Clinical Practice of Nursing Students in South Korea with COVID-19: A Qualitative Study

1. Introduction

The coronavirus disease-2019 (COVID-19) is an emerging respiratory infectious disease and has been spreading worldwide [1].

Community treatment centers (CTCs) temporarily operated in South Korea were non-hospital settings for with medical oversight for mild or asymptomatic COVID-19 patients during isolation, and often established in repurposed facilities such as training centers, dormitories, or public buildings since 2020[2]. The Korean government decided to send nursing students to replenish the lack of nursing staff on CTCs. The nursing activities on CTC fields of nursing students was to be displaced as a part of the nursing clinical practice. The ICN reported that it is desirable to cultivate disaster nursing competencies at bachelor’s degree courses [3]. Many nursing schools have been provided a disaster education in Korea [4]. But, experiencing disaster scenes actually as nursing students is a challenge.

Qualitative studies on nurses’ experiences with COVID-19 patients reported that nurses experience significant mental and psychological stress [5,6,7,8,9,10,11]. A few studies on the experiences of nursing students who participated in disaster scenes for COVID-19 as aids, clinical support workers or students in hospitals have been conducted [12,13,14,15]. There was an empirical study conducted on nursing students on the degree of disaster preparation education [16]. Studies on CTCs in Korea have been conducted on doctors and patients [17,18]. However, the experiences of nursing students in CTCs not a hospital as clinical practice in South Korea have not been reported.

Colaizzi’s (1978) [19] phenomenological research method focuses on deriving the common attributes of all participants rather than individual attributes [19]. In this study, Colaizzi’s (1978) [19] phenomenological research method is needed and appropriate to confirm the common attributes of student nurses who have experienced clinical practice in the disaster nursing field. The purpose of this study is to deeply explore the experiences undeniably valuable and unique of nursing students and understand their actual emotions, challenges, and thought processes with their point of view in disaster fields. These data can serve as a basis for establishing national policies in nursing education.

2. Materials and Methods

2.1. Study Design

This study was designed as a qualitative study and applied Colaizzi’s (1978) descriptive phenomenology to understand the clinical practice experience of nursing students in the CTCs, and COVID-19 pandemic in South Korea.

2.2. Context and Setting

In Korea, there was a shortage of nursing personnel to care for patients due to the Covid-19 pandemic in 2021, and nursing students were unable to even practice. Korean government considered replacing some of the insufficient nursing personnel with nursing students want to participate in CTCs as a clinical practice based on Medical Service Act of South Korea [20]. Medical Service Act states that healthcare services can be performed by nursing student under the guidance and supervision of medical personnel during national disaster situations. The Korean government held a meeting with the heads of nursing colleges. There was one nursing school that responded to the Korean government’s proposal. Nursing students and their parents of the school that accepted the government’s proposal have been explained the necessity of dispatch to CTCs and provided a Q&A session, given the choice of location and timing among the five CTCs, then dispatched in the order of volunteering. Korean nursing colleges are supervised by Korean Accreditation Board of Nursing Education to carry out more than 1,000 hours of practice as a four-year curriculum [21]. The participants were completed the second semester of their third year, including courses “Disaster Emergency Nursing Training”, clinical practices over 500 hours. Before starting the practice at CTCs, the professors conducted a two-day preparatory education using of Personal Protective Equipment (PPE), sharing experiences with nurses working at a CTC. During the clinical practice, the students assisted medical team and managed the patients in person or telemedicine 8 hours a day, 5 days a week for 3–4 weeks. The student strictly followed the lifestyle guidelines set by the medical staff. The practice was conducted according to the three-shift work schedule, as that for nurses.

2.3. Participants

The participants were recruited using the purposive sampling technique. Nursing students who underwent 3 to 4 weeks of clinical practice at a COVID-19 CTC were recruited. Hard copies were posted on the school’s student bulletin board for 4 weeks, and soft copies were notified through online. The contents of the post included the purpose of the study and the timing of the study, the research method (interview type and time required), the name and contact information of the chief researcher, the confidentiality of the participants, and the use of expected research results. The total number of clinical practice experiences in CTCs was 77, of which 10 were applicants. Participants applied directly to the professor or contacted them via email or mobile phone handled by chief researcher scheduled an interview with those willing to participate. Interview Participants were recruited until data saturation was achieved and no additional essential themes or structures were emerging from subsequent interviews. Students informed the research director that they could express that they could withdrawal participating at any time, and revealed that there were no disadvantages, and that students’ names and affiliations were anonymized. Participants were not given benefits or disadvantages for participation.

2.4. Data Collection

Data were collected by a semi-structured interview (Table 1).

The preliminary questionnaire was prepared by a research team gathering and sharing the experiences and knowledge of the researchers. Interview protocol tested at two induction meetings and using 1 pilot interviews. Two researchers with expertise who were not affiliated with the institution where the participants belonged were conducted semi-structured individual interviews via a videoconferencing (Zoom). Interviewers explained the study and sought informed consent, explaining that participants could stop the interview at any time. All interviews were conducted in Korean, recorded using Zoom transcription. Interviews were undertaken February 2022 and last between 45 and 75 minutes. Four to five interviews per week were conducted per day. After each interview, the interviewer made field notes. The researchers asked interviewers to send all the field notes to the research office for analysis and storage. The researchers had regular debriefing sessions one time per week between members of the 3 different institutions.

2.5. Rigor

To ensure the quality of our qualitative research, we followed Lincoln and Guba’s (1985) trustworthiness criteria [22]: (1) credibility: the interviews were recorded, and the transcripts of the interview and analysis results were shared with participants to confirm that the experiences were similar; (2) transferability: we recruited participants who could share vivid experiences and rich statements and collected data until data saturation; (3) dependability: To minimize differences in opinions between the researchers, the data were analyzed and abstracted, and after each interview, we checked the points to be asked and cautions to be mindful of in the next interview; (4) confirmability: we aimed to extend confidence that the results would be confirmed or corroborated by other researchers. We met on Zoom, tried to minimize the effect of our biases by making notes of our understanding, and thoughts about the research and compared the notes during the analysis process.

2.6. Data Analysis

Audio-recordings were transcribed by online application using Zoom. Completed transcription were cross-checked against the recording to ensure accuracy.

All five researchers participated in the data analysis. Three researchers affiliated to same institution as the study participants cross-checked for transcription accuracy (to avoid bias in the researcher’s interpretation). For data analysis, Colaizzi’s seven-step data analysis method (Colaizzi, 1978) was applied: (1) Obtaining a general sense of each Transcript: The contents of each interview were transcribed and should read repeatedly in order to clearly understanding the content. (2) Significant statements were extracted: As per Colaizzi (1978), the researcher read and reread the transcript and analyzed each transcript to identify significant statements from the transcript. These statements were written separately for each participant and coded as transcript page number and line number. (3) Formulation of meanings: In this step, Colaizzi (1978) recommends that the researcher attempts to formulate more general restatements or meanings for each significant statement from the text. Meanings were formulated and discussed with the same peer group member. (4) Organization of formulated meanings in to clusters of themes and themes: Organized meanings were divided into sub-themes and themes. After obtaining formulated meanings from significant statements, the researcher arranged them into clusters of themes. These clusters of themes and the final themes were then given to the peer group member as well as to the expert researcher for checking its accuracy. (5) Exhaustively describing the Phenomenon: The sub-themes and themes were integrated into an exhaustive description. the researcher integrates all the resulting ideas into an exhaustive description of the phenomenon. (6) Describing the fundamental structure of the phenomenon: In this step, findings were reduced to avoid repetitions and to make a clear and concise description of phenomenon. (7) Returning to the Participants to validate the findings from the study participants: This step aimed to validate study findings using “member checking”.

3. Results

3.1. Participants Characteristics

The characteristics of participants are as follows (Table 2).

3.2. Emerging Themes

4 themes and 16 sub-themes related to the participant’s clinical practice experiences at the CTCs were identified (Table 3).

Theme 1: Transformative growth through immersive clinical practice in quarantine

Participants described navigating nursing in a non-contact environment, stepping into the heart of infectious disease response, bearing the emotional weight of quarantine care, finding myself and growing to another level, and discovering professional identity through crisis as transformative growth through immersive clinical practice in quarantine.

Subtheme 1.1. Navigating nursing in a non-contact environment

The participants met the patients through a glass wall at the CTCs, where non-face-to-face treatment was performed. Vital sign measurement, practiced by nursing students, was not carried out directly, but the results recorded by the patients were indirectly checked from the phone or an App. Protective clothing had to be worn when facing the patients directly: “Since I couldn’t contact the patients for their vital signs, I called them by phone. So, I got to know their blood pressure and body temperature, etc., and there was a thing like registering on an app, but if patients were not registered, I called them individually, and at that time, here at CTC A, it was blocked” (P2)

Subtheme 1.2. Stepping into the heart of infectious disease response

The participants stated that they felt as if they were dispatched to a disaster site even though it was a clinical practice and expressed that they were able to experience the real situation of disaster response while checking the national quarantine measures and the health authorities’ response to the emerging infectious disease at the site: “I think I have learned a lot more meaningfully because I have studied a lot about the systematic aspects of the quarantine measures and how the health authorities were responding in such a disaster situation” (P1)

Subtheme 1.3. Bearing the emotional weight of quarantine care

The participants felt various emotions in their interactions with the patients, such as anger, gratitude, resent, or absurdity. Some patients expressed their gratitude to the students for coming to the CTC, and dissatisfaction with the restrictions on autonomy due to the isolation. The participants were baffled or felt hurt not to resolve the patient’s demands: “Some people asked to provide them a chocolate pie right now because they cannot get out the room. It was a little difficult and baffling to deal with people who make such requests that we could not fulfil” (P3)

Subtheme 1.4. Finding myself and growing to another level

The participants stated that the clinical practice at the CTC was rewarding and valuable. In particular, the participants said that although it was a bit risky to care for patients with confirmed COVID-19, the special experience gave them confidence that they could handle anything in the future with a positive attitude: “If you do anything well now, you can do it well later as well. I think I have received a really good education, and based on that, I gained confidence that I would be able to do well anywhere in practice” (P4)

Subtheme 1.5. Discovering professional identity through crisis

In contrast to the existing clinical practice that ends only with observation, at the CTC, the participants met the patients, even though not face-to-face, and sometimes participated in the same tasks as the nurses did, expressing that the participants were more proactive and responsible for this practice. In addition, for the first time, they worked three shifts, including night, and could imagine their future life as a nurse. Therefore, they performed similar tasks with the same work schedule as a nurse, expressing that they were students but felt like they had become nurses: “As a student doing the same work the nurses did, I thought that I would work like this when I become a nurse. Like a little practice? It was a new experience” (P8)

Theme 2: Enduring and adapting: living through uncertainty and emotional turmoil in quarantine practice

Participants described overwhelmed by the threat of infection, living under double restrictions; anxiety in the face of uncertainty, finding moments of relief and connection, and finding myself getting used to it as enduring and adapting: living through uncertainty and emotional turmoil in quarantine practice.

Subtheme 2.1. Overwhelmed by the threat of infection

The participants experienced anxiety and fear of becoming infected while practicing at a CTC with a new infectious disease for which the treatment is not yet known. To avoid infection, they reported that they avoided direct contact with the patients as much as possible or would make sure to wear protective. One participant reported that she/he was too nervous and fainted while caring for a patient in protective clothing: “Actually, when I first put on Level D protective clothing and went in, the goggle was squeezing my eyes too hard, and the mask was very tight, resulting in a lack of oxygen. I had a strong will to not get infected with COVID-19. There were many heaters in the room, and I stood in front of the heater for a while. So, on the first day, 30–40 minutes after I put on PPE, I fainted” (P5)

Subtheme 2.2. Living under double restrictions as students and medical workers

The participants experienced double restrictions because of the guidelines to be followed as a CTC worker and their role as a nursing student. As a staff, even taking a walk was not allowed due to concerns about overlapping contact tracing with confirmed patients in some CTCs. The CTC clinical practice took place at the end of the year, so participants saw a dense crowd through the media at Christmas. The participants expressed their frustration and a relative sense of deprivation of having to isolate themselves from society with sick patients, even though they were students: “We were still working here, and the situation outside didn’t seem to be getting any better, and I was seeing my friends from other schools playing and doing so well through social media; I remember feeling a little upset when photos of the current situation of Lotte World (an indoor amusement park) were published” (P5)

Subtheme 2.3. Anxiety in the face of uncertainty

As for the sudden decision to be placed in the CTCs, no one gave the participants specific information about the duration and type of work they would do in the center, resulting in them experiencing anxiety amid uncertainty: “No one told me where the end was. How long do I have to do this, and how long do I have to live this life? It was so confusing in the middle” (P2)

Subtheme 2.4. Finding moments of relief and connection

The participants overcame the stress of life restrictions and uncertain dispatch situations in various ways. Some participants found comfort by talking with their roommates or classmates and doing small daily activities such as birthday parties, reading, and enjoying the natural environment. In addition, they received strength from the support of family, friends, professors, CTC’s staff, and their seniors/juniors as well as material support from various institutions: “Because we were locked up and the room was so small, it’s a little tiring. I was quite tired because I was mentally and physically less active than usual. But at that time, it snowed, so I went downstairs and made a small snowman, watched the snow, stepped on it, so it was really fun” (P9)

Subtheme 2.5. Finding myself getting used to it

At the CTC, which started with anxiety and vague emotions at first, the participants expressed that their work became easy and that they found themselves gradually adapting to it. Some participants expressed that they were afraid at first, but when they came to the field, they wanted to be helpful and to do well: “We also had some fearful feelings, but after being put on the scene, we had a little fiery emotion” (P4)

Theme 3: Reconciling vulnerability and responsibility: embracing a professional role amid crisis

Participants described torn between anxiety and anticipation, burdened by inexperience and external judgment, embracing the call with a sense of purpose as reconciling vulnerability and responsibility: embracing a professional role amid crisis.

Subtheme 3.1. Torn between anxiety and anticipation

The participants told that one of their colleagues confessed fear and stress, anger as they heard rumors that clinical practice would be changed hospitals to CTCs due to COVID-19. However, some participants expected to be placed to national crisis response sites where they would participate as students rather than as nurses: “I think I was worried because it was my first experience and there was no one who had experienced it before. But, if you had to go anyway, wouldn’t it be better just to go and experience it? A situation like this will come again in the future, so it will definitely be helpful” (P2)

Subtheme 3.2. Burdened by inexperience and external judgment

The participants expressed that they were not prepared because they were students and that they did not know much, so they felt that they would become a burden at the practice site. Concerns from parents and the media about the dispatch of students without a nursing license to an emergency site for which the treatment was not known led to burdens: “I was a little worried that I might cause problems there because I was not yet a medical professional and that I would be a burden to them despite being sent there to help” (P3)

Subtheme 3.3. Embracing the call with a sense of purpose

Although the participants were anxious right after the decision to dispatch students to the scene was made, they expressed that they accepted the order with pride in the disaster nursing education, the confidence gained from the preparatory education provided, and the sense of duty when the country needs them: “If I were just a nursing student at a private university, I wouldn’t have been able to do it. I thought it was a special experience because I was a third-year student at the ‘REDACTED’ and was able to participate in it” (p10)

Theme 4. Validation and pride: becoming visible as future nurses in a national crisis

Participants described recognition from nurses as peers in real practice, public recognition and collective honor, gratitude for a chance to fulfil a calling as validation and pride: becoming visible as future nurses in a national crisis.

Subtheme 4.1. Recognition from nurses as peers in real practice

The participants felt proud to see a nurse who respected them as a nurse, and not just as a student in clinical practice: “We were in a position of contributing something that nursing workers could check directly and easily, and the fact that our time was very valuable to them made our work more meaningful than just practice” (P1)

Subtheme 4.2. Public recognition and collective honor

The participants appreciated the social recognition they gained during the clinical practice at the CTCs. The participants felt proud of positive reports in the media about their contribution as students and being recognized as the only students to be dispatched to disaster sites. In addition, although the dispatch was conducted as a clinic practice, they received special duty allowance: “It seems to have become a title that is always attached to our class. We would have better coping abilities than other classes and would be able to communicate well at work. Well, of course, it’s a compliment, so it seems to be the pride of our class” (P10)

Subtheme 4.3. Gratitude for a chance to fulfil a calling

The participants were grateful that they could contribute to resolving the national crisis. A participant expressed gratitude for the fact that this practice came as an opportunity to participate in solving social problems: “The reason I first decided that I wanted to become a nursing professional was that I wanted to help others. So, the fact that I had the opportunity to do something that can help others came to me as a big opportunity that I am grateful for” (P7)

4. Discussion

The first theme observed was “Transformative growth through immersive clinical practice in quarantine”. Similar to previous studies that assigned positive meaning to nursing activities in special situations [14,15], the participants found that they were growing to the next level and they could imagine their future as nurses. Meanwhile, participants used to be engulfed in ethical conflicts when caring for isolated patients without decision-making authority. Therefore, it is necessary to develop program to deal with ethics conflicts in disaster.

The second theme, “Enduring and adapting: living through uncertainty and emotional turmoil in quarantine practice”, shows that the participants experienced stress from not only the fear and anxiety about contacting COVID-19 but also the restrictions on life and uncertainty and found themselves gradually adapting to this stress. Many studies have highlighted the anxiety and fear that nurses and nursing students experience in the face of emerging infectious diseases [9,10,11,14,15,23]. But, we found that the participants relieved their stress by having conversations and leisure time with the other students. Considering the results, it would be beneficial to send as a team rather than alone to disaster fields. Considering the psychological anxiety of participants, it is necessary to consider the ethical issue of limiting the autonomy of the CTC itself. Previous study said that consideration is needed to find an appropriate and stable balance point between autonomy and restriction of autonomy, not a concept of confrontational choice [24]. Nevertheless, it is meaningful to understand the situation of nursing students who were restricted in autonomy in CTC through this study.

The third theme, “Reconciling vulnerability and responsibility: embracing a professional role amid crisis”, reflects the ambivalent feelings experienced by the participants in the process of deciding on the practice at the CTCs. This result is similar to the study reported that a nursing student or nursing officer had a feeling ambivalent and adapted in the COVID-19 scenes [13,23]. It should be considered that they accepted the clinical practice with a sense of duty as a student, despite of not a nurse. There is an intrinsic reward in being a nurse that for some is linked to the notion of nursing as a vocation or a calling, and many students describe this as a key driver in their choice of career [25,26]. An understanding of the reasons and context in which participants responded to their calling will be helpful to prepare for future disasters.

The last theme, “Validation and pride: becoming visible as future nurses in a national crisis”, indicates that the participants felt proud because they had the opportunity to receive recognition from the nurses and civilians. The theme of recognition from nurses and society has not been commonly reported in clinical practice experiences of nursing students. Studies have stated that nursing students are marginalized, often remaining passive observers [27,28]. Considering that the supportive attitude of nurses in the clinical practice of nursing students is promoting deep learning [29,30], it seems that the participants’ practice at the CTCs was resulting in a fairly positive experience for them.

Limitations of this study include that the data were collected within the initial month after CTC operating. Therefore, this study presents insights into the experiences of the early situations in which the CTC began to operate. In particular, among the five CTCs where the clinical practice was performed, the students from only four CTCs were included, so the specificity of all the CTCs were not reflected. And this study used purposive sampling and analyzed the experiences of nursing students at CTCs, so the results cannot be generalized.

5. Conclusions

The participants of this study accepted this practice of CTCs as an opportunity to overcome the given situation and prepare for their role as a nurse. However, as noted from the study results, the students faced many adverse factors such as stress, uncertainty, and insecurity about emerging infectious diseases at the disaster sites. More disasters will occur in the future, and COVID-19 may continue to spread or another variant may emerge. In a disaster situation, not only psychological and physical difficulties but also ethical concerns due to extreme situations can be aggravated. For nursing students who are deployed to disaster sites, it is necessary to strengthen medical ethics education that can reduce anguish in ethical conflict situations. Accurate protocols and guidelines should be provided for nursing students to deal with facing issues in disaster situation. Finding can also inform future nursing education policymaking and be used to establish a preparatory education program for them.