Introduction

In China, nursing education comprises three main stages: fundamental knowledge stage, professional knowledge stage, and clinical internship stage [1, 2]. The clinical internship is an indispensable part of nursing education. It aims to teach students the necessary knowledge and skills to prepare them for the demanding experience of a registered nurse and gain competence in future work [3]. During internships, fourth-year nursing students will be assigned to different departments to attend face-to-face interactive tutorials conducted by different clinical nursing teachers. Only after completing a clinical internship lasting for at least 10 months can these students graduate and take the licensure exam to become registered nurses [4]. In China, nursing students generally start their clinical internships in April or May. However, in year 2020, the COVID-19 pandemic prevented them from participating in any clinical activity, making it impossible for them to complete school as usual [5].

Electronic learning (e-learning) is an educational system that provides educational or training programs for students or trainees anytime and anywhere by using interactive information and communication technology, such as the internet, TV channels, e-mail, computers, and teleconferencing, synchronously or asynchronously [6]. With its accessibility, flexibility and convenience in facilitating varied interactions without the need for direct contact, e-learning has been used as an alternative strategy to help students continue their learning [7–10].

Early in the epidemic, 103 nursing students in our hospital were in the awkward position of not being able to advance their clinical practice. Fortunately, the hospital nursing teaching and research office then quickly issued the electronic nursing internship program and the online internship syllabus, which were all based on e-learning strategies [11]. Teaching content, methods, schedule, assessment methods, and so on, were made clear. The office suggested that: (1) lectures be delivered online by using the video conferencing platform Tencent Meeting or Dingtalk. On these platforms, virtual rooms can be created, and 300 people can be accommodated at the same time to share the computer screen and various computer files (e.g., documents, PDFs, PowerPoint files), exactly as if the files were projected by video in a lecture hall. (2) clinical nursing skills demonstration be replaced by online demonstration or videos. (3) inquiry of information, providing health education, etc., be carried out through live broadcast. Accordingly, each department made a specific e-internship arrangement based on each department’s characteristics. From July to August 2020, 103 nursing students all participated in e-internships and completed them.

This was the first time in China that conventional education activities had been suspended for so long and nursing students had to depend on e-internships to complete their studies. Therefore, e-internship was a special experience for these students. Although some research had been conducted on nursing education during a pandemic [7, 10, 12], a body of knowledge on internship experiences, especially on e-internship experiences during a pandemic, is lacking. The purpose of this study was to explore the experiences and feelings of undergraduate nursing students carrying out an eight-week e-internships during the COVID-19 pandemic.

Methods

Data collection and data analysis

In this study, data collection and analysis were performed simultaneously during the study period. Semi-structured, in-depth, face-to-face interviews were conducted from October to December 2020 (Fig 1). To minimize the biases of researchers and participants and to maintain neutrality, a master student in nursing who had no direct relationship with the study but had experience in qualitative interviews was recruited to conduct all interviews, and any suggestions from interviewers were avoided. All interviews were conducted in a private, quiet conference room to maintain privacy and comfort. The interview guide was formulated based on the purpose of the study. Before the study, the interview guide was pilot tested in three preliminary interviews to ensure all questions were clear and understandable to the participants. The final interview outline is shown in Table 1. Before the interview, demographic information, such as age, gender, place of residence, and internship status, was acquired. Each interview lasted 30 to 40 minutes and was audio recorded. The audio recording was transcribed verbatim by two members of the research team within 24 hours, and the interviewer’s reflexive notes were also discussed among members of the research team. The interviews and original transcripts were originally recorded in Chinese. All quotations were translated into English by Guoli Yang (a nursing PhD with six months of study experience in the United States) and back translated into Chinese by Aidi Zhang (a nursing PhD with one year of study experience in the United States) to assess semantic equivalence between the original and back-translated versions of the transcripts.

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Fig 1. Flow diagram of the study.

https://doi.org/10.1371/journal.pone.0273963.g001

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Table 1. Interview guide.

https://doi.org/10.1371/journal.pone.0273963.t001

All audio and written data were imported into the qualitative software NVivo V.12 (QRS International). Based on interview transcripts and field notes, data were analyzed using Colaizzi’s (1978) analytic method [17], which comprises a seven-step, intensive and inductive process: 1) reading the contents of the transcribed interviews repeatedly to identify the overall themes; 2) extracting significant statements while marking potentially essential content; 3) formulating the meanings of significant statements; 4) categorizing the formulated meanings into sub-themes, themes, and clusters of themes; 5) integrating the findings into an exhaustive description by using continuous analysis and a refining process; 6) identifying the fundamental structure through an exhaustive analysis (the fundamental structure was found to consist of 4 dimensions); and 7) verifying the research findings with participants. Initial data coding was completed by two members of the research team. Nevertheless, there were ongoing discussions among all research team members about the analysis of the data, and the research team reached an agreement on the final findings presented in this paper. Throughout the paper, we followed the Consolidated Criteria for Reporting Qualitative Research [18].

Results

Participants

Seventeen participants, including five males and twelve females, were recruited into the study. They came from six provinces, including Hunan, Chongqing, Yunnan, Zhejiang, Anhui, and Jilin. The characteristics of the participants are shown in Table 2.

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Table 2. Participant characteristics (n = 17).

https://doi.org/10.1371/journal.pone.0273963.t002

We captured four generic categories and 12 subcategories about the participants’ perceptions of and experiences in the e-internship (Table 3).

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Table 3. Main themes and sub-themes identified in the study.

https://doi.org/10.1371/journal.pone.0273963.t003

Discussion

This study explored the perceptions and experiences of undergraduate nursing students who completed an eight-week e-internship program during the COVID-19 pandemic by using phenomenological methods. Four themes were captured: perceived images of clinical nurses in e-internships, psychological experience, perceived benefits of e-internships, and perceived limitations of e-internships.

The findings of this study showed that during their e-internships, the students gained more knowledge about the images of nurses. In their opinion, nurses are “dedicated and hardworking” and “professional and skillful”. The students appreciated their teachers’ dedication and praised their teachers’ clinical skills and teaching abilities. Robert and his colleagues [20] discovered similar results in their qualitative research, all participants praised the professionalism, courage and humanity of teachers during this crisis. Images of clinical nursing teachers are directly related to what kind of nurses the students will become in the future [21]. In this study, several participants said that they admire their teachers and expected to eventually become nurses like them. Practically, for nursing students, internships are a process of learning and a process of exploring their own future work [22]. The students’ image of nurses is probably what the students perceive of themselves in their future career. With a positive image in their mind, the students will attach a strong sense of professional identity to the job they are committed to and thereby better motivate their self-efficacy to achieve this image. Otherwise, they are likely to show little interest in becoming nurses [23, 24]. Therefore, it is very important to culture and select nursing teachers with outstanding qualities and abilities for nursing students, whether the students receive in-person or e-internship instruction.

When students are faced with the sudden suspension of the internship, it is normal for them to feel regretful and anxious. In our study, few students worried about being infected. In contrast, they were anxious to carry out on-site clinical internships and even expected to play a role in preventing and controlling the epidemic. This finding differs from that of Cristina’s study in Portugal [25]; The aforementioned study showed that during their clinical internships, nursing students were afraid of becoming infected, coming out of lockdown and being in contact with people and providing care. This difference may result from the different epidemic times and degrees in different countries. In July and August 2020, COVID-19 was basically controlled in China [26], while in other countries, the epidemic is still developing rapidly [27].

The feeling of uncertainty is common in the participants’ descriptions of their psychological experiences during the e-internships [28–30]. The participants’ sense of uncertainty comes from two main sources. One is the limitations of e-internships, and the other is the epidemic situation. Obviously, the practical ability of nurses needs to be tested in clinical practice, but in e-internships, nursing students are deprived of this opportunity. In e-internships, nursing students also have no chance to communicate with teachers and patients face to face or to receive direct guidance and supervision from teachers, thus increasing the sense of uncertainty about the effect of e-internships [29, 30]. In addition, the sudden occurrence of the epidemic made nursing students realize their insignificance and their helplessness in the current situation and produced in them a sense of uncertainty [31, 32]. To reduce the sense of uncertainty, teachers should strengthen communication with students, create conditions for them to communicate with patients, convey more positive developments about the epidemic to them and conduct psychological interventions when necessary [28]. Certainly, the most useful method is to resume their most anticipated clinical on-site internships as soon as possible if conditions permit, to purposefully strengthen the assessment of what they have learned during e-internships, and to conduct targeted actions when necessary.

Due to the sudden outbreak of the epidemic and the high mortality rate, it is indeed too risky to carry out on-site internships before the epidemic is controlled. Although there is no way to fully replace the experience of on-site internships, students in this study believed that e-internships were the most reasonable arrangements the hospital could make for them in such a special and critical situation. In our study, the content of the e-internship is student-centered and offers a great deal of flexibility in terms of location. In addition, teachers used many online tools, such as a combination of audio, videos, text, PPT, live broadcast, and so on, to reach out to their students. Moreover, students can watch a video repeatedly to gain a deeper understanding of what teachers said. All these factors made e-internships possible and effective for nursing students. Thus, although these students regretted not being able to participate in traditional internships, the students still showed good acceptance of e-internships and perceived that they achieved much during e-internships.

We are not the only ones to support e-internships. At the height of the epidemic, almost the whole world has suspended face-to-face learning and on-site internships. e-internships, virtual internships [33, 34], and distant teaching [35, 36], similar learning methods based on information technology, have been employed unprecedentedly in the world. Michael et al. [36] found that web-based surgical skills learning is a feasible alternative for face-to-face surgical skills teaching. Hao [37] concluded that standalone digital education modalities were as effective as conventional learning for knowledge and practice. E-internships have also been applied to dental education [38] and urological education [32] and have achieved positive results. Based on these findings, we have reasons to believe that e-internships are promising and worthy of promotion. However, as stated by the participants in this study, there are still many limitations that need to be addressed to make the e-internships better.

In this study, participants presented four main limitations about their e-internships, namely, limitations of practice opportunities, deficits in e-teaching ability, deficits in e-teaching resources and limitations of the learning platforms. The major reason there were so many limitations may be that there is a lack of standards for quality, quality control, development of e-resources, and e-content delivery [39]. Therefore, hospitals should first formulate guidelines and standards for e-internships according to the characteristics of nursing students. Departments and teachers will know how to use these guidelines and standards to improve themselves. The e-teaching ability of teachers needs to be emphasized [39, 40]. The most basic requirement for teachers is to be proficient in operating the network teaching platform. In addition, teachers should present the curriculum in various formats, such as video, audio, and text, to increase students’ interests [11]. Students want two-way interaction; therefore, teachers should fully use the video function of the online platform to interact with students, such as by “calling the roll” and "asking questions”, to improve students’ sense of participation. It would be better if teachers complemented their lectures with video chats, virtual meetings, and so on, to obtain immediate feedback and maintain a personal connection with the students.

For the learning platform, with the continuous update of technology, Tencent Meeting and Dingtalk have become functionally stable learning platforms in China. Of course, it would be better if the institution or hospital could establish its own learning platform. With its own learning platform, each department can build its own resource library, and teachers, students and other relevant personnel can log in to their accounts for free, thus bringing e-learning into a more developed era.

The limitations of our study must be acknowledged. First, only nursing students were interviewed, related nursing teachers and nursing managers were excluded, which limited the reference significance of this research. In addition, e-internships were conducted from July to August, but our interviews started in October. There may be some time deviations in students’ perceptions and experiences.

Conclusion

With the rapid developments of technology, e-learning has been a trend. Carrying out e-internships is a way not only to deal with crisis situations but also to explore more possibilities for internships. In this study, our findings suggest that the e-internship is a suitable method for training and cultivating undergraduate nursing students’ clinical knowledge and skills during a crisis. To enhance the efficiency of e-internships, guidelines and standards should be formulated, and effective measures should be taken to build better e-internship platforms. In the future, we can try to combine on-site internships with e-internships, thereby fully using their advantages, and to improve the efficiency of internships as much as possible.

Acknowledgments

Our study was approved by the Third Xiangya Hospital of Central South University, so we are grateful to all relevant departments and personnel. We would like to thank Guoli Yang and Aidi Zhang for their assistance in data transcription. More importantly, we offer our special thanks to the nursing students who participated in this study. We also offer our special thanks to the editor and reviewers for their critical comments on an earlier version of the manuscript. We also thank AiMi Academic Services (www.aimieditor.com) and American Journal Experts (AJE) for English language editing and review services.