Health Education and Health Promotion

Nursing Students' Experiences of Role Transition in the Internship Program during the COVID-19 Pandemic

Document Type : Qualitative Research

Authors

S. Salarvand 1
M.S. Mousavi 2
Y. Pournia 3

1 Hepatitis Research Center, Faculty of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran

2 Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

3 Department of English Language, Faculty of Medicine, Lorestan University of Medical Sciences, Iran

Abstract
Aims: The internship course is an essential component of the nursing undergraduate program. This study was aimed to explore nursing students' experiences of role transition in the internship program during the COVID-19 pandemic.

Participant & Methods: This qualitative study was conducted on last semester’s nursing students practicing in an internship course during the COVID-19 pandemic at Lorestan University of Medical Sciences, Iran from February to June 2021. The internship BSc nursing students were selected by a purposive sampling that reached 12 students by achieving data saturation.

Findings: The findings included 5 categories of psychological challenges, unsuitable professional support and supervision, self-centeredness and independence, mandatory restrictions, and acquiring a professional identity.

Conclusion: The internship curriculum must be planned and supervised in a nursing education program by faculty authorities to prepare senior nursing students to enter the workplace, not only for their career retention but also for their actual growth/development in any workplace.

Keywords

Internship
Nursing students
Covid-19
Subjects
Introduction
Nurses are the largest group of health care workers (HCWs), who spend more time with patients than other HCWs [1]. Given nurses' leaving the profession due to emotional/physical burnout, the demand for this profession can be felt [2]. On the other hand, newly graduated nurses endure a lot of stress, called the “reality shock” which is still an issue [3], and feel disappointed, vulnerable, and stressed [4]. It facilitates their transition from student to membership in the profession smoothly [5]. Therefore, there is a demanding need to support nursing students to better equip them in their efforts for the workforce [2].
Undergraduate nursing students are expected to obtain necessary competency in practice skills, knowledge, values, and attitudes specific to the nursing profession during their clinical education experiences [6]. Clinical education has been addressed as a critical aspect of professional education by nursing students [6]. According to extensive evidence, the internship course is an essential known component of the nursing undergraduate program [7], and a type of work-based learning [8] also named “work-integrated learning” and “clinical clerkships” [9]. The nursing internship program aims to acquire competence in all emotional, cognitive and behavioral skills before graduating [10]. The baccalaureate (BSc) nursing students as nursing interns start the transition of their role from senior students to professional nurses during an internship training course [11]. Students can benefit from internship experiences by modifying their career goals and understanding their strengths and weaknesses [12]. Nursing students were allowed to do responsibilities and duties independently without faculty supervision and under the direct management of the head nurse or nursing staff [13]. Indeed, they perform daily duties as nurses working in the ward and prepare to become competent nurses in this period [14].
There is a variety of internship program frameworks between institutions [15, 16]. Recently, an internship program has been included in the nursing curriculum in Iran [17]. In our study, nursing interns are defined as students studying in the final semester before graduation, who have passed a 4-year bachelor’s program in nursing and are practicing as interns, over six days per week, morning shift, for one semester, during their senior year. They were being trained in different wards. Moreover, according to the command of nursing faculty administration, internship nursing students should not have been in COVID-19 wards. Also, the duration of this course has been increased to 4 weeks during the COVID-19 pandemic. These students have been vaccinated, as the first dose, at the same time, we interviewed them.
The clinical nursing environment is increasingly difficult today [18]. The coronavirus disease (COVID-19) pandemic has developed a social and worldwide health crisis directly affecting the healthcare system (HCS). Millions of HCWs have dealt directly with patients facing challenging medical conditions across the country. They are exposed to acute or chronic stress and have to meet many HCS needs along with physical and psychological challenges. There is a growing demand for qualified nurses to assist medical institutions in caring for patients with COVID-19 infection [19]. The HCS is experiencing a shortage of employed nurses due to insufficient recruitment of nurses, nurses being infected with COVID-19, and an increase in the workload. Therefore, the nursing profession has been changed and under pressure during the pandemic [20] and hospitals had to redesign their structure to meet clinical needs [21].
The internship has traditionally been seen as the work-based learning of professional skills [5]. Certainly, transiting from a student to a certified nurse can be exciting and challenging [22]. Under normal circumstances, nursing students experience their clinical practice to be partly stressful [23] and they are viewed as HCWs during the training [24]. Thus, it is a stressful experience for senior nursing students due to their increased responsibility and accountability [18].
As mentioned above, the internship program is a learning tool that helps nursing students in role transition from a student to a nurse [25]. Therefore, the internship course is designed to help them enter the workplace and act semi-independently. No qualitative studies have so far been conducted on intern nursing students’ experiences during the COVID-19 pandemic. One study has reported the internship program during the COVID-19 pandemic [26] with a theoretical reflective approach, but has not addressed intern nursing students’ experiences. Thus, questions arise over how senior nursing students pass their internship course in this pandemic crisis, what intern nursing students’ experiences are, and which aspects of these experiences are the most valuable [27]. Therefore, we selected the qualitative approach to deal with these questions. This study aimed to explore nursing students' experiences of role transition in the internship program during the COVID-19 pandemic. 

Participants & Methods
This qualitative study was conducted on last semester’s nursing students practicing in an internship course during the COVID-19 pandemic at Lorestan University of Medical Sciences, Iran from February to June 2021. The internship BSc nursing students were selected by a purposive sampling that reached 12 students by achieving data saturation.
The data were collected by an in-depth semi-structured virtual face-to-face interview with the undergraduate nursing students who had participated in the internship course.
The Ethics Committee of Lorestan University of Medical Sciences (LUMS) approved this study. Before the interviews, the informed consent forms were obtained from the participants electronically. We informed the participants that they could withdraw without any repercussions at any time. Anonymity and confidentiality were assured; the data contained no identifiers and were used anonymously in the final report. Only the main researchers had access to the data. Additionally, the participants were informed of the objectives and methods of the study, including the need to record interviews and their rights, including confidentiality of the information, anonymity, and the unconditional right to withdraw from the study. The interviews were conducted via WhatsApp (2020)  video chats lasting about 20 to 60 minutes individually. The participants’ voices were recorded by a voice recorder. Data collection was conducted through unstructured in-depth interviews in a secluded quiet environment and at a scheduled time at the participants' convenience. The primary research question in this study was “What are your experiences of internship course during the COVID-19 pandemic?” Probing questions were asked according to the participants' statements to get as much in-depth information as possible. The study topic guide /Questions asked in the interviews:
Please, describe your experience of the internship course during the COVID-19 pandemic;
Please, describe your experience providing care as a healthcare aid during the COVID-19 pandemic;
What were the positive aspects you found from this experience?
What were the negative aspects or barriers you found from this experience?
How did you manage your feelings and emotions during this experience?
Can you explain more?
The content analysis approach proposed by Graneheim & Lundman was applied to analyze the data [28] as follows: At the end of each interview, after transcribing verbatim, the researchers read each transcribed interview several times to understand the participants’ experiences and perceptions to identify meaningful units. Then, each meaningful unit was reduced to a condensed meaningful unit and the initial codes appeared. The first author carefully studied the original codes and categorized them according to the similarity of their concepts as subcategories. During this inductive
process, similar subcategories were classified into main categories. This coding process and the emergence of the main categories were reviewed and discussed by three authors. Finally, the created categories were observed as expressing the hidden content of the text. The extracted codes were referred to the participants and the findings were validated with their approval (member check). The researchers also referred the findings and extracted codes to a qualitative research expert who confirmed the validity of the research findings (peer check). The dependability of the findings was achieved by performing the data analysis process by more than one researcher. The researchers tried to put aside their personal experiences and preconceptions in their engagement with evolving the findings and data. Also, the researchers use the audit trail to establish the confirmability of the study by providing the data analysis details and some of the decisions leading to the findings, and also, transferability was ensured by providing a thick description to facilitate the transferability judgment, describing not only the participants’ behaviors and experiences but also the research context. The researchers tried to make reassurance that both the research conduct and evaluation are credible and genuine not only in terms of the participants' experiences but also about the wider social and political implications of the research.

Findings
The participants' mean age was 23.5±4.06 years. The findings included 5 categories and 20 subcategories (Table 1).
Psychological challenges
Some of the students stated that they had not been educated about the course regulations. They were not ready to start an internship course, resulting in stress for the student. They experienced psychological stress associated with workload and unfamiliarity. Other psychological challenges experienced by the students were contamination stress, being carrier stress, twofold stress, and concerns about procedural errors in the supervisor/instructor's absence.
Unsuitable professional support and supervision
The internship nursing students cited unsuitable professional support and supervision such as improper interaction of some nurses, lack of professional support from nurses/supervisors, imposing forced labor on students by nurses, and lack of proper supervision/curriculum of the internship process. The participants stated a lack of proper governance of the internship process due to high workload during the pandemic, definition of the framework and scope of authority, and lesson plan for the internship course by officials and planners.

Table 1) Categories and subcategories of the findings


Self-centeredness and independence
The internship-nursing students experienced self-centeredness and independence during the internship course and all cited this theme as a core concept. The students experienced independence and lack of reliance on the instructor as factors in increasing self-centeredness and self-reliance and developing problem-solving/management skills although this course plan was designed to create relative independence for students. The nurses did not provide educational support for the students due to their workload and nurses' shortage during the COVID-19 pandemic, and the students did the work independently. Most of the participants expressed satisfaction with the independence of their work and tried to do the clinical practicum carefully without the presence of an instructor. Other participants experienced being independent nurses. As mentioned above, the development of independence and problem-solving management skills makes the internship students practice the management styles in clinical affairs. Some of the students stated that due to nurses’ shortage during this pandemic, they practiced as the leading nursing staff instead of the supporter workforce in the ward. This sense of management, problem-solving ability, and coordination of affairs was a good experience for them. The participants stated that they tried alone to solve work challenges.
Mandatory restrictions
The participants experienced restrictions such as the difficulty of working with personal protective equipment and limitation in work due to the use of personal protective equipment and fear of COVID-19. The participants stated a decrease in the duration of clinical education and the removal of some COVID-19 wards from the internship course. Some of the participants were not satisfied to pass internship courses in non-COVID-19 wards. In contrast, other students desired to pass internships in non-COVID-19 departments. They said that allocating some departments to COVID-19 patients caused crowded non-COVID-19 departments, so there were a variety of cases, which were helpful for training and visiting different cases of patients. Most of the participants acknowledged that the internship students' duties were exclusively limited to clinical routine work and expressed dissatisfaction with the impossibility of experiencing all of the department's work. They stated that they had not been allowed to do the tasks such as writing nursing reports and accompanying a doctor to visit patients.
Acquiring a professional identity
Most of the students expressed the experience of the professional world tangibility and bridging the gap between theory and practice. They had observed and experienced the professional realities, workplace conflicts between nurses, nurses, and doctors, workload, etc. It led them to gain an overview of the nursing profession and move towards professionalism. The students experienced developing a network of professional communication with HCPs/patients and realizing the importance of these communications. This experience prepared them to enter the professional world and helped them to socialize in the profession. The students experienced understanding the workplace realities. The practice of administrative discipline during the internship and understanding the feeling of crisis in the hospital were other experiences expressed by the students during the COVID-19 pandemic. The students expressed the experience of developing a sense of community commitment/accountability and felt valued by the community. They experienced the acquisition of professional identity. Additionally, they stated the need to adjust to the present condition and described this course as the last opportunity to learn during their education.

Discussion
This study described the experience of nursing students undergoing internship courses during the COVID-19 pandemic. The students experienced psychological challenges for some reasons: fear of infection and of being a carrier for their families and friends. Other studies have shown that fear of infection and worry for family members is common to all students, and negative emotions, fear of infection, especially about family members, and uncertainty of what will happen caused more anxiety and stress [21, 29]
Additionally, the participants were concerned about low competency in doing ward work, lack of clinical instructor, and stress due to increased workload in this condition. Other studies have shown that transitioning from student to registered nurse can be challenging [3, 30]. Casafont showed that psychological support, follow-up, and orientation in critical situations are vital for inexperienced employees to overcome stressful feelings [21]. It seems that the students' concern was mostly related to the lack of educational support from the head or nurses of the ward due to the COVID-19 crisis. Gashaw concluded that students during the internship were facing many challenges due to a lack of adequate support and guidance [31].
The second category was unsuitable professional support and supervision including improper interaction of some nurses, lack of professional support from nurses/supervisors, imposing forced labor on students by nurses, and lack of proper supervision/curriculum of the internship process. Adel Mehraban showed that the students mostly cited a lack of proper communication between nursing staff and students [32]. Another goal of this course is that students should be accepted in scientific, practicum, and communication aspects by nurses. Therefore, nurses should consider internship students as their colleagues while it is not done in actual circumstances [33]. In our study, one issue reported by some students was the internship students' engagement to do routine tasks. Adel Mehraban's study confirmed this finding, reporting that these activities not only tire students but also prevent them from performing their main tasks, leading to not achieving the minimum learning [32]. A supportive clinical practicum environment must be created. Internship students should transient this step smoothly.
Some of the participants mentioned the lack of a specific curriculum and a specific lesson plan for the course. Other studies have confirmed it. McLachlan reported factors causing an increase in clinical training quality as a robust curriculum, focus on empowering workplace skills, opportunities to practice skills in a safe environment, feedback from mentors, and performance appraisal [34].
The nursing students experienced self-centeredness and independence during the internship. Lack of adequate supervision and nursing shortage were factors in increasing the students' self-centeredness and self-reliance. Other studies confirm that due to nursing shortage, newly qualified nurses often have to take on the responsibilities of experienced nurses early and with low support [22]. Additionally, the internship was a constructive course from most final-year students' viewpoints. They mentioned this period as a favorite due to improving self-confidence, learning, communicating with patients and others in HCS, gaining work independence, and feeling maturation [35].
Since nursing students work independently in this course, fostering their self-reliance, self-efficacy, and engagement with work causes the development of their self-efficacy and problem-solving management skills. They can practice affairs management. This issue was more tangible during the COVID-19 pandemic crisis, so students struggled to solve problems by themselves and feel self-efficacy, and this worthiness/efficiency feeling was enjoyable and valuable for them. Other studies have shown that internships enable students to foster critical thinking, communication skills, leadership, and decision-making in the real world [7, 17].
In our study, none of the participants stated defective self-efficacy due to COVID-induced stress. In contrast, Wang reported that acute stress, in response to the COVID-19 outbreak, can negatively affect professional identity and self-efficacy [19].
The participants experienced mandatory restrictions. They stated that having difficulty working with personal protective equipment or fear of COVID-19 caused some limitations for them. They desired to take an internship course in non-COVID-19 wards due to COVID-19 infection fear. The Association of American Medical Colleges has published guideline recommendations for students, working or elective courses, to limit “direct care of known or suspected COVID-19 infections.” [36]. The students in our study reported limitations in duration and number of wards during the COVID-19 pandemic and forced exclusively limited routine clinical practice. According to them, allocation of some wards to COVID-19 patients had made non-COVID departments crowded with a variety of cases, being helpful in terms of training and visiting different cases in those wards. Also, the internship students' duties were exclusively restricted to routine clinical work. They expressed dissatisfaction with this issue due to the impossibility of experiencing all the work of the department. We did not find any relevant studies in this field.
Most of the students experienced acquiring a professional identity. They stated the professional world tangibility and bridging the gap between theory and practice. Other studies confirm that internship provides an opportunity in the academic world; therefore, students integrate theoretical knowledge within the real-world environment [37, 38].
The students had experienced the professional realities and workplace conflicts between nurses, between nurses and doctors, workload, etc., which gave them an overview of the work of the department and the nursing profession and moving toward professionalism. Other studies confirm that the internship provides a unique opportunity for undergraduate students to learn career-related roles and tasks [39]. They obtain cognition of the profession, and actively enter the field, preparing themselves for acceptance and fulfillment of professional duties [35]. The participants experienced creating a network of professional communication with colleagues and patients and realizing the importance of these communications. It prepared them to enter the professional world and to socialize in the profession. Other studies confirm that the nursing internship course improves students’ self-esteem and communication skills [10, 40]. Seibert showed that students communicated with varied persons in their own or similar professions and developed professional work relationships during the internship course. These contacts, in transition toward the workforce, are invaluable [12].
The participants experienced developing a sense of community commitment and accountability.
Lovrić’s study cited that during the crisis, most of the students became aware of their responsibility to the community and recognized the true significance and risks of nursing [29]. They were very proud to have been actively involved in the COVID-19 crisis [21].
Other experiences shared by the participants included seeing and understanding the workplace realities, needing to adapt and practice administrative discipline, and understanding the sense of crisis in the hospital during the internship. The students stated the need to adjust and practice administrative discipline. Other studies showed that an internship course is a valuable opportunity for students’ adjustment to clinical situations and their preparation for becoming certified nurses [4, 41]. Practicing professionalism to gain responsibility, professional commitment, a humanistic view of the client, and gaining a professional role and identity should be among the other achievements of the internship [35]. The participants faced a crisis in the hospital due to nurse shortage and an increase in the number of patients. Therefore, they had to work as an alternative workforce in the hospital. Galvin showed that during the COVID-19 pandemic crisis, retired nurses and undergraduate students became part of the workforce in the UK [42].
The participants noted the importance of the internship course as the final opportunity for clinical practicum learning in their academic period. Other studies confirm that internship as the pre-graduation final clinical practicum is the last opportunity for nursing students to prepare for the upcoming transition and work-life [43].
We selected nursing internship students from one medical university, and it was a limitation of the study. Nursing students' views on professional values will affect their approach to applying professional values in their upcoming nursing profession. The high quality of the internship course can reduce the anxiety of newly graduated nurses upon entering the workplace and increase professional trust in their retention in the profession. The internship curriculum must be planned and supervised in the BSc nursing education program by faculty authorities to prepare senior nursing students to enter the workplace, not only for their career retention but also for their actual growth in any workplace.

Conclusion
The internship students expressed their need for psychological and practical training support while working in the COVID-19 crisis. In the COVID-19 crisis, educational goals were not addressed and the students did not take enough support, which had some benefits. It had led to their independence and self-efficacy but was not pleasant for some students.

Acknowledgment: We appreciate the research vice-chancellor of Lorestan University of medical sciences and the dear participants who help us.
Ethical Permissions: The research vice-chancellor of Lorestan University of medical sciences approved this research (IR.LUMS.REC.1391.1346). Therefore, we hereby confirm that all the study procedures were performed under the relevant ethical guidelines and regulations.
Conflicts of Interests: -
Authors’ Contribution: Salarvand S (First Author), Introduction Writer/Methodologist/Main Researcher/Data Analyst (60%); Mousavi MS (Second Author),  Assistant Researcher/Data Analyst/Discussion Writer (30%); Pournia Y. (Third Author), Introduction Writer/Assistant Researcher/Discussion Writer (10%)
Funding/Support: The research vice-chancellor of Lorestan University of medical sciences was financially supporting this research.
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Health Education and Health Promotion
Volume 10, Issue 1
Winter 2022
Pages 137-144