Perceptions of senior nursing students on how the COVID-19 pandemic influenced their clinical practice in the Northwest Province, South Africa: a qualitative study

Abstract

Objective

To explore and describe senior nursing students’ perspectives on clinical practice during COVID-19 and provide the most up-to-date information on the quality of clinical experience for nursing students in relation to nursing practice, nursing education, and nursing research.

Design

The research design that was employed is a qualitative, explorative, descriptive in order to explore and describe nursing students’ perceptions of clinical, training during the COVID-19 pandemic.

Setting

The study took place in a local university located in the Northwest province, South Africa.

Participants

The population consisted of 16 senior nursing students who had been exposed to clinical practice during the COVID-19 pandemic. There were 14 women and 2 men. Study included full-time, registered undergraduate nursing students who enrolled in 2019. All nursing students who did not engage in clinical practice before or during COVID-19 were exempt.

Interventions

There were no direct interventions in this study; however, few recommendations were made for each of the themes that emerged in this study.

Primary and secondary outcome measures

The researchers’ aim with the study was to find out the nursing students’ perspective on clinical training during a global pandemic, through interviews and focus group discussions. The researcher did in fact receive such feedback from the participants.

Results

Four major themes emerged: (1) the lack of preceptors to facilitate clinical teaching; (2) not allowed to work in COVID-19 wards; (3) difficulties with online classes and tests and (4) poor communication.

Conclusion

The COVID-19 pandemic influenced how students viewed and experienced clinical training, which in turn had an impact on their learning experiences. These effects also had some impact on their experiences and decisions to continue working as professional nurses.

Correspondence to Sofia Fatima Filomena Apolinario; [email protected]

Strengths and limitations of this study

• One of the strengths of the study is that an explorative-descriptive approach was taken.

• A second strength is that qualitative data were obtained from participants who were directly affected by the COVID-19 during clinical training.

• A limitation is that the COVID-19 pandemic did not allow for large group discussions due to the COVID-19 protocol on mass gatherings.

• Another limitation is that the study findings were derived from 16 participants in in-depth individual interviews and one focus group discussion at the North-West University in the Northwest Province of South Africa, using a qualitative, explorative and descriptive approach that, therefore cannot be generalised to other settings. However, the study’s objectives were met in this study.

Introduction

Nursing education is one of many courses that focuses not only on theoretical work but also on practical and clinical training. The nursing clinical environment has been a topic of many discussions over the years. A meaningful experience in the clinical environment is very important and plays a very huge role in a nursing student’s professional development into a registered nurse for the future.¹ Clinical training and practice are a fundamental part of nursing education because exposure to different clinical environments allows students to gain experience and confidence in different disciplines before they officially start off as professional nurses.² A student’s perception of the clinical facility always depends on the facilities’ environment and atmosphere, when students experience negative exposure in a specific environment it acts as an added stress and anxiety.³ Such negative experiences tend to have an effect on the students’ perceptions in these specific environments, which in turn declines the learning experience of the student. In March of 2019, COVID-19 was declared a pandemic by the WHO.⁴ Nursing education became abruptly interrupted as this disease affected nearly all the clinical facilities where training took place putting nursing students at risk. Several policies were adopted to control and limit the spread of the COVID-19 disease, this included wearing of masks and full protective personal equipment when handling patients, social distancing and decreased time spent on patient care to avoid overexposure to the disease.⁵ It is quite evident that this change to the clinical environment would have had an impact on the nursing students’ views on clinical training. Studies show that students enjoy patient engagement and physical care when it comes to clinical training, but due to the COVID-19 restrictions, this has since changed, leaving an empty almost negative impact on students as they feel that they are not getting the full experience they need for optimal clinical learning.⁶ The pandemic has put such a strain on clinical facilities causing many health professionals especially nurses to resign or seek early retirement leading to a shortage of staff. This shortage has left students filling the gaps and playing the role of the professional nurse with little to no guidance. This sudden change in their roles as student nurses has increased the student’s anxiety and stress further influencing how they view the clinical environment.⁷ On the other hand, some other students saw the pandemic as a learning opportunity as they were eager to learn new things.⁶ Whether positive or negative, it is clear that there is in fact an impact on students’ views and perceptions when it pertains to clinical training during the COVID-19.

Materials and methods

Study design

Qualitative methods were chosen for this study to enable a deep exploration of the participants’ perceptions on their clinical training experience during the COVID-19 pandemic. The study took an explorative approach as it was ideal in tackling the desired research problem. Through in-depth interviews and a focus group discussion, a clear understanding of the views, opinions and experiences of the senior nursing students was acquired. This study investigated the insightful experiences of student nurses and their understanding of their clinical situation during the COVID-19 pandemic.

Data collection

Individual interviews were conducted online via Zoom. A link was shared with the participants beforehand to participate in the scheduled online interviews. The researcher ensured that they were in a closed and private room with their earphones onto ensure privacy. The participants were also encouraged to ensure that they were in a quiet and private room. The focus group discussion was held at a local university in the Northwest Province of South Africa, with the School of Nursing Sciences on campus serving as the study’s primary focus.

The focus group session was held in a cool, well-ventilated seminar room on the Local University’s library grounds. All COVID-19 protocols were adhered to for the contact session.

Population and sampling

The study population consisted of 16 senior nursing students who have been exposed to clinical practice during the COVID-19 pandemic in Northwest Province, South Africa. All of the participants began their nursing programme in 2019 and graduate in 2023. Purposive sampling was used to sample the participants in this study. This sampling method was ideal as it allowed the researcher to hand-pick participants who had experience with and knowledge of the phenomenon under study.⁷ Inclusion criteria consisted of nursing students who began their nursing programme in 2019 and graduated in 2023. This specific sample was ideal as the students had a lot of experiences to share from being in clinical practice prior to the COVID-19 pandemic and were better able to explain how clinical practice was different during the COVID-19 pandemic compared with previous years before the pandemic. All nursing students who did not engage in clinical practice before or during COVID-19 were exempt from the study as they did not have adequate knowledge on the phenomenon at hand.

Time frame

Data were collected from 9 September through 28 September 2022. Study was concluded in May of 2023.

Data analysis

Data analysis is a complex, methodical, ordered and structured process that is frequent in nature.⁸ Data analysis was done on the transcriptions of the in-depth interviews, recorded Zoom meetings, report and notes from focus groups as well. The researcher had an independent cocoder for further data analysis. A meeting was held with the cocoder to reach consensus on the analysed data and the themes that were formulated. There are various methods for analysing data; for this study, the Tesch’s eight-step method was used.⁸

Step 1: All the gathered data were read through and thoroughly, we made sense of the information gathered and attached notes to them.

Step 2: Notes made during the interviews and focus group discussions were transcribed and typed into work sheets for appropriate organisation and preparation of the data. The recordings and typed notes were sorted and organised according to the information sources.

Step 3: After sorting out the gathered information, the data were carefully read to develop a general sense of the overall information. Notes and thoughts about the data were also neatly written, and some were typed into Word documents.

Step 4: The data were coded. A qualified professional coded the data to avoid data mix-ups.

Step 5: The codes generated were used to identify and establish the themes and subthemes.

Step 6: The cases were organised around the established themes and subthemes.

Step 7: Visuals, figures and tables to best represent the findings.

Step 8: An interpretation of the meaning of the data is established in the eighth and final step.

Methodological limitations

There are many factors that could affect the studies’ validity and dependability if not addressed clearly. Credibility, confirmability, dependability and transferability were ensured to minimise and avoid these effects.

Credibility

Credibility was ensured by allowing independent researchers to contact students prior to interviews and focus group sessions to obtain informed consent and explain to the students their role in the study. In order for the participants to provide clear and relevant information throughout the interviews, the independent researcher answered any queries or questions they had.

Confirmability

Confirmability was ensured by voice recordings in order to ensure what was said during the interviews and focus groups. The recordings were also transcribed and shared with the cocoder for analysis, which was ensured by careful auditing. The cocoders also ensured that there were no errors duplication of findings that could jeopardise the study’s credibility.

Dependability

An audit trail and careful documentation ensured dependability in this study. The steps for how data were collected, recorded, and analysed were explicitly detailed, allowing independent researchers to draw the same conclusions from the study’s data.

Transferability

Transferability was ensured in this study by providing detailed, contextualised descriptions of the research findings and research contexts that were applicable to other situations.

Patient and public involvement

None

Results

The following themes were identified in this study: (1) absence of facilitators to facilitate clinical teaching; (2) not being allowed to work in COVID-19 wards; (3) online classes and tests pose challenges and (4) poor communication, as illustrated on the table below.

The findings of the study are described according to table 1 above, and direct quotations from the individual interviews are presented in italics. There were four major themes that emerged: (1) the lack of preceptors to facilitate clinical teaching; (2) not being allowed to work in COVID-19 wards; (3) difficulties with online classes and tests and (4) poor communication. Accordingly, each theme and subtheme were discussed.

Table 1

Table of themes and subthemes established in the study

Theme	Subthemes
1. Absence of preceptors to facilitate clinical teaching	Lack of clinical experience Lack of emotional support No learning opportunities for students
2. Not allowed to work in COVID-19 wards	Fear of contracting the COVID-19 infection Students wanted to experience working with COVID-19 patients Only simulation laboratory training was allowed Patient care was affected
3. Online classes and tests pose challenges	Difficulty adjusting to online classes and tests Watched videos even for practical skills
4. Poor communication	Hospitals were not informed that students should not work in COVID-19 wards

Theme 1: absence of preceptors to facilitate clinical teaching

The absence of preceptors to facilitate clinical teaching emerged as a first theme, with the following subthemes: (1) lack of clinical experience; (2) lack of emotional support and (3) no learning opportunities for students. Participants stated that the purpose of being assigned to clinical practice was to apply theory to practice. They saw clinical practice as putting what they had learnt in class into practice, and they discussed how the COVID-19 pandemic changed aspects of clinical training.

Subtheme 1.1: lack of clinical experience

The COVID-19 pandemic had a significant impact on the healthcare industry and healthcare education.⁴ Nursing education facilities implemented restrictions on students in order to reduce the risk of COVID-19 transmission. Participants expressed that they could have been allowed to work in the COVID-19 ward, so that they could gain more experience. This was echoed as follows:

I feel like we could have learned a lot if they had just allowed us to take part and continue with practice safely, and like I mentioned, we were away for a long time, and I understand that they were trying to protect us, but it just made it worse for me personally because now we had so many hours that we had to catch up on, and it just felt like it was a lot for us, so maybe if they didn't try to overly protect us, we could have gained more from the pandemic in terms of experience—(PC).

Another participant expressed the following:

yes I feel like I would have liked the opportunity to experience what it is like to come into contact with COVID-19 patients or maybe at least just have like an extra module or an extra class that just explains in depth what the pandemic is exactly, what COVID is how to handle COVID and then maybe have like one or two or three practical sessions in real life where we can see COVID patients and deal with them— (PA).

Participants felt they lacked clinical experience due to a lack of allocation during the COVID-19 period, and that they had been away from clinical placement for an extended period of time. In addition, they raised the concern that they were lacking in clinical hours and exposure. One of the main features of nursing is integrating theory to practice, which makes clinical training and experience an important component of nursing education because clinical experiences prepare and stimulate students’ critical thinking and problem-solving skills.⁹ In this study, however, although students identified learning opportunities in clinical practice, the absence of clinical preceptors to facilitate clinical teaching in COVID-19 wards deprived them of learning clinical skills that would have equipped them to care for patients with COVID-19.

Subtheme 1.2: lack of emotional support for students

The difficulties that nursing students encountered in clinical practice during the COVID-19 pandemic have been mentioned several times in this study. In addition to restrictions on clinical experience, nursing students also had to deal with the emotional impact that came with their experience. Participants wished that preceptors could have been there for them to support them emotionally, as everyone was stressed out. The lack of emotional support was highlighted as follows by a few participants in the study:

I would also feel like they should have been personally there for me, maybe with better emotional support, because most of the preceptors really didn’t come into practice to check in on us and how we were doing with certain procedures; they would just came to do attendance and they would see us in the simulation lab, and I felt like it wasn’t really the same as doing it in person practically with the physical human being over there. I also felt that yes, maybe if they were there with us a lot during this time, we wouldn’t feel so stressed and overwhelmed, and maybe it would have been a better experience for me personally—(PC).

Another participant stated:

We were scared first because this is an unknown illness, then there were a lot of patients in the ICU who died, and there were a lot of things going on at the same time, and nobody took the time to just check, like, are the students okay because they are not all adults, some of them are just young adults, so let’s just make sure they are fine. I felt like there was a really big need for that, and there was not a lot of practical guidance, and we were learning new procedures that we still had practical exams on as well as theoretical exams—(PH).

As shown above, participants felt as though they were not offered enough support during the COVID-19 pandemic and expressed that they would have appreciated more clinical guidance and support from their clinical facilitators. Fortunately, in this study, the lack of emotional support did not prove to have major negative effects. But participants indicated the need for emotional support not only because they are young adults but also because some of the procedures were new and unfamiliar to them. Thus, they needed the presence of the preceptors for support and guidance. Most participants said that they could benefit from counselling or debriefing services as a support system during their training to cope with academic demands. The participants also mentioned that they would prefer it if the counsellors were people they knew and were comfortable with, namely their clinical facilitators.

Subtheme 1.3: no learning opportunities for students

It is critical for nurses to have access to ongoing learning and professional development opportunities in order to stay current on best practices and advancements in the field.² This can help nurses provide the highest quality care to their patients and advance their careers. Participants expressed how they missed out on some learning opportunities as the pandemic restricted them from working in certain units and departments. The following was echoed to further stress the statement above:

With the clinical training, they cut our workdays because they divided us into groups, so we weren't crammed into the facility as much due to the COVID-19 “no mass gatherings” rule. Our workdays were reduced, and they also reduced the number of students at a certain places/unit, like if we were placed in casualties, usually we would be placed four or five students at casualties, but this time it was only two students per rotation, and then we had other restrictions from the hospitals, like operating rooms. We couldn’t go into operating rooms because of COVID-19 to minimize the risk of cross contamination. Back then we were working, I think, twice a week if not three times a week, juggling between maybe midwifery and general nursing—(PG).

Another participant mentioned that:

There are some of us; for example, the placements are set so that you do ICU for 8 hours. 8 hours in casualty so on, I didn't get the chance to go to ICU because there was a shortage and staff and our rotations where very limited. The preceptors kept improvising on procedures and making us do them in simulation lab because we couldn’t do our procedures on the patients because most of the procedures could only be done in units, we were restricted from clinical areas, for example, assisting the anaesthetic doctor which is done in the operating rooms that we couldn’t go in, so we had to practice on each other and move for marks—(PP).

The COVID-19 pandemic has had a significant impact on nursing education and student nurses as a whole. Participants expressed how the restrictions caused by the COVID-19 pandemic created a gap in their learning opportunities. Many nursing education facilities prohibit their students from working in COVID-19-related units in an effort to protect nursing students from the risk of possible COVID-19 transmission. This restriction meant that nursing students were limited to only a few ‘safe’ units for clinical practice. Not being able to practice in certain departments caused the students to have fewer clinical skills and knowledge related to those restricted departments.

Theme 2: not being allowed to work in COVID-19 wards

The second theme emerged as not being permitted to work in COVID-19 wards, with the following subthemes: (1) concerns about contracting the COVID-19 disease; (2) students wanted to gain experience working with COVID-19; (3) only simulation lab training and (4) patient care was jeopardised. Since March 2020, the COVID-19 pandemic and social distancing measures to avoid the spread of the disease have provoked widespread global disruption with huge impacts on higher educational institutions and practice learning environments.⁵ The forced rapid closure of face-to-face teaching has compelled academic staff and students to withdraw clinical training into an online learning platform in order to keep students safe from the pandemic’s dangers.

Subtheme 2.1: fear of contracting COVID-19

As a student nurse, it is natural to have concerns about contracting COVID-19, as they are more at risk of exposure due to their clinical work in the healthcare field. Participants had fears related to COVID-19, including getting infected, as expressed below:

OK, it was necessary, but once we got back to campus and once, we got to practice, everything changed. We were not allowed to work in certain wards anymore because those wards had only COVID-19 patients, and I was also very scared and anxious, like wearing a mask was compulsory and sometimes I felt like I couldn’t breathe, and now I had to do a procedure on a patient, and I was scared to touch patients because I didn’t know what was going on or whether this patient had COVID-19 or not, so yeah, it was very stressful—(PA)

One other participant echoed:

You have to be friendly to patients; they also have to see your smile, so it was so difficult in the beginning just with that body language and everything, and then it was fearful; it was so scary because you were wearing PPE the whole time and you kind of knew the protocols…….Hearing the protocols at university and going into practice and finding that they're not being followed correctly, it’s really scary, so yeah, the first couple of months were bad and, you know, it took a lot of the joy out of what we were doing, so that’s how I experienced it—(PD)

Participants expressed their fears surrounding the COVID-19 pandemic and its effects on their clinical training experiences. The participants explained, how the fear of contracting the disease took away the joy they used to experience when doing practical procedures. Stress, anxiety, depression and dejection were identified as important psycho-social factors affecting the student nurses’ clinical experience. Workload, unfamiliar clinical situations (such as the COVID-19 pandemic and its protocols), handling clinical, emergencies and a lack of resources all have a negative impact on students’ learning. Furthermore, the presence of mass trauma and infectious diseases has a negative impact on students’ behaviour and psychology.

Subtheme 2.2: students wanted to experience working with COVID-19 patients

While some participants were afraid to freely practice in clinical facilities due to the fear of contracting the COVID-19 disease, other participants mentioned that they in fact wanted to work with COVID-19 patients. These participants felt that they could have at least had some extra optional in-service training on the disease and its management. This subtheme highlighted the fact that some of the participants would have liked the opportunity to work with

COVID-19 patients. These expressions were echoed as follows:

Um, yes, I would have liked the opportunity to experience what it is like to come into contact with COVID-19 patients, or maybe just have an extra module or an extra class that just explains in depth what the pandemic is exactly like what COVID is and how to handle COVID, and then maybe have one, two, or three practical sessions in real life where we can see COVID patients and deal with them—(PA)

Another participant stated that:

I felt like I wanted the challenge of working with COVID-19 people—a challenge to see how things are done, and it would have been beneficial now that you're in the real world. When you come across such patients, you know how to deal with them—(PB)

Another participant also echoed that:

Personally, I feel like I wanted to experience that feeling of working with COVID-19 patients, like I really wanted to be in the history of those people that were working with the COVID-19 patients, but we did not get much chance because we’re still in school—(PE)

Participants wanted the opportunity to be exposed to the COVID-19 disease in a clinical setting. They felt that it would have been beneficial to them in terms of gaining experience and preparing for the clinical field. Involving students in a large-scale health crisis’s allows student nurses to grow into courageous and self-assured nurses, which leads to the recruitment of resilient and experienced nurses into the healthcare workforce.⁶ Most participants believed they were not gaining knowledge or meeting clinical learning outcomes since they were not assigned to units where those outcomes could be met because of the COVID-19 restrictions set by clinical facilities and nursing education facilities not allowing students to work in COVID-19 units. Participants felt they lost valuable exposure.

Subtheme 2.3: only simulation laboratory training

Due to the COVID-19 restrictions in clinical facilities, nursing students were unable to perform all the required practical procedures in practice and, as a result, had to execute these procedures in a simulation lab under the guidance and supervision of their clinical facilitators. Participants faced the challenge of not being able to execute clinical procedures and expressed their frustrations with regard to having to wait for the simulation lab session.

A participant stated this:

The preceptors are putting pressure on the students to get procedures done and, the students are also putting pressure on them with signing off certain procedures, as you know, there’s just a small portion that we sign off with our lecturers and there’s a bigger portion we sign off at the hospital, so I think that is why the preceptors were so relaxed and they didn’t come to sign off most of the procedures in practice but they waited for us to go to the simulation lab, so most of the procedures were signed off at the lab—(PB)

Another participant stated that:

Yeah, we also heard that we couldn't perform all procedures and sign Them off on the real patient. I didn’t like this waiting for Sim Lab thing—(PJ)

Participants felt that not enough effort was put into helping them sign off on procedures. They felt that they fell behind on signing off procedures because they had to wait for a simulation lab session in order to sign off practical procedures. This delay had a negative effect on the participant’s learning process. The need for community concern is foremost among relatedness needs as translated from the psychological need for existence, and the needs for interpersonal relationships and affection are continuously increasing.⁶ Similarly, the participants in this study were expecting more support from their clinical facilitators and assistance in executing their clinical procedures. Participants expressed that they disliked having to wait to perform a procedure only during simulation lab sessions and felt that their clinical facilitators were too ‘relaxed’ and could have done more to assist them as nursing students to reach their required clinical practice outcomes

Subtheme 2.4: patient care was affected

The COVID-19 restrictions were not only limited to nursing students but also mostly affected during this time. Due to the policies and COVID-19 protocols, patient care changed completely.¹⁰ Participants mentioned how the fear of the COVID-19 disease affected their patient care, making them focus only on the patients’ clinical needs and not on holistic care. Participants also stressed how the lack or restriction of contact and prolonged engagement with patients had an effect on patient care.

A participant expressed this sentiment as follows:

Oh, like with patient management also, I think, like before, we used to engage with the patients and stuff. I think that they got used to just caring for the patients’ needs and not digging deep into the patient’s experiences or that kind of thing. So, right now, I feel like the caring part is also limited. It’s not really back to the normal state—(PC).

Another participant echoed:

I wish we had more innovative ideas or ways to still connect with the patients that are in isolation as well, because it was so interesting to actually work with the people who were persons under investigation because they were also scared, and I mean, me too, I was also scared, so you’re scared to even just be there and care for them properly—(PD)

Participants expressed that not being able to engage with patients the way they used to before the COVID-19 pandemic has had an effect on patient care, according to their observations. COVID-19 restrictions, as well as their own fears, made nursing care absent during the pandemic. It is true that the COVID-19 pandemic has had a significant impact on the healthcare system, including on the ability of patients to receive care, because many hospitals and healthcare facilities have had to implement strict visitor policies and other measures to reduce the spread of the virus, which limited the ability of patients to receive in-person care or support from loved ones.¹⁰ The pandemic has disrupted many routine medical services and procedures, especially those done by student nurses during clinical training, which led to delays or disruptions in care for some patients. The participants advised that institutions should find ways to provide standard care while still following COVID-19 protocols.

Theme 3: online classes and test challenges

The learning flow piques the learner’s interest in learning and encourages students to participate in active learning activities.⁶ Virtual classes reduce the interaction between instructors and students, and a lack of study-related equipment reduces learning flow. Participants stated that it is difficult to use teaching and learning strategies when studying, as these strategies are computer-based, which is not the same in real life and, as one participant stated, ‘makes’ them complacent to learn effectively. The following is supported by the quotes and the subtheme. Online classes and test challenges emerged as the third theme in this study, with the following subthemes: (1) difficulty adjusting to online classes and tests and (2) viewing videos for practical skills.

Subtheme 3.1: difficulty to adjust to online classes and test

Online classes and tests can also be a challenge for nursing students, as they require a reliable internet connection and a quiet, distraction-free environment. Participants expressed the difficulties they faced in migrating to a more digital learning platform due to the COVID-19 pandemic. A participant echoed the following:

Well, personally, um, I had a negative change because everything suddenly became digital, like firstly, we didn’t go to practice for a long time, we didn’t go to campus for a long time, and then, all of a sudden, when we came back, everything was digital; practical procedures were being performed and demonstrated to us via videos that our preceptors would make and share with us, and they didn’t do it physically anymore like we used to before the pandemic—(PA)

Another participant echoed:

You will find yourself unable to recall those things when you get to practice, because most of the time, the things that we learned in online class—if you did not have enough time to study—you will just pinpoint where the stuff is on the textbook, and then, when it comes to the test, you just know where the things are. Then you just write it down from there, and then when you have to perform the procedure now and you have to apply that theoretical information, now you don’t remember it because you did not study it like before, but it was also a positive impact because I think a lot of people passed during that time; that was the only positive thing—(PE)

And another student mentioned:

Feel like it was low because you take time, like to attend class in your group just to rotate to go attend that certain class. So, I feel like it was long, and also, I personally feel like I did not like the online thing because it was just making me lazy to study and everything, and when I had to come back to campus to do things physically, it was just… It was hard. Online, there were lecturer talks because, as students, you can go out of the Zoom meeting and then just do your things while the lecturer is busy doing her stuff, so yeah, that was not okay; catching up with the online learning was a lot—(PG).

Participants expressed that they may have lost some practical skills that came with doing things in person and practically. The shift to online learning was very sudden for the participants. Nursing students in the COVID-19 situation have experienced significant changes in their learning, such as a decrease in clinical practice due to virtual classes, difficulty concentrating on continuous learning and difficulty interacting due to a decrease in direct contact with instructors.⁴ Nursing students need to maximise their potential and maintain high concentration in the process of acquiring theoretical and practical skills to grow as healthcare workers in this changing learning environment. Some may argue, however, that due to COVID-19 restrictions, digital learning has become a safe and effective way to educate nursing students.¹¹ Schools and instructors only need to provide additional support and resources to help students adjust to the new learning environment. This may include providing access to technology, offering additional tutoring or academic support and creating a sense of community through virtual study groups or other activities.

Subtheme 3.2: watched videos even for practical skills

Web-based learning, on its own or in combination with traditional teaching methods, has become a consolidated practice in many countries and has been described as a valid and effective method that supports practical learning in undergraduate nursing students.⁴ Participants were exposed to digital clinical learning through the use of videos to demonstrate practical procedures to them. These videos replaced the in-person sessions they had with facilitators in clinical facilities. Participants described watching videos to learn practical skills as follows:

I also feel like other things, like if it’s a practical module, it was difficult for us to learn it online because of some skills that we had to learn. I think it was our skills that needed us to be physically there, unlike online. What if you do it on camera and I know only you do it that way in a patient, and it’s not like that?—(PG).

Another participant echoed:

And they made sure that we knew how to don and doff; we watched videos, and we had to do an OSCE (practical examination) before you were allowed in practice, so they really made sure that we had the skills to protect ourselves—(PH).

Another participant further mentioned:

Even the practical modules had to become online at some point, and they were making practical videos, and you just had to learn how to do some of the procedures by watching these videos. Yeah, and see these things and then apply them, and so it created a whole gap in our learning experience—(PM).

Some participants found it difficult to adapt and grasp some skills and knowledge through digital platforms. It made them complacent to learn because everything was easily accessible online during tests, and for some, it removed the benefits of learning new skills in real life, such as seeing exactly how it is done on real patients. Although participants expressed their difficulties surrounding the use of videos to gain practical knowledge. Watching videos can be a useful way to gain practical skills, especially when combined with hands-on practice and guidance from a knowledgeable instructor.¹ These videos can provide a helpful visual aid and allow you to see the steps involved in a skill being performed.Although video and online learning is a great substitute to in-person teaching and learning, it is important to keep in mind that learning a new skill usually requires more than just watching a video; therefore, it is still necessary that clinical facilitators ensure that students are competent in executing these procedures by allowing them to practice them during clinical training and giving feedback and guidance from an experienced point of view. This will help students develop muscle memory, fine-tune their technique and troubleshoot any challenges they might encounter along the way

Theme 4: lack of communication

The fourth and final theme was a lack of communication. Its subtheme was that hospitals were not informed that we should work in the COVID-19 ward.

Subtheme 4.1: hospitals were not informed that we should not work in COVID-19 wards

Lack of communication between clinical facilities and nursing schools can have several negative effects on the education and training of nursing students and the overall quality of healthcare.¹¹ Participants expressed their frustrations surrounding the communication between clinical facilities and their nursing institution. One participant expressed the following:

They are the ones who placed us there and did not communicate with the hospitals or clinics as to what changes took place, and some of the managers would also shuffle us around a lot when they saw that we were too many students in one department, and when our facilitators would come and look for us in the department that we were placed in. They would not find us there and blame us for shifting when, in fact, it wasn’t our fault—(PC)

Another student echoed:

Um, yes, personally, I feel like there should have been a better communication system between the facilities and the institution, like I mentioned, the institution didn’t know that we were being shoved around by the managers into other units that we weren’t allowed to be in. Also, some of the health professionals would threaten us not to sign off on our procedures because we would tell them that we are not allowed to work with COVID-19 patients, and they would see it as if we didn’t want to learn or gain practical knowledge, but in fact, we just wanted to obey the rules and the protocols of our school—(PH)

Another participant expressed that:

They (clinical preceptors) should have told the hospitals what is expected of us, or what they shouldn’t let us do like that. I feel like it was the university’s job to protect us, but what they did is they just gave us simple guidelines and threw us in the deep end, but they didn’t even communicate with the hospitals and staff about how to treat us during our practices—(PO).

Addressing issues of communication in clinical facilities, clinical managers should hold regular meetings with the lecturer or other educators from the university and work collaboratively with the students. Furthermore, in order to improve communication between clinical facilities and nursing institutions, it is important for both parties to establish clear lines of communication and to try to stay in touch throughout the clinical experience. This may include regular check-ins, the use of communication tools such as email or messaging apps and the development of protocols for addressing issues. When clinical facilities and nursing schools do not communicate effectively, nursing students do not receive the necessary information for preparation for their clinical rotations. This can lead to confusion, frustration and potentially even danger for students and patients. As discussed above, participants were sent to COVID-19 wards despite being restricted by the nursing institutions. This was, however, not clearly communicated between both the clinical facilities and nursing institutions. It is critically important for clinical facilities and nursing schools to have effective communication in order to ensure that nursing students receive the education they need.

Discussion

The results of this study have shown that student nurses lacked clinical experience, lacked support and did not have a clear communication system between facilitators and clinical training facilities during the COVID-19 period. This impacted negatively on their learning as they could not meet the requirements of clinical hours and their clinical practice objectives. These findings were further elaborated in the themes below.

Theme 1: absence of facilitators to facilitate clinical teaching

The absence of nursing clinical facilitators can be a challenge for clinical teaching in the nursing profession. Clinical facilitators, also known as clinical instructors or clinical teachers, play a critical role in the education and training of nursing students. They provide guidance and support to students as they learn.¹¹ They also practice their skills in a clinical setting and are responsible for evaluating their performance and providing feedback. Without clinical facilitators, it can be difficult for students to receive the hands-on, supervised experience they need to develop their skills and knowledge. This can lead to a lack of confidence and competence in students, which can negatively impact patient care.¹⁰ The participants of this study mentioned and expressed their perceptions in this regard. They explained how they lacked some support from their clinical facilitators and how they did not receive enough clinical guidance and experience during the COVID-19 pandemic. Participants also mentioned that they would have appreciated the opportunity to learn procedures in clinical practice under clinical guidance rather than just in simulation because they felt that the learning experience was not the same and would not be completely helpful in a real-life setting. Previous studies confirm that the main feature of nursing is integrating theory and practice, which makes clinical training and experience an important component of nursing education.¹¹ The same studies further explain that clinical experiences prepare and stimulate students’ critical thinking and problem-solving skills.¹¹ In this study, however, although students identified learning opportunities in clinical practice, lack of guidance and lack of placement in COVID-19 wards deprived them of learning clinical skills that would have equipped them to care for patients with COVID-19.

Theme 2: not allowed to work in COVID-19 wards

It is not uncommon for nursing students to be restricted from working with COVID-19 patients, as this can be a high-risk environment for inexperienced healthcare workers. The safety and well-being of both nursing students and patients are of the utmost importance. Nursing schools and clinical facilities have implemented policies to reduce the spread of COVID-19. There are a few reasons why nursing students may not be allowed to work with COVID-19 patients. One reason is to protect the students from the potential risks associated with working with infected patients, such as exposure to the virus and the potential for contracting the disease. Additionally, nursing students may not have the necessary knowledge and skills to effectively care for COVID-19 patients, as this requires a high level of expertise and experience. Some of the participants in this study expressed the fear they felt during the COVID-19 period when they were sent back into clinical facilities. Although they were restricted from working with COVID-19patients, some participants came across patients who ended up testing positive for the disease after their care. Stress, anxiety, depression and dejection were identified as important psychosocial factors affecting the student nurses’ clinical experience. Workload, unfamiliar clinical situations (such as the COVID-19 pandemic and its protocols), handling clinical emergencies and a lack of resources all have a negative impact on students’ learning.⁵ Furthermore, it has been well documented that the presence of mass trauma and infectious diseases has a negative impact on students' behaviour and psychology.⁵ Participants mentioned that the fear of not knowing the patients’ results was what made it difficult to provide good patient care. During the in-depth individual interviews, participants further expressed that they were no longer able to interact and engage with patients because they were afraid of contracting the COVID-19 disease themselves. Contrary to this, some participants also mentioned that they would have liked the opportunity to be able to work with COVID-19 patients and be part of the front line. Participants expressed that working with COVID-19 patients would have been a great opportunity for them to gain experience and skills in nursing during the COVID-19 pandemic. They also shared their thoughts on how the COVID-19 restrictions impacted patient care. The importance of clinical placement is highlighted in many studies.⁵ These same studies confirm that it empowers students to acquire knowledge from patients, families and communities, so that students are enabled to integrate theory and practice.¹¹

Theme 3: online classes and test challenges

The COVID-19 pandemic has presented many challenges for nursing students, including the transition to online classes and testing. The sudden shift to remote learning can be difficult for students, as it requires a different set of skills and can be isolating. Additionally, the lack of in-person interaction with instructors and classmates can make it more difficult for students to fully engage in the material and get the support they need. The participants point out that the shift to digital learning was somewhat unpleasant. They further explain how learning skills through videos and online simulations were not always effective in helping them gain the skills to execute the procedures in a real-life setting. Participants also mentioned that learning online made them lazy as their lecturers could not tell whether or not they were paying attention to the online class or busy with something else. The learning flow piques the learner’s interest in learning and encourages students to participate in active learning activities. Virtual classes reduce the interaction between instructors and students, and a lack of study-related equipment reduces learning flow.⁶ However, other studies argue that due to COVID-19 restrictions, digital learning has become a safe and effective way to educate nursing students.² Schools and instructors only need to provide additional support and resources to help students adjust to the new learning environment. This may include providing access to technology, offering additional tutoring or academic support and creating a sense of community through virtual study groups or other activities.

Theme 4: poor communications

Poor communication between clinical facilities and nursing institutions can be a challenge for nursing education. Effective communication is essential for the smooth operation of clinical placements, as it allows for the exchange of important information about the needs and expectations of both parties. When communication is poor, it can lead to misunderstandings and miscommunications, which can disrupt the clinical experience for both students and patients. For example, if a clinical facility does not clearly communicate its policies and procedures to the nursing school, students may not be aware of the expectations and may not be prepared to meet them. Similarly, if a nursing school does not provide clear and timely feedback to a clinical facility, it can be difficult for students to know how they are doing and what they need to work on. Evidence shown in the verbatim quotes by the participants shows how there was a lack of communication between the nursing facilities and the nursing schools. Participants were placed in high-risk COVID-19 areas even though they were restricted by their clinical facilitators. Participants had encountered some issues with placement because clinical facility managers would shuffle them around to other wards to reduce the number of staff in a certain unit. Furthermore, the shuffle was made without informing clinical facilitators, causing difficulties in locating participants during clinical evaluations and facilitations. When clinical facilities and nursing schools do not communicate effectively, nursing students do not receive the necessary information for preparation for their clinical rotations.² This can lead to confusion, frustration and potentially even danger for students and patients.¹⁰ Recent studies confirm that the main feature of nursing is integrating theory and practice, which makes clinical training and experience an important component of nursing education.⁹ These studies further explain that clinical experiences prepare and stimulate students’ critical thinking and problem-solving skills.⁹ In this study, however, although students identified learning opportunities in clinical practice, lack of guidance and lack of placement in COVID-19 wards deprived them of learning clinical skills that would have equipped them to care for patients with COVID-19. With evidence found in some published articles, it is clear to see just how big of an influence clinical training plays on nursing students and their education. Positive environment or the absence thereof greatly influences how students perceive clinical training and education as a whole and this can impact their decision to work as professionals in the future.⁷ Related studies further conclude that a negative clinical environment needs to be considered as notably having a great impact on the views and opinions of student nurses on clinical training.⁷ Clinical facilities have a direct influence on students’ perception on clinical training and can at times be a source of stress and anxiety for students.³ Although articles were found on student’s experiences on clinical training, not many explore the impact of the pandemic on the student nurses’ personal view on clinical training or recommendations for a different approach to learning especially in the Northwest province of South Africa. Data collection and results pertaining to the nursing students’ perceptions of clinical training during the COVID-19 pandemic discussed in the paragraphs above give a detailed insight into the perceptions of the nursing students from the Northwest province and even highlight some recommendations that could benefit nursing research and nursing practice and nursing policy as a whole.

Implications for nursing research, practice and policy nursing research

The majority of participants stated that using videos and simulations for practical skills alone was insufficient because procedures and execution are not the same on real-life patients. Further research can be done on different clinical teaching methods and preferred clinical training methods by conducting survey studies, these studies would aid in finding out how student nurses would prefer to be taught especially during a pandemic based on their own experiences. Participants also expressed the lack of support they experienced and felt like they did not see enough of their facilitators during clinical training, while other participants also mentioned that facilitators would only come into sign attendance. Participants felt as though their facilitators could have done more and shown more support not only for their educational needs but also their emotional needs. With all that is mentioned further, research could be done on the effects student nurses mental well-being has on nursing care and on student health as a whole. The researcher noticed that a few participants would have liked the opportunity to openly work with COVID-19 patients and felt that they would have gained some knowledge and skills as well as experience. Further studies on field work can be done to show how different parts of the world deal with pandemics and clinical training and how South Africa can incorporate these methods into their own practices.

Nursing practice

Participants identified several issues with clinical placement, including being shifted from their initial placements. Limited rotations were also mentioned as some of the challenges experienced by the participants. The researcher suggests that students be placed according to their practical needs. Preceptors should support the students on a regular basis to meet their learning outcomes. Students should be placed in the clinical facility based on specific learning outcomes to meet their objectives. Facility managers should encourage professional nurses in the units to acknowledge and meet their responsibilities of teaching students to achieve their learning outcomes and improving quality nursing care for patients. Facility managers should foster a safe working environment for all students by ensuring that they have all the resources they need to accomplish their learning outcomes. Unit managers should provide orientation on current practices and interpersonal relationships to nursing staff and students.

Policy

The study contributes to policy formation by providing accurate information gathered through the data collected during interviews and focus group. Perceptions and recommendations made by participants including additional information and further analysis will influence policymakers and practitioners through knowledge mobilisation, which could lead to outcome of the impact made by the study findings through engagement and networking.

Recommendations

Table 2 of themes, subthemes and recommendations that emerged from the study

Table 2

Summary of themes, subthemes and recommendations of the study

Themes	Subthemes	Recommendations
1. Availability of preceptors to facilitate clinical teaching	Lack of COVID-19 clinical experience Lack of emotional support No learning opportunities for students	Clinical facilitators should facilitate follow-up demonstrations in clinical practice. Frequent and routine de-briefing sessions with students after each term or semester, by their study leaders. School of nursing should create platform for students to identify which procedures and wards they still need to be exposed to and plan their training schedule accordingly.
2. Not allowed to work in COVID-19 wards	Fear of contracting COVID-19 infection Students wanted to experience working with COVID-19 patients Only simulation laboratory training was allowed. Patient care was affected	School of nursing should introduce optional module/short course to deal with pandemic and allow students who want to participate to do so (willingly) Provide alternative option for students who choose not to participate
3. Online teaching and learning	Difficulty to adjust to online classes and tests Watched videos even for practical skills	School of nursing should Incorporate more contact classes Nursing lecturers should give students online exercises to stimulate their engagement on e-learning.
4. Poor communication	1. Hospitals were not informed that we should not work in COVID-19 wards	School of nursing can have a representative from the school who is also a staff member in clinical facilities that can act as a clear and direct bridge of communication between the school and the clinical facilities

Conclusion

Clinical training (like bedside nursing) requires active student–patient participation. The nursing field and situations experienced in healthcare facilities can be physically and emotionally challenging and require nursing students to have control over their emotions in order to cope. As a result, nursing students may experience negative feelings and emotions that existed prior to the start of the COVID-19 pandemic. The goal of this study was to investigate and describe senior nursing students’ perspectives on clinical practice during the COVID-19 pandemic in South Africa’s Northwest Province. The research study was qualitative in nature, and data were analysed using Tesch’s method of data analysis. It is possible to conclude that the study objectives were met based on the study findings. The study further calls attention to the challenges participants faced during their clinical training. Considering all that has been discussed, it is clear that the pandemic has caused a stir in the nursing education system. These reasons have prompted the researcher to conduct this study and further discover the perceptions shared by the participants, which included : (1) absence of facilitators to facilitate clinical teaching; (2) not being allowed to work in COVID-19 wards; (3) online classes and tests pose challenges and (4) poor communication. Because the study raised awareness of the challenges expressed by the study participants, it will contribute to the improvement of clinical facilitation and training. Factors highlighted by the participants in this study to further promote a positive and healthy learning environment in clinical facilities.

The authors wish to thank all participants who kindly gave their time to share their perceptions for the study. We would also like to thank all individuals who showed support throughout the study.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not Applicable.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by NWU Health Research Ethics Committee, ethics number: NWU-00018-22-A1. Participants gave informed consent to participate in the study before taking part.

Footnote

Contributors All authors (SFFA, ENB, MM) were involved in the conception and design of the study; analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published. SFFA conducted all the interviews and bulk of the analysis; and wrote the first draft of the manuscript. SFFA was overall responsible for the study as guarantor.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer-reviewed.

References

¹ Brown J, Nolan M, Davies S, et al. Transforming students' views of gerontological nursing: realising the potential of enriched environments of learning and care: a multi-method longitudinal study. Int J Nurs Stud 2008; 45: 1214–32. doi:10.1016/j.ijnurstu.2007.07.002

² Boore J, Deeny P. Nursing education: planning and delivering the curriculum. Los Angeles: Sage, 2012. doi:10.4135/9781473914872

³ Aslan H, Pekince H. Nursing students' views on the COVID‐19 pandemic and their percieved stress levels. Perspect Psychiatr Care 2021; 57: 695–701. doi:10.1111/ppc.12597

⁴ Agu CF, Stewart J, McFarlane-Stewart N, et al. COVID-19 pandemic effects on nursing education: looking through the lens of a developing country. Int Nurs Rev 2021; 68: 153–8. doi:10.1111/inr.12663

⁵ Carolan C, Davies CL, Crookes P, et al. Covid-19: disruptive impacts and transformative opportunities in undergraduate nurse education. Nurse Education in Practice 2020; 46: 102807. doi:10.1016/j.nepr.2020.102807

⁶ Park J, Seo M. Influencing factors on nursing students’ learning flow during the COVID-19 pandemic: a mixed method research. Asian Nurs Res (Korean Soc Nurs Sci) 2022; 16: 35–44. doi:10.1016/j.anr.2021.12.006

⁷ Lopez V, Whitehead D. Sampling data and data collection in qualitative research. Australia: Mosby, 2012: 124–7.

⁸ Pietkiewicz I, Smith JA. A practical guide to using interpretative phenomenological analysis in qualitative research psychology. Psychological Journal 2014; 20: 7–14. doi:10.14691/CPPJ.20.1.7.

⁹ Bruce JC, Klopper HC, Mellish JM. Teaching and learning the practice of nursing. Cape Town: Heineman, 2011: 600–90.

¹⁰ Xiong J, Lipsitz O, Nasri F, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020; 277: 55–64. doi:10.1016/j.jad.2020.08.001

¹¹ Czeisler MÉ, Marynak K, Clarke KEN, et al. Delay or avoidance of medical care because of COVID-19- related concerns - United States. MMWR Morb Mortal Wkly Rep 2020; 69: 1250–7. doi:10.15585/mmwr.mm6936a4