Nursing Students' Satisfaction and Perceptions Under the Unprecedented Abrupt Online Clinical Practicum During the COVID‐19 Pandemic

Abstract

ABSTRACT

Aim

To explore nursing students' satisfaction levels of each specific item and perceptions under the unprecedented abrupt online clinical practicum during the COVID‐19 pandemic.

Design

A mixed‐method design comprises a questionnaire and qualitative content analysis.

Methods

The study used purposive sampling using data from nursing students in grade 3 of a 4‐year bachelor RN programme at a technological university in the north of Taiwan, compiled from May 2021 to June 2021 using an online questionnaire. Students were invited to fill out a 5‐point Likert scale to answer questions on their satisfaction with online clinical practicum and an open‐ended question describing their experiences and perceptions of online clinical practicum. Quantitative data were analysed using the mean and standard deviation. Qualitative data were analysed using content analysis.

Results

A total of 157 nursing students participated. Students' overall satisfaction with online clinical practicum gained the lowest score with a mean score of 3.33 (±0.98). By contrast, students' satisfaction with the attitudes of teachers for online clinical practicum gained the highest score with a mean score of 4.53 (±0.69). Based on qualitative data analysis, the advantages of online clinical practicum include providing flexible learning time and space and improving the learning depth of the nursing profession; the disadvantages include the negative impact of long‐term online learning on body and mind and difficulty replacing the learning in real clinic scenarios.

Conclusions

Students have a moderate level of overall satisfaction with online clinical practicum, but a high level of satisfaction with teachers' teaching attitudes. Students perceptions that online clinical practicum can provide flexible learning time and space and improve nursing professional knowledge through multiple teaching strategies; however, online virtual practicum can scarcely replace the real experience gained by nursing patients.

Impact

The findings highlight the value of online practicum in offering flexible learning opportunities and enhancing nursing knowledge through multiple teaching strategies. However, students also underscore the irreplaceable role of hands‐on patient care experiences in developing comprehensive clinical competence, suggesting the need to balance virtual and real‐world practicum in nursing education.

Patient or Public Contribution

No patient or public contribution.

Introduction

Clinical practicum is an essential element in the development of students' nursing competence. The nursing competence that students can acquire in clinical practice usually includes general nursing skills, critical thinking, clinical judgement, teamwork/collaboration, ethical decision making, lifelong learning and problem-solving skills (Ayaz-Alkaya et al. 2018; Chen et al. 2020). However, the Coronavirus disease 2019 (COVID-19) pandemic has jeopardised nursing students' learning trajectory. Due to the spread of COVID-19, most institutions were unable to provide clinical practicum sites for safety reasons (Kang and Hwang 2023). Given the inability to provide clinical practice for students, teachers must quickly turn to virtual and online simulations according to the goal of the nursing practicum programme.

In our university during the May 2021 pandemic period, some students had only finished their clinical practicum, while some students were in the middle of clinical practicum and were immediately shifted to online clinical practicum. Abrupt remote online clinical practicum was a challenge to clinical practicum encounters. The unprecedented online clinical practicum within the COVID-19 pandemic, which has abruptly suspended in-person clinical practicum, is a point of concern in this study. Thus, this study aimed to explore the satisfaction and perceptions of Taiwanese nursing students with the unprecedented abrupt online clinical practicum during the COVID-19 pandemic. This study is the first in Taiwan to explore the impact of online practicum on students from the perspective of students. Findings will inform interventions to address these concerns and develop educational strategies (contingencies and readiness plans) for effective and sustainable nursing education during times of crisis.

Background

Students' satisfaction is the fundamental goal of nursing educators. Satisfaction has been defined as a desire for delight or disappointment resulting from an event and a person's prior expectations of himself or herself (Oanh et al. 2021). During clinical practicum, instructors need to plan clinical activities suitable for learning outcomes, create an environment and opportunities for students to learn, guide students in the clinical setting, and evaluate their performance. Furthermore, students are required to apply what they have learned in class to the real world and attain a professional level of nursing competence to provide safe and high-quality patient care (Chen et al. 2020). Thus, nursing students improve learning satisfaction by closing the gap between theory and field through clinical practicum experience. Nursing students' satisfaction with clinical practicum can influence clinical competency (Visiers-Jiménez et al. 2021). Therefore, nursing students' satisfaction is an important element to consider in clinical practicum.

Nursing education is built on a framework of didactic and clinical experiences. Nursing schools typically rely on clinical agency practicum to support students in the simulation of didactic theory to application (Konrad et al. 2021). Clinical practicum is essentially experience learning. It achieves the purpose of learning through practical operation, observation and thinking. It is a continuous process of experience transformation, reorganisation and transformation into knowledge. However, the unprecedented online clinical practicum during the COVID-19 pandemic, which has abruptly suspended teachers' and students' face-to-face contact, is a concern not limited to Taiwan but is a global trend. When traditional clinical practicum is cancelled or modified, it may lead to students harbouring negative feelings (Ramos-Morcillo et al. 2020). Online learning is reasonable in the context of the pandemic. However, for nursing education that emphasises in-person clinical practicum, nursing students' satisfaction and perceptions of online clinical practicum are worthy of attention.

During online clinical practicum, teachers used synchronous online communication software, such as Google Meet, Cisco WebEx, or Microsoft Teams (Huang and Fang 2023; Kang and Hwang 2023). Online clinical practicum means that nursing students lose important opportunities such as reducing fear of the clinical field and gaining confidence as future nurses by providing the nursing process to actual patients (Kang and Hwang 2023). As a result, students were dissatisfied with their online clinical practicum. Studies showed that students expressed dissatisfaction with the discontinuation of in-person clinical attachments and practical lessons (Dutta et al. 2021; Natarajan and Joseph 2022; Shorey et al. 2022). In addition, Suliman et al. (2021) showed that most nursing students had substantial concerns over online learning with regard to the achievement of the competencies and intended learning outcomes of the clinical courses. Michel et al. (2021) and Tambunan and Sinaga (2023) showed that nursing students believe that using a virtual environment and online simulation could not be a substitute for direct patient care; they would reduce contact with patients and reduce their clinical experience.

Online clinical practicum has its advantages over conventional teaching methods such as availability to a wider population, especially in difficult areas where face-to-face teaching is not feasible, time efficiency, flexibility to students, convenience and accessibility (Dost et al. 2020; Dutta et al. 2021). In addition, using online learning to teach clinical skills is as effective as conventional learning in developing the nursing competencies needed for safe practice (McCutcheon et al. 2015). However, the inability to gain hands-on and in-person experience, the lack of motivation, absence of physical interaction with the teacher, social isolation, negative effects on the body and absence of immediate feedback from the teacher are major disadvantages (Dutta et al. 2021; Liesveld et al. 2023; Singh et al. 2021; Suliman et al. 2021).

Methods

Design

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

Participants, Setting, Clinical Practicum

Nursing students in grade 3 of a 4-year bachelor RN programme in a university of science and technology in northern Taiwan were taken as the subjects investigated. A purposive sampling method was performed to recruit participants. A total of 195 nursing students who had a 4-week Medical-Surgical Nursing Practicum from May 10, 2021, to June 4, 2021, were the major population. An invitation letter with a Google form was distributed to each student via email and LINE Link. A total of 157 nursing students agreed to participate and signed the consent form. The students who did not completely finish the questionnaire or responded without the consent form and who withdrew from the clinical practicum during the period of data collection were excluded. This study employed the sample size calculator provided by Creative Research Systems. Parameters were set with a 95% confidence level, a 5% margin of error and a population size of 195. The computed optimal sample size was 130 participants.

During the COVID-19 epidemic, the Ministry of Education, Taiwan, had banned face-to-face teaching since May 19, 2021, to reduce the COVID-19 epidemic and contagiousness. Accordingly, we switched our clinical practicum to online clinical practicum learning. Thus, students only had one week of the face-to-face Medical-Surgical Nursing Practicum but had an online clinical practicum for the remaining three weeks. Therefore, in the face of the epidemic and the change in practicum mode of nursing students, clinical nursing teachers must design online clinical practicum courses according to the practicum objectives; introduce clinical scenarios and cases, teaching films, and technical films for guidance.

Instrument

A questionnaire includes the demographic data sheet, Practicum Satisfaction Scale and an open-ended question to obtain students' experiences and perceptions about online clinical practicum. First, the demographic data sheet involved gender, non-nursing work-study experience, religious belief, interest in nursing and willingness to engage in nursing work in the future. The Practicum Satisfaction Scale was developed by Liu et al. (2020). The Practicum Satisfaction Scale contains the following four questions to evaluate nursing students' satisfaction with online clinical practicum: (1) Overall satisfaction with online clinical practicum, (2) Satisfaction with online clinical practicum teaching activities, (3) Satisfaction with online clinical practicum assignment arrangement and (4) Satisfaction with online clinical practicum teachers' attitudes. The 5-point Likert scale scoring method is adopted with 1 representing very dissatisfied, 2 dissatisfied, 3 ordinary, 4 satisfied and 5 very satisfied. The satisfaction scores are divided into three levels: low (1.00–2.33), moderate (2.34–3.67), and high (3.68–5.00). A higher score means better satisfaction of students. Finally, an open-ended question was provided. Nursing students were invited to describe their experiences and perceptions on online clinical practicum. The Cronbach's alpha of this study was 0.84.

Data Collection

Data were collected using a brief, self-administered, online survey of undergraduate nursing students enrolled at a university of science and technology in northern Taiwan. The survey provided an opportunity for participants to respond to one open-ended question regarding their perceptions about the online clinical practicum on their education. Students' satisfaction levels under the unprecedented abrupt online clinical practicum have also been collected and analysed. All data were collected during the COVID-19 pandemic, from May to June 2021. Responses to the question are the focus of this paper.

Data Analysis

In this study, the number (percentage) and mean (standard deviation) of descriptive statistics were used to analyse students' basic attributes and their satisfaction with online clinical practicum. In the qualitative research, the content analysis recommended by Waltz et al. (2005) was adopted to analyse the open-ended question on students' experiences and perceptions of online clinical practicum to accord with the rigour of qualitative research. The qualitative data according to the topic of research underwent content analysis by two experienced nursing researchers. Each researcher meticulously reviewed the content of each text to ensure a comprehensive understanding of the qualitative data and proceeded with coding. Subsequently, the researchers consistently discussed to confirm and verify unit coding, ensuring the consistency and accuracy of the data. Throughout the data analysis process, they continuously compared and analysed differences among individual units, further forming categories while ensuring the integrity and consistency of the categories' content. Finally, the researchers engaged in in-depth discussions based on the relevance of categories related to core concepts and issues addressed in the study, amalgamating similar categories into broader themes.

The rigour of the analysis can be achieved by ensuring credibility, applicability, transferability and dependability. In this study, credibility was established through several methods, including prolonged engagement with nursing students and their learning process, simultaneous collection of qualitative and quantitative data (triangulation), and peer debriefing. Additionally, the use of purposive sampling and providing detailed descriptions could enhance applicability and transferability. Finally, dependability was ensured through well-preserved raw data, the analytical process and the establishment of an audit trail.

Ethical Considerations

The Institutional Review Board (IRB) of the concerned hospital approved this project. The participants were informed of their rights to participate in this study and relevant information including (1) the purpose of the study, (2) research methods and processes, (3) possible consequences and gains, (4) and preserving and respecting the confidentiality of their information. Such information was written on the informed consent. The participants could withdraw from the study at any time without any excuse. Their personal information was coded by number to ensure confidentiality. Data collection was carried out via a voluntary and online survey.

Findings

Demographics of Subjects

A total of 157 students participated in this study. The response rate was approximately 80.51%. In demographic statistics, the women accounted for 91.72%. Students with non-nursing work-study experience accounted for 63.06%. Most of the students had religious beliefs (60.50%), and most of the students were interested in nursing (59.88%). Moreover, students who decided to engage in nursing in the future accounted for 68.79% (Table 1).

TABLE 1 Demographic characteristics of the nursing students (N = 157).

Characteristic	Category	N	%
Gender	Male	13	8.28
Female	144	91.72
Non-nursing work-study experience	No	58	36.94
Yes	99	63.06
Religious beliefs	Buddhism, Taoism	73	46.49
Christianity, Catholicism	22	14.01
None, others	62	39.50
Interested in nursing	Not interested at all	3	1.91
Not interested in	8	5.09
Ordinary	52	33.12
Interested in	73	46.50
Very interested	21	13.38
Engage in nursing in the future	Very unsure	3	1.91
Mostly not sure	5	3.18
A little unsure	23	14.65
Somewhat sure	18	11.47
Mostly sure	73	46.49
Very sure	35	22.30

Satisfaction With Online Clinical Practicum

The students' overall satisfaction with online clinical practicum gained a mean score of 3.33 (±0.98). Students' satisfaction with online clinical practicum teaching activities gained a mean score of 3.63 (±1.03). Students' satisfaction with online clinical practicum assignment arrangement gained a mean score of 3.75 (±0.99). Students' satisfaction with online clinical practicum teachers' attitudes gained a mean score of 4.53 (±0.69) as in Table 2. This study result shows that the satisfaction score for teachers' attitudes was rated as a high level, while the satisfaction score for other items was rated as a moderate level.

TABLE 2 Students satisfaction with online clinical practicum (N = 157).

Item	Mean	SD
1. Overall satisfaction with online clinical practicum	3.33	0.98
2. Satisfaction with online clinical practicum teaching activities	3.63	1.03
3. Satisfaction with online clinical practicum assignment arrangement	3.75	0.99
4. Satisfaction with online clinical practicum teachers' attitudes	4.54	0.69

Experiences and Perceptions of Online Clinical Practicum

This study comprehensively analyses the feedback of students' practice in distance education. The advantages and disadvantages of online clinical practicum courses are captured as two topics for each, as shown in Table 3. The advantages of online clinical practicum include (1) providing flexible learning time and space and (2) improving the learning depth of the nursing profession; the disadvantages include (3) the negative impact of long-term online learning on body and mind and (4) difficulty replacing the learning in the real clinic situation. Result analysis is detailed as below.

TABLE 3 Experiences and perceptions of online clinical practicum (N = 157).

Advantages
Theme I	Providing flexible learning time and space	Theme II	Improving the learning depth of nursing profession
Categories	Increase sleep time Eliminate the traffic time/one second to get home Abundant planning preparation report/improve the integrity of assignments Instant use of online resources Improve the timeliness of problem solving	Categories	Focus on individuality: learning with the teacher (instant feedback to students' questions, attention to each student's learning) Multiple teaching resources and channels (multiple media, film teaching, situational teaching)
Disadvantages
Theme III	Negative impact of long-term online learning on body and mind	Theme IV	Difficulty replacing learning in real clinical scenarios
Categories	Overuse of eyes Physical fatigue/musculoskeletal stiffness Decline in attention: low motivation and enthusiasm for learning Depressed, boring	Categories	Lack of communication and interaction training with patients and medical team Lack of real clinical scenarios (presence) like taking a class Imagine Teaching: limitation on skills and practical Experience Ability to respond to clinical events

Providing Flexible Learning Time and Space

Qualitative data analysis results show that the first positive impact of online clinical practicum is flexible learning time and space. Most of the students expressed that online clinical practicum courses eliminate the traffic time and fatigue due to the long journey from their homes to practicum institutions. Accordingly, they can gain relatively much time for sleeping, which accords with the concept of one second to get home, turn on to work and turn off to go off work. Similarly, more abundant time is exchanged for the preparation of reports and written assignments, which improve the integrity of assignments. In addition, students mentioned that online clinical practicum can allow them to search for data in real time at any time by using Internet resources, without waiting to get home to search after the in-person practicum. It can improve the timeliness of data searching and problem solving, reduce the gap and interference between time and space to answer (resolve) current questions immediately, and improve the timeliness of problem solving. The flexible use of time and space in teaching and learning has indeed become their advantages in learning.

Nursing students who go to medical hospitals or institutions for clinical practicum can gain real nursing experience. However, the distance to and from the practicum institutions will take up a certain amount of time. Online learning can save the traffic time for students to increase their sleeping time and reduce the learning load. Many students said: It could reduce the commuting time and avoid spending time commuting and getting up early (42). Yes, I could sleep later. I did not have to spend time in the hospital. So, I was not so tired (98). I could sleep enough, and I could live in a warm nest without moving and worrying about the car fare (101). I could sleep quite late, and turning off the computer at 4 o'clock (afternoon) was equal to going off work and being at home … (118). Learning in a comfortable environment, did not need to go to hospital, so I could sleep quite late (131).

Online clinical practicum saves the traffic time for students. For other students, they gain much more time to prepare for their reports and assignments, which can improve the integrity of assignments. Students stated the following: No need for spending time commuting; so, we began to have much more time. Therefore, we could read more literature (8). Due to online practicum, we had much more time for reading literature, which could improve our relevant knowledge and realise new research results (76).

Many students stated that another advantage of online learning is that students can conduct data searches against current questions using online resources to solve problems immediately. They can also determine the gap between time and space only when being improved and when going home. Many students said: We could make up for the missing scientific principle of the classroom style. If we have any questions, we could immediately find solutions based on Internet resources at a fast speed (71). We had much more time to use and could find answers to the unknown problems via the Internet (108). We could read books. If we have any questions on computer data, we could find answers at once, while avoiding the accumulation of problems until we reach home in a face-to-face scenario (115). If teachers asked questions, we could find out the data immediately and answer teachers' questions (127).

Students expressed that online clinical practicum provides them with much more flexible learning time and space. Online learning saves them time going to the institutions, thus affording them plenty of time to sleep and complete assignments. Additionally, they discover more efficient methods via real-time Internet resources to solve current questions and problems, which in turn further supports their learning.

Improving the Learning Depth of Nursing Profession

Researchers summarised another positive impact of online clinical practicum: Improving the learning depth of the nursing profession. Most of the students said that the online clinical practicum mode allowed each of them to coexist with the teacher on the same learning platform simultaneously. Compared with clinical practicum, online clinical practicum teachers were no longer busy and rushing to each ward to guide students. Therefore, teachers had much more time to take care of every student at the same time and could also simultaneously respond to the situation and questions of each student. Students had more opportunities and time than in clinical practicum to interact and communicate with teachers. They would gain richer professional guidance through teacher-student interaction and discussion. It indirectly improves students' nursing professional knowledge. Students said: online practicum teaching … Teachers had much more time to discuss courses or problems in the clinic with us and could offer extra attention to students' learnings (72). Teachers had more time to discuss with us about the mechanisms of science, physiology, and pathology. They also provided us with materials to simulate the diseased conditions of patients and the practice of shift handover. Based on this activity, students could share discussions and learn from each other, while teachers could provide immediate feedback and tell us how to improve (86). Our studying was also efficient and effective. Teachers would give us more data or feedback and promptly share practical experiences. Prompt guidance in the clinic is impossible, but it can be implemented online. I felt that I had benefited a lot (89). We had much more time to interact with teachers, deeply discuss patients' conditions, or clinical scenarios (91). Teachers and students had more time together. They could deeply discuss the mechanisms of science, pathology, and pharmacology of diseases to deepen our impression of diseases and medication, which helped us prepare for the future licence examination (128). The teacher had time to teach us how to write the homework, and they could guide us one by one, so that we could understand more about the homework… and could understand and analyse more about our respective diseases (154).

Apart from increasing the time for interaction between teachers and students, online clinical practicum courses are also taught by teachers through a variety of teaching methods and resources, such as analysis and discussion on clinical teaching plans, application of multiple media, film teaching, situational teaching, to guide students' learning in many ways. Based on the application of multiple teaching channels and teaching resources, students have made substantial improvements and progress in professional nursing knowledge. Many students said: By carefully arranging the teaching materials and homework schedule of online practicum, we could learn effectively and systematically. We could also adjust according to the differences among members in the progress. Such training could lay a solid foundation for our learning (15). We could learn more about the science of diseases. We could also learn more about nursing knowledge and see different clinical aids in the process of discussion via the Internet. Teaching also became diversified and creative. For example, searching for relevant videos or pictures on the Internet could deepen our understanding and impression of the science of diseases. Additionally, group discussions could improve communication with the team and achieve a win-win situation by cooperating with each other (55). More things could be extended through online practicum, such as the generation of lesions or signs of diseases. Apart from explaining the condition of the disease and the key points of nursing, teachers would teach us to respond and simulate patients to ask questions through scenario practice in the afternoon (65). We could understand the knowledge about the science of diseases from students' reports and teachers' films in the process. This distance teaching increased the time for reading books compared to basic nursing practicum. The hand-raising activity encouraged us to make statements boldly. Teachers did not blame us when we committed mistakes and also told us the correct knowledge (103).

From students' feedback, online clinical practicum is found to allow teachers extra time to observe students' needs, provide students with appropriate guidance, and allow students to experience in-depth learning. In addition, teachers are willing to move clinical scenarios to virtual network through multiple teaching strategies to enhance students' sense of reality and thinking about clinical practice and improve students' professional knowledge.

Negative Impact of Long-Term Online Learning on Body and Mind

Study results show that long-term distant or online learning will pose relatively high pressure and impact on the bodies or minds of most students. According to many students' feedback, sitting at the computer for a long time can easily lead to overuse of eyes; experience of fatigue, stiffness, pain and discomfort; and other problems. Moreover, long-term continuous gaze at a single screen and exposure to a single stimulus can easily lead to a decline in attention, learning enthusiasm and learning motivation, which will affect the learning effect. Students said: Although rest periods were set in between courses, eyes get easily tired and the body muscles stiffen (26). Sitting in front of the screen all day actually hurt my body. I always had a sore back when standing up. If it was time to hand in school homework, I had to continue to be in front of the screen at night after class (49). Online practicum is almost all about discussing and reading textbooks on the Internet. My eyes would be very tired after a whole day of learning (111). Sitting at the computer for a long time would make people fat, cause sore and astringent eyes, and easily lead to dizziness and headaches. Moreover, the computer information is consumed quickly (113). After looking at the computer for a long time, my eyes would be sore. For a huge homework assignment, we were really tired of using the computer after class (151).

Some students also gave feedback that long-term use of computers for learning would easily lead to distraction, difficulty in concentrating, decline in learning ability and low mood. They said: Practicum at home would make students a bit lazy on the whole. Compared with in-person practicum, it could not motivate me (17). I attended class for 8 h (external) and spent several hours on assignments. To avoid hurting my eyes, I had to sleep all the time to rest my eyes. But due to sleeping and watching computer all the time, we easily get trapped in a depressed mood. Without patients, I had no sense of achievement. I began to wonder if I should learn nursing? (42). (online practicum) … Sitting in front of the computer all the time, sometimes I would lose my concentration, and my eyes were uncomfortable. In addition to looking at the computer in class, we must watch the computer all the time after class. I did not like it … Although I may be scolded by the upperclassmen or teachers in the clinic, it was better than staring at the computer for 8 h (53). Staring at the screen all the time would hurt my eyes, and sitting for a long time also made my whole body ache. So, I would lose my concentration, and the absorption effect of knowledge would be poor (57). I did not want to use the computer after online practicum courses, so I did not have the motivation to complete my homework (91).

Difficulty Replacing Learning in Real Clinical Scenarios

Another disadvantage of online clinical practicum is that clinical practicum cannot actually be replaced by other learning methods. Students can be cultivated to acquire some abilities in the clinical practicum different from those gained in the classroom, such as the establishment of relationships between nurses and patients, cooperation and communication skills with others, ability to think and analyse and ability to respond to clinical events, among others. Students said that online clinical practicum teachers exerted their best to use multiple teaching strategies, such as multimedia or clinical cases, to bring students closer to the real clinical scenarios. However, most students still clearly said that replacing real clinical scenarios was difficult. First of all, students said that based on online clinical practicum, responding to real clinical scenarios; actually feeling or experiencing the establishment process of the therapeutic relationship between nurses and patients; and cooperation, communication and interaction between medical teams were indeed difficult for them. Given the lack of on-site feelings and experience, the practicum process became very illusory and unreal. Students' feedback: In clinical practicum, we could see the actual situations of patients, establish professional relations with patients and their families, and learn some clinical experience from seniors. However, we could only see written data in online practicum without on-site feelings (50). We could only discuss online cases via visual communication and practice the relations between nurses and patients via simulation. In addition, we could not actually implement technologies and experience the relationship between nurses and patients in a clinic and cases. It was a pity (60). No matter how realistically simulated it is, it can not be as real as in the clinic. It is impossible to collect data and acquire health education on real patients. We always faced our teachers. It was easy to collect data, but there was no sense of reality in talking to patients. Collecting information from teachers, I felt it is fake. We always assume without substance (46).

Moreover, the participants on the online practice platform are only teachers and students. Owing to the limited teaching aids and moulds available, students cannot directly use the technologies and knowledge they have learned to practise on individual cases. In addition, it will affect students' skill practice. Most of the time, students can only replace clinical technical operations with imagination or movies, resulting in a relatively low experience value of students in clinical practice. Students said: Online practicum is really too impractical. The meaning of practicum is going to the clinic to practise and communicate with real patients. Online practicum is almost the same as attending classes at school (141). Online practicum makes it impossible to practise in technical courses. We can only learn from videos, and the learning effect is worse than that of technical courses at school (107). It's all talk on paper. Those technologies cannot be actually operated but only watched in videos and shared by teachers. Many of the assignments are done through imagination … (25). Online practicum is like talking on paper without practical interaction with patients and doing real technologies. There will be a gap in technology (68). We cannot really face patients, just like at school, no sense of reality. All the lessons in the nursing records have to be performed by ourselves, and we cannot do well in technology, just like at school as before (22).

The ability of thinking and coping is very important in the nursing process of clinical cases. This ability is slowly cultivated in the practicum process based on observation, practice and thinking of case nursing. Online clinical practicum can be done unilaterally by teachers and students in the framework of the set clinical situation. Therefore, learning on the video platform limits students' learning of adaptability in clinical nursing, and their clinical thinking and coping ability cannot be improved. Students' feedback: By online practicum, we could not really realise the nursing work in the hospital and also could not see the progress of the diseased condition and patients' real feelings. Far different from what can be learned in real practice in the hospital, and we have no way to see the updates of medical records. I had a feeling that I had no goals in practicum every day (107). The greatest regret is that after all, there are many technologies that cannot be actually operated, and there is no way to train their on-the-spot reaction ability. The biggest feature in the clinic is that each case will change every day, so we need to adjust our nursing measures according to the changes and give the most suitable scheme to each case (76). There is no opportunity to practice on-the-spot reaction and the ability to adjust to changing circumstances. In a clinic, the cases or diseased conditions are changeable, and no script is available (102). I think the biggest disadvantage of online practicum is that students can not really contact patients. Many technologies cannot be implemented in practice. They can only visually imagine the procedure by themselves, play videos about the technologies practised in school, or look for books and find videos via the Internet. However, all of them cannot compare with the clinical practicum. Patients are more and changeable in the clinic, with great differences. They may play against the rules, and the routines in hospitals are different. It is difficult to copy and paste the whole set of textbooks in clinical practicum, which is a pity for me (157)!

Discussion

Clinical experiences are essential for the student's integration of skills, theory and critical thinking processes into professional practice. Practicum environments are “crucial links to students' successful experience(s)” (Mitchell and Delgado 2014). The traditional clinical environment prevailed as the gold standard as nursing students perceived gains in knowledge, practice of skills of communication, nursing process, holistic care, critical thinking and development of self-efficacy (Badowski et al. 2021). The COVID-19 pandemic has dramatically changed nursing students' learning pathways. The learning system has changed dramatically from face-to-face learning to online clinical practicum at home. This study aims to explore the satisfaction of nursing students in Taiwan with the unprecedented sudden online clinical practicum during the COVID-19 epidemic and their experiences, perceptions and views on online clinical practicum.

Satisfaction With Online Clinical Practicum

The results show that students' overall satisfaction with online clinical practicum is moderate (3.33 ± 0.98). Compared with other studies, Natarajan and Joseph (2022)'s study found that the majority of nursing students (71.8%) had low satisfaction with emergency remote teaching. Dutta et al. (2021)'s study found that the majority of the students (42%) gave a negative response (very dissatisfied and dissatisfied) to online clinical practicum with no significant difference between medical and nursing students (p = 0.192). Our research results are inconsistent with theirs, which may be due to differences in the teaching strategies used in the online clinical practicum. Their students expressed that they were largely dissatisfied with the cancellation of clinical rounds, ward posting and real patient interaction which had deprived the students of gaining and enhancing their clinical skills. The authors believe that this result may be due to the fact that 7–8 participants were on the online clinical practicum platform, and the teaching process is limited to the interaction between teachers and students, which causes difficulty in providing people outside the teachers and students with learning on communication, interactive exchange and team cooperation between medical teams and between nurses and patients in real clinical scenarios. Dutta et al. (2021)'s study also found that students were generally satisfied with the support and response from the teaching personnel but dissatisfied with the lack of practical or clinical learning. Suliman et al. (2021)'s study also found that students described that although several platforms and strategies including instructional videos, simulations and case studies were used, they were worried about not attaining the skills they needed to practise.

This study also found a moderate level of students' satisfaction with the teaching activities (3.63 ± 1.03) and assignments (3.75 ± 0.99) of online clinical practicum, while the average satisfaction with teaching activities and assignments was slightly higher than the overall satisfaction. The reason for this result is supported by students' statements. In online clinical practicum, teachers are provided with more abundant and flexible time and space to arrange their courses and guide students to do online clinical practicum using different strategies, thereby bringing students closer to the actual clinical setting while affording them much more time to prepare and do assignments. This study result shows that students' satisfaction with online clinical practicum teachers' attitudes is the highest. This result may show that although teachers incorporated many teaching strategies for online clinical practicum and invested hours in preparing and delivering videos and activities to engage students, students still perceived that online clinical practicum is not suitable for nursing practicum, but the students were very satisfied with the teachers' attitude toward online instruction. The author's conjecture suggests that this finding may be due to the teachers' ability to quickly respond to the epidemic and adjust face-to-face clinical practicum to an online practice course, stay together with students on the platform in the teaching process, and pay attention to each student and give timely feedback, which concerns the students all the time. Most importantly, some students said that the hand-raising activities of teachers encourage us to speak in class, with no blame if we make mistakes, and also told us the correct knowledge (103). Teachers give positive affirmation rather than criticism to students' responses.

In conclusion, this study result shows that students' overall satisfaction with online clinical practicum is not high. Students are still looking forward to the traditional learning mode of on-site clinical practicum. Nonetheless, their satisfaction with online clinical practicum teachers' teaching attitude is the highest. Teachers' attitude of encouraging instead of criticising remains one of the most important teaching abilities for this generation of students. The online clinical practicum mode at this stage is the online clinical practicum adopted for a long time in Taiwan for the first time. The current online clinical practicum programme is incomplete. Is the effect of online clinical practicum course planning on students' satisfaction with online clinical practicum due to the differences in teachers' pedagogical experience, teaching resources and teaching strategies? Can the online clinical practicum course also achieve the clinical nursing training goal? Furthermore, future employment, adaptation and clinical nursing abilities are worth exploring in the future.

Experiences and Perceptions of Online Clinical Practicum

Providing Flexible Learning Time and Space

In this study, most students said that online clinical practicum could reduce their traffic time to and from the practicum institutions and indirectly increase their sleeping time. Students also said that they had much more time to plan and write reports and assignments to improve the integrity of their assignments. This research result corresponds with other studies. Suliman et al. (2021)'s study also found that most of the students described several advantages of online clinical practicum, such as saving money and time travelling, spending more time with families, revising the sessions at their convenience and enjoying more rest and sleep.

Furthermore, the nursing students in this study stated that data query in real time via the Internet can improve the timeliness of problem solving. Rasmussen et al. (2022) also found that some students expressed increased confidence because online clinical practicum suited them. In particular, online clinical practicum gave them extra time to reflect on their learning, and they could access learning material at convenient times. The online clinical practicum mode can effectively save students' traffic time to and from the practicum institutions, allowing them to properly plan and use the saved time for sleeping, assignments, and data query. Using online clinical practicum mode, students can find and solve current problems at any time and in real time. This practicum mode really helps shorten the differences in time, traffic and space from traditional in-person practicum.

Improving the Learning Depth of Nursing Profession

During the pandemic, nursing schools have been challenged with providing innovative clinical experiences that allow for distance learning while maintaining the development of clinical reasoning and critical thinking skills (Lewandowski et al. 2021). This study result is slightly different from the findings in international literature (Dutta et al. 2021; Suliman et al. 2021). To illustrate, some students expressed perceptions of a loss of faculty support or mentoring. Others felt more engaged and able to connect directly with their faculty through virtual platforms (Leaver et al. 2022). In this study, most students stated that the online clinical practicum mode enables each student to simultaneously coexist with the teacher on the same learning platform, which allows teachers and students to have abundant time for interaction. Teachers quickly answer students' questions in real time and pay attention to students' learning. Moreover, students have much more time to prepare and search for materials. The nursing professional knowledge of students can be indirectly improved by repeatedly learning the professional knowledge. Most students expressed that the online clinical practicum together with teachers enables each student to accept individual guidance, which is helpful to improve and deepen the scientific principle of the nursing profession. However, the results of this study are mostly obtained from students' self-description and self-perception. Without previous study data as a scientific reference, the results can be referenced by subsequent research. In the future, we will further compare the learning effects of the nursing profession in clinical practicum and online clinical practicum.

Moreover, most students appreciate teachers who make good use of scenario cases, clinical teaching cases, video guidance, practical activities and assignments in online clinical practicum teaching to do clinical teaching. They achieve the latter through multiple teaching resources and channels to provide real clinical scenarios as much as possible and prevent students from experiencing boredom about learning through multiple teaching designs and activity arrangements to gain relatively more and establish deep learning. Suliman et al. (2021)'s study also found that online learning allows students to acquire knowledge at their own pace and actively engage in discussions, debates and problem solving. Similarly, McCutcheon et al. (2015) suggested that using online learning to teach clinical skills is as effective as traditional learning in developing the nursing competencies needed for safe practice. Therefore, the study results show that the online interactive learning of teachers and students and multiple teaching strategies help students focus on professional knowledge and enhance students' ability to link nursing professional knowledge with nursing care.

Negative Impact of Long-Term Online Learning on Body and Mind

The students in this study described the physiological and psychological effects of long-term online learning, including increasing load on eyes, physical fatigue, muscle pain, bone stiffness, distractibility, decreased learning motivation and enthusiasm and depression, among others. This research result accords with recent literature. Singh et al. (2021)'s study found that 37%–58% of the students reported health issues due to prolonged screen time. Loss of concentration (58.1%) was the most common problem followed by eye strain (54%), sleep disturbance (42.8%), neck pain (40.5%), back pain (40.4%), and headache (40%). Rasmussen et al. (2022) found that long-term online learning would worsen students' lack of learning motivation, which affected their attention and participation in teaching activities. Their students also felt isolated and experienced stress and anxiety that affected students' well-being and their ability to learn and study. In a word, the online learning mode is a double-edged sword. It provides real-time, individualised learning, convenience and improves the security of technical operations (Dost et al. 2020; McCutcheon et al. 2015; Suliman et al. 2021). Conversely, it has impact and effects on the body and mind. Therefore, apart from considering the liveliness of teaching contents in the future development of online clinical practicum course design, we should study the proportional allocation of teaching, activity and rest. We recommend designing online clinical practicum courses that are more suitable and in line with the clinical practicum objectives and which improve the physical and mental load and impact brought by the online clinical practicum.

Difficulty Replacing the Learning in Real Clinical Scenarios

Theoretical and professional knowledge and skills are insufficient for nursing students. They must master critical thinking to make appropriate judgement and choose the correct nursing decision, thereby solving patients' problems (Arrue and Caballero 2015; Forsgren et al. 2014; Gholami et al. 2017). Clinical practicum is essentially experience learning. It achieves the purpose of learning through practical operation, observation and reflection. It is a continuous process of experience transformation, reorganisation and transformation into knowledge. However, in this study, students clearly express that compared with clinical practicum in real scenarios, online clinical practicum lacks communication and interactive training with patients and medical teams and real clinical scenarios (on-the-spot feelings), leading to insufficient skills and practical experience. The students said that even though the teaching of online clinical practicum by teachers is diversified, flexible, resourceful and strategic, it remains a challenge in terms of closing the gaps from in-person practicum ability training, which inevitably creates anxiety among students about their future performance after entering the clinic. Therefore, online learning is unable to replace the learning scenarios and feelings provided by real clinical scenarios. Additionally, it may not meet the learning expectations and practicum goals of nursing students in the clinical practicum process. These study findings are consistent with relevant literature on students' perceptions of online learning or virtual simulation learning. Michel et al. (2021)'s study showed that nursing students believe that using a virtual environment and online simulation could not be a substitute for direct patient care, as they would reduce contact with patients and reduce their clinical experience. Moreover, Badowski et al. (2021) explored student perceptions of virtual simulation versus traditional clinical and mannequin-based simulation. Its result indicates that traditional clinical experiences meet students' perceived learning needs for all degree programmes of study for subscale items of communication, nursing process, holism, critical thinking and self-efficacy. Thus, nursing students are prepared for professional life by acquiring many attributes, such as the formation of professional identity in clinical settings, role modelling and developing patient–nurse relationships. These results show that the learning in clinical scenarios is necessary for the training of professional capacity. These results corresponded with our quantitative finding of satisfaction on online clinical practicum. Some studies also support these findings. In Head et al. (2022)'s study, nursing students consistently reported that the clinical experience was an “outstanding” or “favourite” learning experience, and it increased their confidence at the bedside.

Previous studies show that hands-on practice is significantly associated with students' competency in nursing care. Online learning has many advantages, such as extendibility, accessibility, suitability, affordability and travel cost and time savings. However, further verification is required to determine whether it is appropriate for subjects with learning objectives oriented towards skills and critical thinking. In Cengiz et al. (2022)'s study, nursing students favoured hands-on experiences and face-to-face contact to ensure proficiency in clinical practicum; many students also expressed that clinical applications were insufficient, and they had no solution regarding how to gain skill-based learning via online learning. Moreover, Suliman et al. (2021) and Rasmussen et al. (2022) stated that most nursing students expressed learning skills online to be impossible, and it would negatively affect their clinical readiness upon graduation. Moreover, Hoang et al. (2022) highlighted that most students feel underprepared for theoretical and practical skills assessment, and their primary concern was the loss of authentic clinical experiences and, more specifically, the ability to observe and assess patients through direct engagement. From these findings, nursing students' concerns regarding their clinical competencies implied that they were concerned about their safe practice and hence patient safety. Nursing students favoured hands-on experiences to ensure proficiency in clinical practicum. However, for nursing students who must take online clinical practicum during the epidemic, whether their nursing competence, clinical employability, communication and cooperation with the team in the future are affected by this teaching mode is a topic that deserves continuous attention.

Limitations and Recommendation

This study has several limitations. First, the students' responses to the questionnaires may be far from being objective as they were obtained through their own self-evaluation. Second, nursing students' satisfaction and perceptions of the online clinical practicum on Medical-Surgical Nursing explored in this study cannot be extended to those students of other subjects in online clinical practicum. Finally, analysing online messages without verbal cues could mean that our interpretation of their content is wrong. However, we analysed all the responses within the context by closely reading all of them.

This study result recommends a continuous follow-up on nursing students of online clinical practicum to understand their clinical competence in future practicum and after graduation. In addition, whether the modified teaching strategies in response to the epidemic situation affect their clinical competence should be understood.

Conclusions

Owing to the COVID-19 epidemic, the clinical practicum of nursing students has to break away from the traditional learning mode and turn from in-person clinical practicum to online clinical practicum. The shift in teaching is an innovative and different teaching mode for teachers and even students. Both teachers and students must constantly learn, adapt and adjust quickly. This study result shows that students have a moderate level of overall satisfaction with online clinical practicum, but a high level of satisfaction with teachers' teaching attitudes. Students are satisfied with the flexible use of time and space provided by online clinical practicum. They also appreciate the deep exchanges and interactions between teachers and students, which additionally improve the depth of students' understanding of the nursing profession. By contrast, online clinical practicum students have to use computers for a long time to study, discuss, share and do assignments, resulting in a physical and mental impact and learning load on students, a lack of more external stimulation, and an affect learning motivation. Most students accept online clinical practicum during an epidemic, but they still believe that clinical learning in real scenarios cannot be replaced by case teaching in virtual scenarios, and only clinical practicum can genuinely provide students with opportunities in communication, cooperation and skill practice, which can help improve their nursing knowledge and ability, thinking ability and clinical experience.

Author Contributions

Li-Hung Tsai designed and managed the research project. Li-Hung Tsai substantially contributed to the study conceptualisation and design. Li-Hung Tsai substantially contributed to data collection. Li-Hung Tsai, Chia-Jung Wu, Sum-Fu Chiang and Chuan-Mei Chen significantly contributed to data analysis and interpretation. Li-Hung Tsai drafted the article and critical revision of the article. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank all the participating students.

Ethics Statement

This study was approved by the Institute Review Board, Chang Gung Medical Foundation (No. 201901913B0).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

Arrue, M., and S. Caballero. 2015. “Teaching Skills to Resolve Conflicts With Acute Confusional Syndrome Patients in Nursing Using the Case Method (CM).” Nurse Education Today 35, no. 1: 159–164. https://doi.org/10.1016/j.nedt.2014.09.006.

Ayaz‐Alkaya, S., Ş. Yaman‐Sözbir, and B. Bayrak‐Kahraman. 2018. “The Effect of Nursing Internship Program on Burnout and Professional Commitment.” Nurse Education Today 68: 19–22. https://doi.org/10.1016/j.nedt.2018.05.020.

Badowski, D., K. L. Rossler, and N. Reiland. 2021. “Exploring Student Perceptions of Virtual Simulation Versus Traditional Clinical and Manikin‐Based Simulation.” Journal of Professional Nursing 37, no. 4: 683–689. https://doi.org/10.1016/j.profnurs.2021.05.005.

Cengiz, Z., Z. Gurdap, and K. Işik. 2022. “Challenges Experienced by Nursing Students During the COVID‐19 Pandemic.” Perspectives in Psychiatric Care 58, no. 1: 47–53. https://doi.org/10.1111/ppc.12923.

Chen, S. L., J. L. Sun, and J. Y. Jao. 2020. “A Predictive Model of Student Nursing Competency in Clinical Practicum: A Structural Equation Modelling Approach.” Nurse Education Today 95: 104579. https://doi.org/10.1016/j.nedt.2020.104579.

Dost, S., A. Hossain, M. Shehab, A. Abdelwahed, and L. Al‐Nusair. 2020. “Perceptions of Medical Students Towards Online Teaching During the COVID‐19 Pandemic: A National Cross‐Sectional Survey of 2721 UK Medical Students.” BMJ Open 10, no. 11: e042378. https://doi.org/10.1136/bmjopen‐2020‐042378.

Dutta, S., S. Ambwani, H. Lal, et al. 2021. “The Satisfaction Level of Undergraduate Medical and Nursing Students Regarding Distant Preclinical and Clinical Teaching Amidst COVID‐19 Across India.” Advances in Medical Education and Practice 12: 113–122. https://doi.org/10.2147/AMEP.S290142.

Forsgren, S., T. Christensen, and A. Hedemalm. 2014. “Evaluation of the Case Method in Nursing Education.” Nurse Education in Practice 14, no. 2: 164–169. https://doi.org/10.1016/j.nepr.2013.08.003.

Gholami, M., M. Saki, T. Toulabi, P. Kordestani Moghadam, A. H. Hossein Pour, and R. Dostizadeh. 2017. “Iranian Nursing Students' Experiences of Case‐Based Learning: A Qualitative Study.” Journal of Professional Nursing 33, no. 3: 241–249. https://doi.org/10.1016/j.profnurs.2016.08.013.

Head, M. L., S. Acosta, E. G. Bickford, and M. A. Leatherland. 2022. “Impact of COVID‐19 on Undergraduate Nursing Education: Student Perspectives.” Academic Medicine 97, no. 3S: S49–S54. https://doi.org/10.1097/ACM.0000000000004530.

Hoang, H., B. Jessup, K. Obamiro, et al. 2022. “Impact of COVID‐19 on Rural and Remote Student Placements in Australia: A National Study.” Australian Journal of Rural Health 30, no. 2: 197–207. https://doi.org/10.1093/jtm/taaa060.

Huang, H. M., and Y. W. Fang. 2023. “Stress and Coping Strategies of Online Nursing Practicum Courses for Taiwanese Nursing Students During the COVID‐19 Pandemic: A Qualitative Study.” Healthcare (Basel) 11, no. 14: 2053. https://www.mdpi.com/2227‐9032/11/14/2053.

Kang, Y., and H. Hwang. 2023. “The Impact of Changes in Nursing Practicum Caused by COVID‐19 Pandemic on New Graduate Nurses.” Nurse Education Today 121: 105675. https://doi.org/10.1016/j.nedt.2022.105675.

Konrad, S., A. Fitzgerald, and C. Deckers. 2021. “Nursing Fundamentals—Supporting Clinical Competency Online During the COVID‐19 Pandemic.” Teaching and Learning in Nursing 16, no. 1: 53–56. https://doi.org/10.1016/j.teln.2020.07.005.

Leaver, C. A., J. M. Stanley, and T. Goodwin Veenema. 2022. “Impact of the COVID‐19 Pandemic on the Future of Nursing Education.” Academic Medicine 97, no. 3S: S82–S89. https://doi.org/10.3912/OJIN.Vol25No03PPT51.

Lewandowski, S., K. Landry, and V. Prieto. 2021. “Rising to the COVID‐19 Nursing Education Challenges and Transitioning to Online Clinical Practice: Reflecting a Year Later.” Nurse Educator 46, no. 6: E141–E142. https://doi.org/10.1097/nne.0000000000001113.

Liesveld, J., J. Rohr, K. Petrovic, S. Grohman, and C. L. Bourgeois. 2023. “Nursing Student Challenges During the COVID‐19 Pandemic From 2020 to 2021: A Thematic Analysis.” Teaching and Learning in Nursing 18, no. 1: 50–55. https://doi.org/10.1016/j.teln.2022.10.006.

Liu, Y. M., M. C. Chen, F. F. Chung, et al. 2020. “Challenges to the Nursing Practicum During the COVID‐19 Pandemic.” Journal of Nursing 67, no. 6: 25–31. https://doi.org/10.6224/jn.202012_67(6).05.

McCutcheon, K., M. Lohan, M. Traynor, and D. Martin. 2015. “A Systematic Review Evaluating the Impact of Online or Blended Learning vs. Face‐To‐Face Learning of Clinical Skills in Undergraduate Nurse Education.” Journal of Advanced Nursing 71, no. 2: 255–270. https://doi.org/10.1111/jan.12509.

Michel, A., N. Ryan, D. Mattheus, et al. 2021. “Undergraduate Nursing Students' Perceptions on Nursing Education During the 2020 COVID‐19 Pandemic: A National Sample.” Nursing Outlook 69: 903–912. https://doi.org/10.1016/j.outlook.2021.05.004.

Mitchell, M. M., and C. Delgado. 2014. “Online Learning: Advantages and Challenges in Implementing an Effective Practicum Experience.” Open Journal of Nursing 4, no. 6: 379–384. https://doi.org/10.4236/ojn.2014.46044.

Natarajan, J., and M. A. Joseph. 2022. “Impact of Emergency Remote Teaching on Nursing Students' Engagement, Social Presence, and Satisfaction During the COVID‐19 Pandemic.” Nursing Forum 57, no. 1: 42–48. https://doi.org/10.1111/nuf.12649.

Oanh, T. T. H., N. T. Y. Hoai, and P. T. Thuy. 2021. “The Relationships of Nursing Students' Satisfaction and Self‐Confidence After a Simulation‐Based Course With Their Self‐Confidence While Practicing on Real Patients in Vietnam.” Journal of Educational Evaluation for Health Professions 18, no. 1: 16. https://doi.org/10.3352/jeehp.2021.18.16.

Ramos‐Morcillo, A. J., C. Leal‐Costa, J. E. Moral‐García, and M. Ruzafa‐Martínez. 2020. “Experiences of Nursing Students During the Abrupt Change From Face‐To‐Face to e‐Learning Education During the First Month of Confinement due to COVID‐19 in Spain.” International Journal of Environmental Research and Public Health 17, no. 15: 5519. https://doi.org/10.3390/ijerph17155519.

Rasmussen, B., A. Hutchinson, G. Lowe, et al. 2022. “The Impact of Covid‐19 on Psychosocial Well‐Being and Learning for Australian Nursing and Midwifery Undergraduate Students: A Cross‐Sectional Survey.” Nurse Education in Practice 58: 103275. https://doi.org/10.1016/j.nepr.2021.103275.

Shorey, S., T. L. B. Pereira, T. W. Zhou, E. Ang, L. T. Ching, and D. D. Samarasekera. 2022. “Navigating Nursing Curriculum Change During COVID‐19 Pandemic: A Systematic Review and Meta‐Synthesis.” Nurse Education in Practice 65: 103483. https://doi.org/10.1016/j.nepr.2022.103483.

Singh, H. K., A. Joshi, R. N. Malepati, et al. 2021. “A Survey of E‐Learning Methods in Nursing and Medical Education During COVID‐19 Pandemic in India.” Nurse Education Today 99: 104796. https://doi.org/10.1016/j.nedt.2021.104796.

Suliman, W. A., F. A. Abu‐Moghli, I. Khalaf, A. F. Zumot, and M. Nabolsi. 2021. “Experiences of Nursing Students Under the Unprecedented Abrupt Online Learning Format Forced by the National Curfew due to COVID‐19: A Qualitative Research Study.” Nurse Education Today 100: 104829. https://doi.org/10.1016/j.nedt.2021.104829.

Tambunan, E. H., and R. R. Sinaga. 2023. “Stress Levels and Coping Strategy of Nursing Students in Online Learning During COVID‐19 Pandemic. A Mixed‐Methods Study.” Investigación y Educación en Enfermería 41, no. 2: e09. https://doi.org/10.17533/udea.iee.v41n2e09.

Visiers‐Jiménez, L., A. Suikkala, L. Salminen, et al. 2021. “Clinical Learning Environment and Graduating Nursing Students' Competence: A Multi‐Country Cross‐Sectional Study.” Nursing and Health Sciences 23, no. 2: 398–410. https://doi.org/10.1111/nhs.12819.

Waltz, C. F., O. L. Strickland, and E. R. Lenz. 2005. “Content Analysis.” In Measurement in Nursing and Health Research, edited by C. F. Waltz, O. L. Strickland, and E. R. Lenz, 239–245. Springer Publishing Company.