of three main themes: (1) A journey of mixed emotions through remote practicum: exploring joy and challenges; (2) Career prospects exploration and anxiety: contemplating future employment; and (3) Post-pandemic practicum experiences: reflections and growth.

Conclusion

Graduating nursing students expressed the lowest level of satisfaction with the overall of online clinical practicums. Students believed that online and school-based clinical practicum could affect their future nursing competences and career choices. Healthcare institutions need to show high levels of understanding towards new nurses who could not gain sufficient practical experience due to the pandemic. Moreover, a training program for newcomers should be established to enhance patient care quality and help new nurses adapt to the workplace.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-04005-9.

Introduction

Students’ satisfaction is a fundamental goal of nursing educators. Satisfaction is a desire for delight or disappointment resulting from an event and a person’s prior expectations of himself of herself [1]. In clinical practicum, students are required to apply what they have learned in class to the real world and attain a professional level of nursing competence to provide safe and high-quality patient care [2]. Thus, nursing students improve learning satisfaction by closing the gap between theory and field through clinical practicum experience. Nursing students’ satisfaction with clinical practicum can influence clinical competence [3] and is significantly related to their learning outcomes and choice of nursing career [4–5].

A clinical practicum course is critical to strengthen the nursing competence of nursing students. Nursing students must develop the ability to deal with potential and actual problems through clinical practicum experiences [6]. Practicum environments are “crucial links to successful experience(s) for students.” Students want to transfer learning to the workplace and new situations and must “demonstrate their learning in authentic contexts for workplace readiness” [7]. Clinical practicum is essentially experiential learning, which is achieved through the appropriate use of experience [8]. Therefore, nursing schools arrange a series of clinical practicum courses for students so students can accumulate professional knowledge and skills through repeated experiential learnings and become competent nurses after graduation.

The coronavirus disease 2019 (COVID-19) pandemic disrupted nursing students’ learning trajectories, as many institutions suspended traditional clinical practicums for safety reasons. Consequently, alternative formats such as online or school-based practicums were implemented, incorporating instructional videos, simulations, skills practice, and case studies. While online practicums relied on virtual platforms, school-based practicums allowed limited in-person practice in skills and simulation laboratories [6, 9]. However, compared with traditional face-to-face patient care, these alternatives deprived students of key opportunities to build confidence and clinical readiness, leading to widespread dissatisfaction with the loss of hands-on training [6, 10–12].

Previous research primarily focused on nursing students’ perceptions of online clinical practicum [9, 13–18]. The effectiveness, satisfaction levels and feedback from nursing students after engaging in online or school-based clinical practicums are important in nursing education. However, limited literature explored satisfaction with school-based clinical practicum and the perceived impact on their future nursing practice. This topic deserves further exploration and can provide valuable insights for nursing educators in planning practicum courses and teaching strategies aimed at achieving effective and sustainable nursing education during crises.

Methods

Aim

During the outbreak of COVID-19, our school implemented alternative practicum modes, including online and school-based clinical practicums. This study aims to investigate the satisfaction and perceptions of graduating nursing students in Taiwan towards their a one-year clinical practicum experiences, encompassing traditional in-person clinical practicum and the alternative modes implemented in response to the pandemic.

Design

A mixed-methods design comprises a questionnaire and qualitative content analysis.

Clinical practicum

At our school, four-year bachelor’s nursing students are scheduled to complete their clinical practicum courses from the second semester of their third year through the first semester of their fourth year. They are required to complete a range of practicums, including fundamentals of nursing practicum, medical–surgical nursing practicums (I and II), maternity nursing practicum, paediatric nursing practicum, psychiatric nursing practicum, community health nursing practicum, and comprehensive clinical nursing practicum. The students who participating in this study were scheduled to complete their nursing practicum courses between from February 2021 to January 2022. However, medical institutions prohibited nursing students from participating in clinical practicums from May to August 2021 due to the COVID-19 outbreak in Taiwan during 2021. Following the easing of the pandemic situation and implementation of infection control measures, the school arranged for students to participate in either online or school-based clinical practicums.

Setting and participants

Purposive sampling was employed, targeting fourth-year bachelor’s nursing students enrolled at a technological university in northern Taiwan. Out of 489 eligible students, 360 consented and provided their agreement to participate, comprising 317 females (88.1%) and 43 males (11.9%), with an average age of 21.4 (± 0.6) years. During their a one-year practicum, the students coincided with the COVID-19 pandemic, with all of them having undergone online clinical practicum and 163 (45.3%) students having experienced school-based clinical practicum (Table 1).

Table 1.

Demographic characteristics of the nursing students (N = 360)

Variable	N	%	Mean ± SD
Age			21.4 ± 0.6
Gender
Male	43	11.9%
Female	317	88.1%
Practicum modes
Online clinical practicum	360	100%
School-based clinical practicum	163	45.3%
Traditional clinical practicum	360	100%

Note: Some participants experienced more than one practicum mode; therefore, the percentages do not total 100%

Data collection

Data were collected in May 2022, prior to the students’ graduation. The “Practicum Satisfaction Scale” was used to collect data. Based on a review of relevant literature and teaching experience, the investigator developed the scale to evaluate students’ satisfaction with traditional clinical practicum, online clinical practicum and school-based clinical practicum. The content included satisfaction with teaching activities, the arrangement of practicum assignments, the attitude of teachers and their overall practicum experience. A 5-point Likert scale (1 = very dissatisfied, 5 = very satisfied) was adopted, with higher scores indicating greater satisfaction. The content validity index (CVI) ranged from 0.97 to 1.00. Cronbach’s α for the scale was 0.85, indicating good internal consistency.

Clinical practical training serves as a crucial challenge and milestone for nursing students in their professional development, with their professional behaviour heavily reliant on their actual clinical experiences. However, during the pandemic, the adoption of online and school-based clinical practicum modes marked a shift from a patient-centred to a teacher-student-centred alternative practicum approach. Assessing the effectiveness and feedback of nursing students following online or school-based clinical practicums is crucial for nursing education. Therefore, four open-ended questions were used to collect qualitative data, asking students to describe their experiences with different practicum modes and their impact on future nursing practice. The questions included: (1) What are your perceptions about online clinical practicum? (2) How do you think online clinical practicum will affect your future nursing work? (3) What are your perceptions about school-based clinical practicum? (4) How do you think school-based clinical practicum will affect your future clinical nursing work?

Data analysis

Descriptive statistics was adopted to analyse quantitative data. For qualitative data, content analysis method proposed by Waltz et al. [19] was employed to analyse students’ perceptions towards different practicum modes and their impacts on future nursing work. The qualitative data according to the topic of research, underwent content analysis by two experienced nursing researchers. Each researcher meticulously reviewed the content of each text to ensure a comprehensive understanding of the qualitative data and proceeded with coding. Subsequently, the researchers consistently discussed to confirm and verify unit coding, ensuring the consistency and accuracy of the data. Throughout the data analysis process, they continuously compared and analyzed differences among individual units, further forming categories while ensuring the integrity and consistency of the categories’ content. Finally, the researchers engaged in in-depth discussions based on the relevance of categories related to core concepts and issues addressed in the study, amalgamating similar categories into broader theme.

Rigor

To ensure the rigor of the qualitative analysis, this study adopted the four trustworthiness criteria proposed by Waltz, et al. [19]: credibility, dependability, confirmability, and transferability. Credibility was established through prolonged engagement with nursing students, triangulation with quantitative data, member checking, and peer debriefing. Dependability and confirmability were supported by maintaining an audit trail, providing detailed documentation of the coding process, and involvement independent researchers in theme validation. Transferability was enhanced by purposive sampling, rich contextual descriptions, and the use of verbatim quotations to illustrate key themes.

Results

Quantitative research results

The study result showed that the average scores for overall satisfaction with online, school-based and traditional clinical practicums were 3.08 (± 0.83), 3.44 (± 0.71) and 3.85 (± 0.64), respectively. The average scores for teaching activities satisfaction in online, school-based and traditional clinical practicums were 3.21 (± 0.80), 3.50 (± 0.72) and 3.90 (± 0.61), respectively. The average scores for assignment arrangement satisfaction in online, school-based and traditional clinical practicums were 3.14 (± 0.81), 3.36 (± 0.71) and 3.49 (± 0.71), respectively. The average scores for satisfaction with the attitude of teachers were 3.74 (± 0.81) for online, 3.78 (± 0.81) for school-based and 3.85 (± 0.67) for traditional clinical practicums. (Table 2)

Table 2.

The results of the quantitative data analysis

Online clinical practicum (N = 360)	Mean	SD
1. Overall satisfaction with online clinical practicum.	3.08	0.83
2. Satisfaction with online clinical practicum teaching activities.	3.21	0.80
3. Satisfaction with online clinical practicum assignment arrangement.	3.14	0.81
4. Satisfaction with online clinical practicum teachers’ attitudes.	3.74	0.81

School-based clinical practicum (N = 163)	Mean	SD
1. Overall satisfaction with school-based clinical practicum.	3.44	0.71
2. Satisfaction with school-based clinical practicum teaching activities.	3.50	0.72
3. Satisfaction with school-based clinical practicum assignment arrangement.	3.36	0.71
4. Satisfaction with school-based clinical practicum teachers’ attitudes.	3.78	0.81

Traditional clinical practicum (N = 360)	Mean	SD
1. Overall satisfaction with traditional clinical practicum.	3.85	0.64
2. Satisfaction with traditional clinical practicum teaching activities.	3.90	0.61
3. Satisfaction with traditional clinical practicum assignment arrangement.	3.49	0.71
4. Satisfaction with traditional clinical practicum teachers’ attitudes.	3.85	0.67

Qualitative research results

Based on the written feedback received from 360 students regarding their experiences with online and school-based clinical practicums, the analysis conducted herein aimed to align and interpret the quantitative survey findings. As a result, three primary themes were extracted and outlined in Table 3.

Table 3.

The results of the qualitative data analysis (N = 360)

Theme	Category
A journey of mixed emotions through remote practicum: exploring joy and challenges	1. Opportunities for flexible learning, deep understanding, and review
	2. Physiological load and learning limitations of online clinical practicum
Career prospects exploration and anxiety: contemplating future employment	1. Gap and anxiety in virtual learning skills
	2. Employment concerns under online clinical practicum
	3. Confusion and uncertainty in future clinical workplace choices
Post-pandemic practicum experiences: reflections and growth.	1. Providing simulation environment and technical training
	2. Emphasis on teacher-student interaction
	3. Recognising the necessity of in-person clinical practicum

A journey of mixed emotions through remote practicum: exploring joy and challenges

Opportunities for flexible learning, deep understanding, and review

Initially, a majority of students responded optimistically and favourably to the transition of clinical practicum to an online mode. They enumerated several advantages, including the elimination of early morning commutes, which freed up time for sleep and study and the convenience of learning in a familiar environment. Furthermore, the absence of direct interaction with medical teams, teachers, patients and their families alleviated the psychological stress commonly associated with practicums. Students also noted that online clinical practicum was less hurried than hospital setting, with less time spent on nursing techniques and activities, allowing for a more relaxed learning experience. Teachers had more time to utilise relevant videos, photos, and discussions to provide more in-depth explanations and reviews, even delving into exam topics for national exams. Therefore, students perceived that this alternative learning method enabled them to achieve a deeper understanding of professional knowledge and nursing theory, enhancing their depth of comprehension in nursing expertise. Students said: During the online practicum, the advantage was that I could get more rest, and the teachers had more time to explain what we needed to do (3 − 1). The instructor utilised numerous scenario simulations and extensive group discussions, enabling me to gain a deeper understanding of the theoretical concepts. The advantage of this was that I had more time to handle assignments and reduced stress levels (12 − 1). It was relaxing not having to wake up early for commuting, feeling the anxiety of being chased by time, and not having to actually be in the medical environment, which usually stresses me out (246-1).

Physiological load and learning limitations of online clinical practicum

Long-term online clinical practicum also brought some negative effects on students. In clinical practicum, students typically acquire practical experience through direct patient care. But, due to the pandemic, it was replaced by static, platform-based nursing clinical learning conducted primarily through computer screens, relying on instructor-prepared lesson plans. With the prolongation of online clinical practicums, most students reported physical discomforts, such as eye strain, muscle soreness, and stiff necks and shoulders from sitting in front of computers for long periods. Gradually, students began to express concerns regarding the physiological strain caused by online clinical practicum and doubts about their learning experiences. To compensate for the absence of authentic clinical cases in the online setting, teachers assigned additional homework, thereby increasing the burden on students’ after-class learning. Students said: During the online practicum, the instructor… tried to keep us close to the clinical environment, but as a result, the workload increased significantly. With eight hours of classes every day, we had to spend several more hours on the computer completing assignments, which made our eyes sore (7 − 2). Sitting in front of the computer for extended periods during the online practicum caused muscle soreness and stiffness in the neck and shoulders, which was uncomfortable. There were also more assignments compared to traditional practicum, so the stress didn’t decrease with the shift to online (50 − 2). We don’t need to wake up at 5:00 AM like in clinical practicum… But we can only simulate techniques through videos, and some teachers increase the workload, making it difficult for me to cope (84 − 2).

Online clinical practicum not only imposed physical and academic burdens and stress on students but also made them worry that this format of practicum couldn’t provide hands-on nursing experiences. They recognised that learning in front of a computer screen, without real patients, families, or direct interactions, hindered their understanding of hospital routines, patient responses, and symptom management. Students expressed dissatisfaction with the lack of realism during the online clinical practicum and were concerned that this learning method might limit their clinical experiences. Students said: Online practicum feels like attending classes. Although there are scenario simulations, they’re just simulations. It doesn’t feel real… (83 − 2). During online practicum… We haven’t seen actual patient conditions, and we can only imagine. It’s similar to sitting in classes before (266-2). At first, online practicum seemed like a relief from facing nurses, real patients, and families. However, I realised that the learning content online is very limited, and not being able to practice skills, spending the whole day in front of a computer, and sitting for long hours are uncomfortable. If possible, I would prefer to continue with traditional practicum (275-2).

The shift in practicum mode made students transition from initial excitement to gradually experiencing mental and physical stress and burden as the online clinical practicum progressed. The lack of face-to-face interaction with teachers and peers, coupled with prolonged computer-based learning and assignment completion, made students feel exhausted and fatigued. Despite teachers’ efforts to diversify teaching methods, students found it challenging to simulate real clinical scenarios and lacked the clinical sense gained through practical experiences. Although online clinical practicum served as the best alternative during the pandemic and had its benefits, students strongly expressed their preference for traditional clinical practicum experiences.

Career prospects exploration and anxiety: contemplating future employment

Gap and anxiety in virtual learning skills

Clinical practice demands precision and proficiency in skills. Students recognised that online simulation practicum made it challenging to perform technical procedures, rendering their previous learning less effective in clinical settings. It resulted in inability to evaluate and verify self-skills, nursing care, teamwork, and communication abilities. Therefore, it gave rise to doubts, anxiety, and concerns about their future nursing capabilities and clinical practice. Students were particularly worried about the lack of skill practice leading to technical unfamiliarity, which not only affected personal professionalism but also potentially compromised patients. Students said: Online practicum may result in unfamiliarity with hospital resources and limited communication with nurses or real patients. Consequently, solving problems and communicating with patients and their families may require additional effort and adjustment in future clinical work, increasing the likelihood of making errors and eroding confidence and morale (139-3). I believe that online practicum will heighten my fear of working in clinical settings in the future, as both technical skills and scenarios are simulated (13 − 3). Online practicum offers fewer opportunities to practice skills, and we can only simulate them in our minds through videos. The lack of actual communication with patients and their families makes me apprehensive about entering clinical practice later. I’m afraid I won’t be able to handle the reactions of patients and their families, and I worry about potentially harming them due to my lack of proficiency (157-3).

Employment concerns under online clinical practicum

Online clinical practicum has impacted students’ practical abilities and self-confidence, leading to concerns about entering the workforce. Specifically, they are apprehensive about the attitudes and perceptions of institutional supervisors and nurses towards this group of new nurses who have undergone online clinical practicum due to the pandemic. This appears to have become a pivotal factor in their employment-related stress and decision-making process. Students said: I believe that work ability is partly gained through experience, and missing out on any practicum opportunity means forfeiting valuable experiences. … Our inexperience can also have an impact on the mood of the nurses guiding us. If the nurses have a negative attitude or encounter significant work-related setbacks, it could potentially affect the turnover rate of new recruits (136-4). Internal medicine and surgery are the two departments where one can practice the most skills, but I only went through an online practicum and missed out on numerous opportunities for hands-on practice. As a result, I will have to learn most things on the job when I actually enter the clinical setting, which means I will be heavily reliant on the nurses (62 − 4). The impact is significant. We lack a lot in terms of skills, understanding of the environment, and even knowledge about diseases. In the future, when we enter the workforce, nurses may think, ‘Why don’t you know…?’ leading to us being perceived as ignorant (27 − 4). During the interview, the interviewer told me, ‘You, the ones who did the online practicum…’ What do you think about that (360-4)?

The stress might stem from the cultural traits unique to nursing. Although nursing professionals undergo formal education and training, much of their practical experience is derived from the apprenticeship system in clinical settings. When students enter the workplace, they still rely on the experiential guidance and mentorship of senior nursing colleagues. So, after engaging in online courses that lack practical practicum experience, students’ self-assessment of their nursing practice abilities is relatively low. They worry that, in the early stages of their new workplace, they will not only need to adapt to the nursing workplace culture but also relearn nursing skills and meet the expectations of institutional supervisors and senior colleagues. The combination of these factors poses doubts and invisible stress regarding future employment prospects.

Confusion and uncertainty in future clinical workplace choices

Nursing students gain exposure to various specialties and cultures through clinical practicums, allowing them to assess their employment preferences and suitability through hands-on patient care activities. However, due to the pandemic, real-life clinical practice has been transformed into simulated practice on virtual platforms. Students express concerns that online and school-based clinical practicums lack real clinical environments and experiences, preventing them from understanding actual nursing care scenarios and accumulating practical knowledge. Consequently, they struggle to evaluate their career fit and plan for the future, affecting their adaptability and retention in the workplace. Students said: I might be hesitant to enter specialties where I had online practicum experiences in the future (156-5). Due to the lack of clinical experience, I might not feel connected to the specialties I had online practicum in. I’m unsure if I’ll be able to handle clinical situations or if I’ll be a burden to my colleagues. So, when choosing a workplace in the future, I might not consider the specialties where I had online practicum (174-5). With online practicum, I only know about the unit and specialty through the teacher’s description. Therefore, when choosing a workplace in the future, I might not consider the units or specialties I had online practicum in because of the lack of understanding (192-5). Without actual interactions with clinical seniors, the help for actual work might be limited. For example, in obstetrics, without clinical experiences, I feel there’s a big difference. It will affect my willingness to choose specialties in the future (117-5).

Post-pandemic practicum experiences: reflections and growth

After experiencing alternative practicum modes during the pandemic, students have emphasised the fundamental and essential core values of nursing practicum courses, which involve simulating real scenarios, providing technical practical exercises, and facilitating face-to-face interactions and teaching between teachers and students. Most students prefer school-based practicums over online ones, primarily because they offer realistic laboratory settings for interaction with simulated patients and related tools, thus facilitating the development of practical skills. Moreover, teachers can provide professional advice and technical guidance in-person.

Providing simulation environment and technical training

Students believe that school-based clinical practicums are superior to online ones, primarily because they provide realistic environments and opportunities for technical training, enhancing the sense of realism compared to online clinical practicums. This mode of practicum maintains authenticity without the added stress of clinical practicum. Students said: The in-school public health practicum is excellent because we are spared from excessive exposure to the sun. Activities like community health events and home visits are often organized, which have minimal impact on us (15 − 6). During school-based practicum, the school provides models, enabling us to utilize them for technical practice in simulated scenarios (74 − 6). I firmly believe that school-based practicum is significantly superior to online practicum. In a more formal setting than home, such as a classroom, which is less stressful than a hospital, we can engage in clinical practices using simulated patients and scenarios (186-6).

Emphasis on teacher-student interaction

When comparing online and school-based clinical practicum modes, students favour the latter primarily because they can engage in face-to-face interactions with teachers and classmates simultaneously. Students’ feedback indicated that this generation of students prefers interactive learning styles, and the school-based clinical practicum format aligns well with this preference. Students said: Communication between group members and teachers is real-time and comprehensive. We can also perceive each other’s emotions more clearly, making communication much more convenient. Even though we still rely on videos and teacher explanations, at least we can simulate face-to-face interactions with group members, which is much more reassuring than the online practicum experience (129-7). During school-based practicum, students can think and make judgments in a less stressful environment, using simulated patients and scenarios. Teachers can provide prompt feedback or correct misconceptions in a timely manner, incorporating the experiential aspect (39 − 7). Teachers have more time to review high-risk scenarios, which I believe is beneficial. Coupled with the school’s adequate equipment, it’s easy to visualize and discuss these scenarios. Reviewing and discussing scenarios with classmates and teachers is beneficial for future work (76 − 7).

Recognising the necessity of in-person clinical practicum

Despite students rating school-based clinical practicums higher than online ones, they are still aware of the limitations and shortcomings of both modes. They strongly recognise the irreplaceability and significance of practical clinical experiences in nursing education. In their minds, the necessity and importance of in-person clinical practicums are unequivocally confirmed. Students said: School-based practicum may seem satisfactory, but it could just be an illusion. Being surrounded by familiar faces brings no stress. However, when suddenly thrown into clinical work in the future, I might be shocked. Given a choice, I would definitely opt for in-person practicum over online or school-based practicum (136-8). Patient models in the skills lab can be used to practice technical operations, but they are not real people and cannot provide feedback. Therefore, while we may feel smooth in practice, operations might not go smoothly in a clinical setting due to issues like force control or patient discomfort (193-8). After starting work, due to insufficient practice and the variability of patient conditions, there might be gaps between our skills and the actual clinical situation, leading to psychological and physiological stress. We fear performing the job, making mistakes, and lack confidence in facing it (162-8). like answering patient questions, the varied conditions of patients cannot be learned just by studying in school (275-8).

Discussion

This study aims to investigate the satisfaction and perceptions of graduating nursing students in Taiwan with clinical practicum. The results reveal that students’ overall satisfaction with clinical practicum is in the following order: traditional clinical practicum, school-based clinical practicum, and online clinical practicum. Our study results are similar to the report of Kang and Hwang [6], who stated that newly graduated nurses’ satisfaction with alternative practicum types is in the following order: simulation laboratories, skills laboratories, virtual simulation and written assignments. Traditional clinical environments are the gold standard for students to develop nursing competence, where students perceive traditional clinical environments as enabling them to acquire knowledge, practice communication skills, engage in nursing processes, holistic care, critical thinking, and develop confidence [20]. Therefore, students hold expectations for clinical practicum. If they meet their expectations, they will be satisfied with their clinical practicum and conclude that they are suitable for this profession [21]. Our study results also indicate that our students are more satisfied with traditional clinical practicum in hospitals, expressing dissatisfaction with alternative clinical practicum during the pandemic, especially online clinical practicum. These study results are broadly consistent with international research findings. Shorey et al. [12] conducted a systematic review and meta-analysis of relevant studies on online nursing education during the COVID-19 pandemic, showing that nursing students expressed dissatisfaction with the cessation of face-to-face clinical practicum and practical courses. Dutta et al. [10] reported that 42% of students were dissatisfied (very dissatisfied or dissatisfied) with online clinical practicum, with no significant difference between medical and nursing students. They were particularly dissatisfied with the cancellation of clinical rounds, ward postings, and real patient interactions, which limited opportunities to acquire and improve clinical skills.

Clinical experiences are essential for the nursing student’s integration of skills, theory, and critical thinking processes into professional practice. Due to the COVID-19 epidemic, nursing schools made an effort to replace traditional clinical training with several activities, primarily based on simulation or virtual activities [22]. However, studies showed that a virtual environment and online simulation could not replace direct patient care because students did not interact with patients [9, 17, 23–25]. As they could not have actual contact with real patients, even though they practiced communication skills and discovered patient problems while proposing corresponding measures in simulated situations, it did not replace the experience of interacting with patients and healthcare teams in clinical settings [9, 23]. Online courses also struggled to connect theoretical knowledge with practical application, limiting the development of clinical competence [12]. As a result, students were dissatisfied with their clinical competence development during alternative clinical practicum [6, 23]. Our study results show that students are least satisfied with the teaching activities of online clinical practicum, followed by school-based clinical practicum. From students’ qualitative feedback, students expressed a significant gap between online clinical practicum and clinical practice, especially in the cultivation of skills operation ability, communication and clinical adaptation ability, which are difficult for online clinical practicum courses to provide opportunities or adequate training for. Therefore, students are anxious about their clinical competence and technical proficiency, and they worry that insufficient clinical competence and lack of adaptability may affect their future employability. Our study results are consistent with previous research findings [9, 12–18]. Therefore, healthcare institutions should provide empathy, tolerance and understanding for students or new nurses who cannot gain enough practical experience due to the epidemic. At the same time, a set of new staff training courses should be established to help them adapt to the workplace smoothly, improve their adaptability and reduce the risk of reality shock.

Nursing students value clinical practice and the possibilities it offers in the process of growing to become a nurse and a professional [26]. Alternative clinical practicum prevents students from facing real patient reactions and changing situations. Our study results show that although school-based clinical practicum can provide simulated scenarios to meet students’ needs for learning skills operation and interpersonal interaction, and alleviate the burden and difficulties faced by online clinical practicum, students still perceive significant gaps between these simulations and real clinical situations. For example, the ability to adapt to patient complaints, establish nurse-patient relationships, and cultivate actual care skills cannot be fully learned solely through simulated case scenarios. Students emphasise the importance of technical practice and operation during clinical practicum and point out that clinical teachers can provide real-time guidance, feedback, and interactive communication during students’ participation in actual patient care processes, which are relatively critical elements. In addition, missing valuable opportunities for interaction with real patients, families, and healthcare teams may have adverse effects on their future clinical work. By contrast, students prefer real-time and two-way interactive face-to-face traditional clinical practicum, which will better meet their practical needs. Through practical exercises and practical learning, students can accumulate professional nursing competence, adaptability, and confidence, which will help them adapt to future workplaces and fulfil their duties smoothly. Steven et al. [27] reported that students identified clinical practice experiences as important occasions for their personal and professional development. Meanwhile, nursing students deepen their understanding on the characteristics and cultures of various departments through a series of clinical practicum experiences to help them assess their own job preferences and suitability more deeply through actual participation in care activities and interactions of patients in that department. However, this is restricted due to the pandemic [16]. Sun et al. [5] indicated that negative clinical practicum experiences impacted on future career choices and uncertainty about future workplace choices. Our students’ feedback indicates that alternative clinical practicum due to the pandemic has made the on-site clinical practical experience relatively insufficient, which may affect their professionalism in the workplace in the future and may be subject to questioning from colleagues and seniors, thereby increasing anxiety and stress before employment. Our study results are similar to those of Michel et al. [25] and Kobayashi et al. [16]. Additionally, our students’ feedback also indicates that neither online nor school clinical practicum can provide them with real clinical environments and experiences, making it difficult for them to assess and plan their future career suitability. Therefore, students tend to exclude the specialties of online or school-based clinical practicum from their future nursing specialty employment considerations. However, under these considerations and decisions, fundamental changes may be brought to the employment ecology of the nursing profession, or even affect the adaptability and long-term retention rate of nursing students in the workplace. These changes also highlight the challenges and adjustment needs of the nursing professional education system in responding to the impact of global epidemics.

Our study results show that students are least satisfied with the assignment arrangements in online clinical practicum, compared to traditional and school-based clinical practicum. From students’ qualitative feedback, students express that due to the inability of online clinical practicum to participate in patient care, teachers arrange more assignments to compensate for the lack of learning, but this also increases their workload. Additionally, students express physiological discomfort, such as increased eye strain, physical fatigue, muscle soreness and stiff joints, from long hours of online clinical practicum. They also have to spend several hours on the computer to complete assignments after class, leaving them physically and mentally exhausted. This may indicate one of the reasons why students are dissatisfied with the assignment arrangements of their online clinical practicum. Our study aligns with previous research findings. Kang and Hwang [6] showed that satisfaction with written assignments is the lowest, compared to skills laboratories, simulation laboratories, and virtual simulation, as alternative clinical practice methods during the COVID-19 pandemic. Moreover, newly graduated nurses also expressed the lowest utility of written assignments for real clinical practice [6]. Similarly, Liesveld et al. [17] and Tambunan and Sinaga [24] reported that students experienced stress and difficulty in coping with the heavy workload and assignments associated with online learning and practicum during the pandemic. Although our students are dissatisfied with alternative clinical practicum, whether in terms of overall satisfaction, teaching activities or assignment arrangements, students are most satisfied with the teaching attitude of teachers. The satisfaction scores for online clinical practicum, school clinical practicum, and traditional clinical practicum are 3.74, 3.78 and 3.85, respectively. Although teachers integrate many teaching strategies into alternative clinical practicum and invest a lot of time in preparation and providing videos and activities to engage students and even though students perceive alternative clinical practicum as unsuitable for nursing practicum, they are very satisfied with the teaching attitude of teachers. The most effective teaching strategies of clinical teachers from nursing students’ perspectives were respectively “treating students, clients, and colleagues with respect” and “being eager for guiding students and manage their problems” [28]. Our study results are similar to previous research findings. Dutta et al. [10] indicated that students were generally satisfied with the support and response from the teaching faculties and dissatisfied with the communication/technology issues and lack of practical or clinical learning. Abbasi et al. [14] stated that a majority of participants appreciated E-learning for timely response and feedback from teachers on assignments and assessments.

At the initial stage of the transformation from traditional clinical practicum to online platforms for nursing practicum, our students showed novelty and excitement. This emotion stems from the advantages brought by online clinical practicum. Online clinical practicum not only saves students commuting time between home and practicum institutions but also reduces the learning stress of facing busy clinical work and communicating with healthcare teams, clinical teachers, patients and their families. However, online clinical practicum does not focus on real cases as the main learning objects, which simplifies teaching practices and technical exercises, providing teachers and students with more time for case analysis and theoretical understanding. Students can thus delve into theoretical learning and assignment production, thereby deepening their professional nursing knowledge. Additionally, the study results also show that deepening students’ professional knowledge is not limited to clinical practicum experiences. During online clinical practicum, teachers’ use of diverse strategies for guidance and detailed explanations also plays a crucial role, while giving students sufficient time for reading absorption and understanding is equally important. This combination of guidance and autonomous learning provides students with comprehensive learning experiences, assisting them in building a solid foundation in the deepening of nursing professional knowledge. Several studies reported similar views of students on online clinical practicum [9, 14, 23, 29]. However, during the experience of online learning, students also face some unexpected burdens. Firstly, they need to sit in front of the computer and screen for long periods, leading to many physiological discomforts such as increased eye strain, physical fatigue, muscle soreness and stiff joints, similar to the results of Singh et al. [30]. Secondly, in online clinical practicum courses, teaching mainly revolves around teachers and students, and teachers often use strategies such as simulated cases, videos, or images to conduct lectures to make the course more closely related to clinical reality. However, long periods of teaching are prone to distract students, fatigue and boredom, which leads students to question the clinical sense, authenticity and learning effectiveness of this practicum teaching mode. Nursing students generally considered clinical environments and simulation laboratories to be the best places to learn clinical care skills [14]. Students also suggested increasing the school’s simulation laboratories or in-person laboratories, which are crucial for their technical and clinical skill development [31]. This concept is confirmed in our study, where students are more satisfied with school-based clinical practicum than online clinical practicum. Although our students are more satisfied with school-based clinical practicum and rate it higher than online clinical practicum, they still recognise the limitations and shortcomings of both practicum modes, and more strongly recognise that traditional clinical practicum experience is irreplaceable and important in nursing training.

Limitations and recommendation

Although this study explored the experiences of nursing students during the COVID-19 pandemic with traditional clinical practicum, online clinical practicum and school-based clinical practicum, it has several limitations. Firstly, not all clinical teachers utilise the same teaching methods when delivering online or school-based clinical practicum courses, which may influence students’ perceptions. Thus, caution must be exercised when interpreting the study results. Secondly, the frequency and departments in which students participate in online or school-based clinical practicum may affect nursing students’ learning experiences. However, such data were not investigated in this study. Third, the survey was conducted at a single university in Taiwan, which may limit the generalizability of the findings. Therefore, the results may not fully reflect the perspectives of nursing students from other universities or regions.

The following recommendations are proposed based on the results of the study: 1. Enhance the clinical simulation of virtual practicum: Academic institutions can integrate highly realistic virtual clinical simulation platforms to compensate for the interruption of clinical practicum caused by the pandemic. 2 Strengthen practice-oriented teaching: Schools should emphasise a practice-oriented approach in curriculum design, integrating theoretical knowledge with practical skills. 3. Enhance workplace adaptability training: Schools and healthcare institutions can collaborate to provide workplace adaptability training for graduating nursing students. 4. Future research could delve deeper into the needs and applicability of clinical practicum learning for nursing students, comparing the impact of various practicum modes on students’ learning outcomes as well as their professional development capabilities.

Conclusion

This study aims to investigate the satisfaction and experiences of graduating nursing student in Taiwan who underwent a one-year consecutive practicum program, encompassing traditional clinical practicum as well as alternative clinical practicum modes necessitated by the COVID-19 pandemic. The study findings indicate that students rank their satisfaction with clinical practicum in the following order: traditional clinical practicum, school-based clinical practicum and online clinical practicum. Students’ express dissatisfaction with the “teaching activities” and “assignment arrangements” of the online clinical practicum but are satisfied with the “teaching attitude of teachers.” Based on students’ qualitative feedback, they recognise that the opportunities of providing simulation environments and hands-on technical operations, teacher-student interactions and real clinical practicum experiences are essential elements in cultivating nursing professionals. Students believe that online and school-based clinical practicum will have an impact on their future nursing competences and career choices.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

COVID-19

Coronavirus disease of 2019

Author contributions

LHT designed and managed the research project. LHT substantially contributed to data collection. LHT, CJW, CMC and SFC significantly contributed to data analysis and interpretation. LHT drafting of the article and critical revision of the article. All authors read and approved the final manuscript.

Funding

We are grateful to the Ministry of Science and Technology, Taiwan [MOST 110-2511-H-255-004 -MY2] for their grant support of this study.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethical approval and consent to participate

This study was conducted following the Declaration of Helsinki and approved by the Institute Review Board, Chang Gung Medical Foundation (Approval No: 201901913B0, Date: 23.01.2020). The objectives and procedures of the study were explained to the participants, with an emphasis on voluntary participation, anonymity, and confidentiality. All participants provided written informed consent. Each participant was assigned a number to maintain anonymity, and all information collected was kept strictly confidential. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.