INTRODUCTION
In March 2020, after the first Coronavirus disease 2019 (COVID-19) outbreak in China in December 2019, the World Health Organization declared a pandemic. Since January 2020, when the first confirmed case was reported, 17,237,878 cumulative confirmed cases had occurred in South Korea by April 30, 2022 [1]. Although vaccine development, national social distancing recommendations, and quarantine guidelines had been applied [2], COVID-19 continued to spread worldwide due to easily transmitted virus mutations. Prolonged COVID-19 infections pose a significant threat to society as a whole. When a new infectious disease such as COVID-19 occurs, people use various online media to obtain related knowledge and preventive action information [3]. However, COVID-19 infections are prolonged, and related news is continuously reported; moreover, false and uncertain information has emerged that increases people's anxiety [4,5]. A previous study showed unclear information and negative attitudes toward infectious diseases such as COVID-19, leading to distress and panic [6].
Although college students in early adulthood are still forming healthy habits [7], there is a lack of interest owing to their relatively good health from the point of view of preventive medicine [8]. However, college students also xperience depression and anxiety from COVID-19 [9]. Nursing students are particularly interested in public health through clinical practice in hospitals and communities [10], but they are also in their early 20s. The knowledge and optimistic attitude about COVID-19 lead to good preventive practices [6], therefore, it is necessary to understand their knowledge, attitudes, preventive behavior, and anxiety regarding COVID-19.
The COVID-19 outbreak changed our lives, especially in education. Many colleges and universities need help maintaining face-to-face teaching. This situation has made them innovate and implement alternative educational strategies [11]. Besides this unprecedented educational crisis, faculty members have tried to provide learning opportunities like before COVID-19. So they have developed lots of E-learning classes [12,13]. Of course, nursing students and faculty members did their best in their school and clinical site circumstances. However, despite these efforts, due to COVID-19 and fewer learning opportunities at the clinical site, nursing students felt lost in their way.
The KAP (Knowledge, attitude, and practice) model suggests that individual knowledge changes attitudes and ultimately affects preventive practice under any infectious disease [14]. Individual compliance with preventive behaviors is mainly affected by their KAP toward COVID-19 under KAP theory [15]. Previous studies applying the KAP model to infectious diseases have been attempted in Middle East Respiratory Syndrome (MERS) [16], Ebola [17], and COVID-19 [6]. A review study of KAP among healthcare workers, medical students, and nursing students during the COVID-19 pandemic suggested that a high level of knowledge, positive attitudes, and good preventive practices are held [6]. However, anxiety and fear of COVID-19 levels were high among nursing students in Turkey [17]. It shows that anxiety of nursing students about COVID-19 pandemic is affect from the social mood. So it needs more studying about anxiety of nursing students after pandemic in South Korea. With the resumption of clinical practice, suspended at a time when there were still many COVID-19 patients, nursing students fear participating in clinical practice. However, influencing factors associated with nursing students’ anxiety exposure in clinical settings are relatively lacking. Therefore, This study attempted to investigate the relationship between knowledge, attitudes, preventive practices, and the anxiety of nursing students in clinical practice during the COVID-19 pandemic.
METHODS
Study design
This is a cross-sectional, descriptive study to determine the influencing factors of nursing students’ anxiety in participating in clinical practices during the COVID-19 pandemic.
Setting and samples
A total of 203 junior and senior nursing students participating in clinical practice education at three universities in Daegu city, South Korea, responded to an online survey. The reason why the subjects of the study were limited to nursing students in Daegu was that it was one of the cities with the largest number of COVID-19 patients in 2020, and the clinical practice began to resume in the second semester of 2020 partially. In addition, among nursing universities in Daegu, nursing students from universities that resumed clinical practice were selected as subjects of the study. Therefore, data were collected from March to April 2021. Among them, 172 questionnaires were analyzed for this study after 31 with missing data were excluded.
Instruments
Knowledge
The knowledge refer to information on what is known by a specific population [6], and it was measured using a questionnaire developed by Jang et al. [18]. This instrument consisted of 10 items, scoring one point for correct answers about disease onset (i.e., COVID-19 is a respiratory infectious disease caused by a coronavirus), four items about symptoms (e.g., fever, cough, sore throat, muscle pain, and shortness of breath are possible symptoms), three items on disease transmission (e.g., using face masks can help prevent disease transmission), and two items about prevention (e.g., if soap and water are not available, use a hand sanitizer that contains at least 60% alcohol). The maximum possible score was 10 points; the higher the score, the higher the level of knowledge.
Attitude
Attitude refer to information on what is believed by a specific poputaion [6]. Attitudes toward the COVID-19 pandemic were measured using a scale also developed by Jang et al. [18]. It consisted of two items for beliefs about overcoming a COVID-19 infection (e.g., confidence in winning the battle against COVID-19), two items on the importance of following directions (e.g., carefully reading and following instructions from the government), and one item (Do you agree that COVID-19 is a very dan-gerous contagious disease?) on the perceived severity of the infection. Each item was rated on a five-point Likert scale ranging from 1 (Not at All) to 5 (Absolutely). The Cronbach's α coefficient was 0.72 in a previous study [18], and in this study, Cronbach's α was 0.53.
Preventive practices
Practice refer to information on what is done by a specific populaion [6]. Preventive practices was measured using scale developed by Jang et al. [18], based on Centers for Disease Control and Prevention guidelines. It measured COVID-19 preventive behavior during the previous two weeks by ten items. Each item was rated on a four-point Likert scale from 0 (Not performed) to 3 (Performed all the time). Reliability based on Cronbach's α coefficient was 0.86 at the time of development [18], and Cronbach’s α was 0.77 in this study.
Anxiety
Anxiety is an emotion such as worry, tension [19], and it was measured using the Hospital Anxiety Depression Scale for Anxiety (HADS-A) which was developed by Zigmond and Snaith [20]. The HADS-A consists of seven items, each item ranging from 0 to 3. A total score of more than eight points out of 21 (the maximum possible) indicates con-siderable anxiety. The mean Cronbach's α coefficient was 0.83 in 747 literature reviews [21], and Cronbach's α was 0.69 in this study.
Data collection
Data were collected with an online survey through the nursing departments of three universities in South Korea, which was conducted from March 29 to April 12, 2021. A link to the questionnaire was pre-sented, along with a notice about the study's purpose and an explanation of the recruitment of students participating in clinical practice. It took about 15 minutes to complete the questionnaire.
Data analysis
The final 172 responses were analyzed using SPSS 28.0 (IBM Corp., Armonk, NY, USA), with statistical significance (p-value) at less than 0.05. First, descriptive statistics of the general characteristics and variables represented frequency as a percentage and the mean with standard deviation. Preventive practices and anxiety according to the general characteristics were analyzed via Pearson's correlation coefficient and independent t-test. Pearson's correlation coefficient was used to determine correlations among knowledge, attitudes, preventive practices, and anxiety. Finally, to determine influences on anxiety, a multiple linear regression analysis was conducted. There were no autocorrelations among the variables, with the Durbin-Watson statistic ranging from 1.92 to 2.04, and there was no problem over multicollinearity, with a variance inflation factor ranging from 1.02 to 1.44.
Ethical considerations
This study gained the approval of the Institutional Review Board (IRB) of University of Ulsan in South Korea (IRB No.: 1040968-A-2020-011), which verified ethical processes and the protection of respondents’ rights. All data collection was conducted after approval, and only subjects who voluntarily wanted to participate in the study responded to the survey through the link. Before starting the online survey, the purpose, method, and assurances of confidentiality in the research were described. In addition, participants were informed that they could withdraw any time they wanted without consequence. After checking ‘ I agreed’ if the sub-ject agreed to participate in the study, they proceeded to the questionnaire. The study subjects did not include minors.
RESULTS
Anxiety according to general characteristics
There were no statistically significant differences in anxiety according to age (r=-0.06, p =0.460), grade (t=1.07, p =0.288), isolation experience (t=-0.71, p =0.479) except gender (t=-4.42, p <0.001) (Table 1).
Table 1.
Preventive practice and anxiety according to the general characteristics (n=172)
Levels of knowledge, attitudes, preventive practices and anxiety
The average total score for knowledge was 8.21±1.10 out of 10 points. The mean attitude score was 4.22±0.36 out of 5, the preventive practice was 2.28±0.41 out of 3, and anxiety was 7.67±3.20 out of 21 (Table 2).
Correlations among knowledge, attitudes, preventive practices, and anxiety
Anxiety showed statistically significant negative correlations with attitude (r=-0.16, p = 0.037) and preventive practices (r=-0.16, p = 0.036), but not with knowledge (r= 0.08, p = 0.330) (Table 3).
Factors influencing anxiety
As a result of analyzing the effects on anxiety of nursing students, gender (β=0.33, p <0.001) and attitude (β=-0.18, p =0.026) were significant variables. The regression model was significant with explanatory power at 16% (F=4.45, p <0.001) (Table 4).
Table 4.
Factors influencing anxiety (n=172)
DISCUSSION
This study attempted to understand the anxiety of nursing college students participating in clinical practice during the pandemic of infectious diseases. Clinical practice is essential in the education curriculum for nursing students because they are future healthcare workers. However, nursing students are at greater risk of infection in clinical practice, just like hospital staff. Therefore, this study attempted to assess knowledge, attitudes, preventive practices, and psychological anxiety about COVID-19 to provide appropriate education and support and ensure safe clinical practices.
As a result of this study, the average score for anxiety was 7.67±3.20, and 24 subjects (15.0%) showed moderate to severe anxiety. That was lower than the 55.9% from the seven-item Generalized Anxiety Disorder scale (GAD-7) in nursing students in Israel [22] and higher than the 5.5% from the Beck Anxiety Inventory (BAI) of midwifery students in Turkey [23]. In general, the anxiety level of nursing students is reportedly higher than college students in other departments [23]. In particular, nursing students experience more significant anxiety in clinical practice than during lectures [24,25]. Although there is no study on the relationship between anxiety and nursing intention, in previous studies during the MERS epi-demic, high stress lowered future intentions to care for patients with infectious diseases [23]. Therefore, anxiety, negative emotion in nursing students, should be carefully monitored, and it was found to be a significant, influential factor.
Gender significantly affected anxiety. Anxiety was exceptionally high in female nursing students compared to male students, similar to previous studies [17,23,26]. Women were also an important predictor of fear of COVID-19 [17,27]. However, the results of this study should be interpreted carefully because there were only 20 males (11.6%). Nursing students face anxiety for various reasons, such as economic uncertainty, fear of infection, and difficulties in education [23,28]. In this study, concerns about COVID-19 infection are believed to have played a major role in anxiety because the subjects are nursing students participating in clinical practice during the COVID-19 pandemic. Therefore, nursing educators should continuously contact, encourage, and support students, suggesting various coping strategies.
In this study, knowledge was not a significant factor affecting anxiety. The average knowledge score was 8.21±1.10 out of 10, similar to the results of studies of nursing students in Saudi Arabia (82.1%) and Australia (82.9%) [29]. It is thought that most of the subjects in this study had a high level of knowledge owing to access to related information through various resources, such as social networks and guidelines. In addition, this study found that a higher anxiety level was significantly associated with negative attitudes toward COVID-19 and lower preventive behaviors, but it did not correlate with knowledge. This was a result in contrast to the a high level of knowledge is significantly correlated with positive attitudes and practices [30]. In the KAP model, it was suggested that the person’s knowledge of infectious disease positively affected on attitude and preventive practices [6]. However, despite the fact that nursing students have high knowledge of infectious in this study does not positively affect attitudes. It is thought that the fear of infection due to participation in clinical practice influenced the results.
Negative attitude toward COVID-19 was an influencing factor in increasing anxiety. In addition, the significant relationship between anxiety and attitude toward COVID-19 is similar to that of Alrubaiee [31]. Higher perceived susceptibility and severity affected anxiety [32], but a positive perception and attitude toward the disease can act as a factor that decreases anxiety. Therefore, organizing knowledge and focusing on positive attitudes toward preventive practices is more effective when training nursing students in clinical situations. It is also necessary to provide education that can reduce anxiety.
This study has some limitations. First, it is limited to generalize results because the data in this study were collected from three different universities in one specific region. Second, there is a possibility that the responses were incorrect (compared with face-to-face surveys) because the data were collected online. Third, verifying reliability and validity through repeated studies is necessary because of the tool developed for use.
CONCLUSION
This study attempted to determine the effects of knowledge, attitudes, and preventive practices on anxiety in nursing students in clinical practice during the current pandemic. As a result, attitudes, preventive practices, and anxiety were found to be significantly correlated, regardless of knowledge levels. In addition, gender and attitude were found to be significant influencing factors in anxiety. Despite vaccinations, COVID-19 continues to spread due to its many variants. When COVID-19 infection is still prolonged, the results of this study can be used to develop nursing interventions that reduce anxiety among nursing students.
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