Experience of Nursing Interns during COVID-19 in Taif University, Saudi Arabia: A Qualitative Study

1. Associate Professor, Department of Nursing, College of Applied Medical Science, Taif University, Taif, Saudi Arabia.

Abstract

Introduction: Coronavirus Disease-2019 (COVID-19) has affected nursing staff and students mentally and physically due to their role in the frontline fighting the virus. However, data on the effect of COVID-19 on nursing students are limited and there have been no studies about Saudi nursing intern experience during this crisis.

Aim: To explore the impact of COVID-19 pandemic on nursing students during their interns at hospitals and how they dealt with the COVID-19 pandemic.

Materials and Methods: A qualitative descriptive study was done where 12 interviews were conducted among nursing student at the Nursing Department in the College of Applied Medical Science at Taif University, Taif, Saudi Arabia. The study was conducted from 1^st January 2021 to 10^th April 2021. The descriptive method was used to collect, understand, organise and represent in depth data. All the nursing student participants were interns and started their intern programmes during the COVID-19 pandemic. All interviews were auto-recorded, transcribed and analysed using a thematic method.

Results: The four themes which emerged from findings were: student plans during COVID-19; students’ perspectives of the nursing profession; intern students’ mental states; and hospital roles.

Conclusion: While the virus may negatively affect the experience of nursing intern students, the support of the media and society towards nursing staff during the pandemic has encouraged them significantly. So this study recommended that nursing stakeholders collaborate with the media to create greater interaction and embrace the nursing profession for younger generations.

Infection disease, Qualitative research, Staff-student relationships

Coronavirus Disease-2019 (COVID-19) is a virus which emerged from Wuhan, China in December 2019 and quickly spread to the rest of the world (1). In March 2020, the World Health Organisation (WHO) announced it as a worldwide pandemic. Since then, COVID-19 has affected people living around the globe in many different ways. As a health crisis, nurses and medical workers have been the most affected professional since they played a major role in fighting the COVID-19 virus and providing daily healthcare services (2). As a result of the growth in COVID-19 cases, some countries around the world faced nursing and healthcare workers shortages in medical centres. Therefore, nursing students were mobilised in hospitals and medical centres during the lockdown (3).

Nursing intern programme is a hospital practice one year after graduation for nursing students. It is designed to provide them with necessary training and to develop medical professionalism when dealing with patients and colleagues (4). For the kingdom of Saudi Arabia, The Saudi Ministry of Health published an urgent report during the early stages of the country’s lockdown caused by COVID-19 pandemic. It called for healthcare affairs directors around the country to allow and encourage all hospitals and health centres to continue all training programmes for nursing students in coordination with their universities. The report stated the importance of training and qualifying health workers in order to enhance their ability to face any emergency cases and health crisis. The report highlighted that all students must be trained in environments where all the necessary and preventive measures had been applied for their safety (5). In addition, the Saudi Commission for Health Specialties released a statement in May 2020 urging Saudi universities to mitigate nursing shortages in medical facilities by signing up all nursing students who had already finished their clinical training and were willing to start their intern period to the six-month nursing temporary service realised by them. The programme will help link signed students to the nearest medical facility needing more nurses in practice (6).

The purpose of this study was to investigate the experience of Taif University nursing students as interns during the COVID-19 pandemic. Also to explore the impact of COVID-19 pandemic on nursing students from the students’ perspective.

Material and Methods

This was a qualitative descriptive study conducted at the Nursing Department in the College of Applied Medical Science at Taif University from 1^st January 2021 to 10^th April 2021. The descriptive design was used to collect, understand, organise and represent in depth data (7). All the nursing student participants who were interns at the Nursing Department in the College of Applied Medical Science at Taif University and started their intern programmes during the COVID-19 pandemic. Taif University Research Ethics Committee, Saudi Arabia, reviewed and approved this study under the code (42-0075).

Inclusion criteria: Students from Nursing Department at Taif University, who had finished their academic years and started their intern at hospitals were included in the study.

Exclusion criteria: Students who were not in intern at hospitals were excluded from the study.

The researcher conducted a meeting with the clinical affairs to propose the research objectives and the procedure of data collection. After their approval they agreed to contact all intern students through the university system, inviting them to participate along with the information and consent forms. Twelve students replied, of which eight females and four males, agreed to participate in in-depth semi-structured interviews.

All students were recommended by the clinical affair at College of Applied Medical Science, Taif University. The data was collected through individual semi-structured interviews with the participants. Open-ended questions were asked during the interviews to allow the students to share their full experience. The interviews questions such as “How did the COVID-19 affect your decision to start training?”, “What are the challenges and difficulties you faced during COVID-19?”, “To what extent have you been able to get support from your co-workers and nurses in the hospital?”, “What are the factors that affected your performance positively, and what are the factors that affected your performance negatively?”. Interviews were done in the Arabic language according to students’ preference. All interviews were done through using Blackboard at Taif University website due the social distancing rules in the country and was approved by author and participants. Ten interviews were enough to achieve saturation and identified all themes, however, this study added two more interviews to ensure the data saturations.

All the participants received an information sheet and signed the consent form. All of them understood their right to skip questions, stop recording and to stop the interview at any time. They were also aware that their contribution would be published in anonymised form. The interviews were in the Arabic language as requested by the students and lasted for 30–60 minutes. Each interview was recorded in Arabic and transcribed and analysed in English using thematic analysis.

Rigour

The study credibility, transferability, dependability and reproducibility were confirmed. For example, ensured that all genders were included and all participants had the chance to experience an internship during the pandemic. Participants were given the entire period for expression in order to achieve data saturation. In addition, researcher may add additional questions, if clarification is required. Also, researcher may repeat the participant’s answers to emphasise meanings. All interviews were conducted by the same researcher following the interview schedules. The data analysis was conducted by researcher, and they agreed on the finding’s themes.

Results

The total participants in this study were 12 Saudi nursing students from Taif University, Saudi Arabia. Their ages were between 22 to 24 years of age. Participants started their internship in beginning months as shown in (Table/Fig 1). From the results, four themes were identified: Student plans during COVID-19; students’ perspectives of the profession; intern student’s mental state and hospital roles.

Theme 1: Student interns’ plans during COVID-19

Without doubt, the COVID-19 pandemic affected the internships of nursing students at Taif University, Saudi Arabia, although the degree of impact on the students differed according to their starting time and the stage of COVID-19. At the start of the country’s lockdown period, the Ministry of Health chose some hospitals to be limited for Coronavirus cases and did not accept nursing students. Moreover, the hospitals introduced new rules and regulations during this crisis before accepting nursing students. All these things affected the training of nursing students, as some of them stopped for a while, some were transferred to another place, and some of them reduced their training period in some nursing places, as indicated below:

‘I started before COVID-19, when the virus appeared in Saudi Arabia. My plans were messed up. Firstly, we were ordered to stay at home for two months. Secondly, my plan contained specific departments that were removed because of COVID-19. Those departments were closed for isolation. Lastly, I had to reduce my time in certain departments in order to be able to catch up on the remaining departments because of the missing two months. It is causing me a lot of stress’ (Participant 4).

‘COVID-19 affected my training experience because we were afraid of the unknown. Some hospitals were closed for COVID-19 isolation, which created pressure on the hospitals that remained open as more patients joined the open hospitals as well as more intern students’ (Participant 7).

‘Some students chose to be trained in hospitals outside the city of Taif. Due to COVID-19, their requests were rejected, and they had to train in Taif, which increased the demand. Before COVID-19, we asked to be trained in one hospital, but due to COVID-19 we were asked to split into two groups. The first group would be training in a hospital and the second group in a medical centre to minimise crowding. After two months, groups would have to switch with the others to equalise the experience’ (Participant 3).

Theme 2: Students’ perspectives of the profession

Most of the interviewees were proud of their participation in training during the COVID-19 period, because the crisis enhanced the importance of nursing as a profession and improved the role of nurses in society. Moreover, this crisis increased nursing students’ responsibilities and their need to work as a team. Despite having the right to start their training or to postpone it, they preferred to start training, as quoted below:

‘When the crisis started in Saudi Arabia, I wanted to postpone my internship because I was scared I might infect my family, but as time went by, I felt more confident about starting my internship. After the pandemic, I felt lucky that I was a nurse and I felt the importance of my role in any health crisis such as COVID-19, although it was not my first choice when I applied to university’ (Participant 3).

‘COVID-19 made me realise the importance of my rule as a nurse. My perspective changed, but so did other people’s. One of the benefits of the virus is that it created more courses online. In my opinion, COVID-19 made people more collaborative and they showed more initiative. I saw a lot of volunteers; I think the crisis has inspired people to work together towards one goal’ (Participant 7).

‘Entering my internship during COVID-19 made me feel that I should be more responsible, although it was hard making the connecting between the theoretical and the practical’ (Participant 5).

Theme 3: Intern students’ mental states

Few of the students hesitated before starting to train in a time of pandemic. The students’ fears were of getting infected, infecting their families and, in the worst scenario, dying. In addition, some of them stated that they regretted entering the nursing field at the beginning of the pandemic, but during the training they felt the fear and the beauty of working in the nursing profession at the same time, as quoted below:

‘This time of training is beautiful but terrifying at the same moment. Beautiful, because it allows you to learn so much and help, and you may never experience a similar situation ever in your life such as a pandemic. Terrifying, because I did not know what this disease would do to people when I heard of infections and deaths growing everyday’ (Participant 4).

‘Due the crisis, many of my friends were unhappy with the profession and thought they had put themselves at risk. As for me, I felt excited to be lending a hand. At first I feared I might infect my family with the virus, but I was more confident when I returned to my internship as I took my protection procedures very seriously’ (Participant 1).

‘We heard that some nurses in our hospital died because of COVID-19, which had a negative impact on us as nursing students. By observing my teammates during COVID-19, I saw some of them were very confused during training because of the fear. Others were positive and gave their attention to God well’ (Participant 4).

Theme 4: Hospital roles

Given the presence and spread of COVID-19, the Kingdom's Government, including the Ministry of Health, put in place a number of rules and regulations aimed at protecting patients and hospitals employees. For example, students were not allowed to enter some hospitals or hospital departments, and all students had to obtain a certificate for the prevention of infectious diseases. Some of these decisions affected students’ training programmes, as quoted below:

I was not allowed to treat COVID-19 patients, unfortunately, because I was an intern student and had not received my infection control course certificate yet, although I was willing to offer my help. You know, COVID-19 has affected my intern experience. I was not allowed to be trained in some departments of the hospital, such as the emergency and intensive care departments, as they were closed for COVID-19 patents (Participant 1).

My working hours as intern changed from am to pm, and this was due to nursing shortage. The hospital contacted our college and asked if students would like to change their working hours to cover the pm shift nursing shortages and we agreed. Also, we had to take an infection control course from the Red Cross to be able to start our internships (Participant 6).

We were not allowed to have direct contact with COVID-19 patients. Because of COVID-19, some departments had nursing shortages as they went to COVID-19 field hospitals. They would use intern students in their advantage and made us take more responsibility than we should. I would not have minded if they had been polite and supportive to us, but they were not. Also, they would not give me more credits for it (Participant 4).

Discussion

The main context raised for discussion from the findings are: student interns’ plans during COVID-19; students’ perspectives of the profession; intern students’ mental states; and hospital roles. Present research showed that students started their internships at different stages of the pandemic; some students started one month before COVID-19 emerged in Saudi Arabia, others started in the middle of the pandemic and a few started later. All students were affected by the pandemic, however, the amount of damage varied depending on the period in which they started. Students who started before the pandemic were the most affected because of the changes of laws and legislations while implementing their internship year. This finding was also recorded in the study of Vázquez-Calatayud M et al., the study explained that due to the pressure of the pandemic and the insufficient time to adapt and prepare for the change, nursing students had to transform from students to professionals during the pandemic (8). Furthermore, this transition of nursing students to professionals could result in student not receiving the essential guidance and reflection needed to integrate learning outcomes during their intern (9).

Saudi Arabia Ministry of Health took the decision to stop their internships for two months in order to protect their safety. However, the decision was cancelled two months later, after ensuring that the updated rules and regulations would protect the students’ health. As a result, they had to skip their training in a few departments during those months.

In the early stages of the COVID-19 pandemic, students showed concern about whether they would start their internships during the pandemic or postpone them for a few months. Moreover, Arnetz JE et al., had mentioned that due to the direct contact with the virus, the students feared being infected, and it will restrict their work. Furthermore, it was found that the students had concerns about infecting their families with the virus. These concerns could also impact the family members themselves (10). Likewise, a study was implemented on children of nurses during the pandemic. The children had expressed that they were sacred for their parent’s wellbeing. Thus, it caused major psychological pressure on the nurses themselves (11). Likewise, it was explored in previous studies such as a cross-sectional design in 2020 with 662 nursing students at three universities in eastern Turkey (12), and high levels of stress among 1715 nurses in Hong Kong (13).

In present study, students explained that they were told to not have any direct interactions with COVID-19 patients in order to protect their safety, which was similar to the report of Monforte- Royo C and Coronials FP, which stated that nurse educators most take responsibility for minimising the negative impact of the virus on nursing students (14). Furthermore, a study found that students had felt valued by the professionals during their participation in the pandemic and they further explained that they felt a high level of involvement and collaboration by the healthcare system (15). Consequently, according to Alkarani AS et al., this factor contributes to increase the nurses’ confidence and role in awareness. The study further explained that the acknowledgement and appreciation that nurses received during the pandemic lead to advance nurses’ experience because of the major support from the health professionals (16).

Moreover, according to Shu-Ching CH et al., one of the positive impacts of the pandemic is the increased of research on nurses’ roles and responsibilities during crisis (17). According to Maxton F et al., the rising research on the challenges nurses had to face helped in advancing the technologies and information for nurses and patients (18).

Besides COVID-19 itself, there are many factors caused by the virus that have radically affected the experiences of students, such as hospitals not allowing students to be trained in major departments such as the emergency department due to the need for COVID-19 patient isolation. Most students said that excluding those departments from their plans will not affect their future as a nurse because it involves similar procedures undertaken in other departments. This finding was supported by Mollaog? lu M and Çelik P, who explained that nursing care in all clinical departments is very similar. Only one student reported concerns that she could not train in the Paediatric Department; her worries involved the importance of training in dealing with children during procedures (19).

Additionally, with all of the challenges faced by the COVID-19 outbreak, students had the chance to deeply understand the occupational status and morals of the profession. Changing hospitals frequently allowed the students to explore different working environments and explore different cases. Research by Galehdar N et al., stated that patients become attached to the nurses taking care of them, which makes nurses proud of their profession (20). Likewise, current results show that a variety of students have expressed that patients’ prayers and satisfaction after receiving treatments made them proud to be future nurses.

Limitation(s)

Firstly the results of this research represent an intern nursing perspective in only one city in Saudi Arabia; and secondly, this research aims to explore the student experience in the current situation, meaning that the results may change in the future with the crisis and the stakeholder responses.

Conclusion

This study explored the experience of Taif University nursing intern students during the COVID-19 pandemic in Saudi Arabia. Several factors affecting their experiences during the pandemic were highlighted. By reviewing how the nursing profession has been affected by many different diseases in the past few years, nursing education may consider what training nursing students should receive to deal with a health crisis. In addition, present study highlighted the impact of society’s opinion about the nursing profession on nursing staff and students. Therefore, the study suggests that it is important that nursing stakeholders collaborate with the media to create greater interaction and embrace the nursing profession for younger generations.

DOI and Others

DOI: 10.7860/JCDR/2022/57699.17041

Date of Submission: May 10, 2022
Date of Peer Review: Jun 21, 2022
Date of Acceptance: Aug 10, 2022
Date of Publishing: Oct 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 11, 2022
• Manual Googling: Aug 05, 2022
• iThenticate Software: Aug 08, 2022 (5%)

ETYMOLOGY: Author Origin