Although the new infectious disease COVID-19 caused some negative psychological responses like anxiety and depression among the nursing interns in our survey, their anxiety was not statistically different with that of normal Chinese people and the magnitudes of their depression were averagely lower than that of Chinese norm (Table 2). This is consistent with the findings from a previously published study, in which the researchers found that a new infectious disease could cause negative psychological responses such as anxiety, depression, fear, and panic among patients, their contactor, relatives and surrounding people . The potential reason might be the lack of knowledge and understanding of the disease. As a new infectious disease, when COVID-19 appears, the country needs time to explore, understand, and learn its pathogenesis, transmission routes, preventive measures, and treatment methods. The public also needs time and information channels to learn relevant knowledge. During the lag time period when the infection cases increase, both the healthcare professionals and the public may worry about the infectious disease not being controlled in time, being infected, or unable to study, work, or live normally. In our study, the nursing interns had studied at medical universities for about two or three years and practiced in the hospital for about eight months, therefore they showed certain basic medical knowledge and skill in the prevention. We should note that, when COVID-19 outbroke, most of the nursing interns had been at home and did not take care for COVID-19 patients. It might contribute to the less risk of infection and lower mental stress.
Although no statistically significant difference, compared to the junior undergraduates, the senior undergraduates showed higher anxiety and depression scores (Table 1). The possible reason might be that the higher level of education of the interns, the better ability the interns may have to acquire and analyze necessary or relevant knowledge and information, to understand the situation, and know the risk. Therefore they may face the COVID-19 epidemic with more pressure. From Table 1, we also see that the interns who live in cities showed higher anxiety and depression scores. The possible reason might be that in China the large and top hospitals with high quality and complete facilities are mainly located in urban areas, and few are in suburban or countryside. When Chinese people are sick, they tend to visit large and top hospitals first [22, 23]. When people were diagnosed with COVID-19 infection, they would be transferred to the hospitals in cities. In this case, the number of infected patients would be more and more in cities. During the COVID-19 epidemic, the local and central Chinese government required people to stay at home as much as possible . Furthermore, the public traffic was restricted or even canceled in order to prevent virus transmission and spread of the disease. Although internet hospitals or online medical services have been adopted more and more, where people can seek for help from medical professionals, being afraid of failure in getting proper diagnosis or treatment in a timely manner may cause the nursing interns’ anxiety.
It is interesting that the nursing interns would like to seek for help from different resources. We also see that they prefer their instructors instead of family or friends, social media, or other medical professionals when they would like to ask for advices/help. Most of nursing interns would go to the hospital for treatment if they suspected symptoms (Table 3). The potential reason might be as following:
When the epidemic was approaching, few (n = 17) nursing interns who remained on duty received relevant training on the latest knowledge of COVID-19 in the hospital or department, and participated in the work against the epidemic together with their teachers or instructors. Therefore, when they appeared suspicious symptoms or wanted help they would ask for their teacher or other healthcare professional in the department or see a doctor in the hospital first. In this hospital, there is an online “Wechat” group including all nursing interns and their teachers and instructors who may discuss about COVID-19. Teachers and instructors may provide consultation immediately and continuously. Nowadays the internet have been very popular in China, searching information from the internet is ubiquitous among adolescents . The nursing interns can also learn the incidence and progress of the disease throughout the local area to the country, and extract related information and knowledge through various news medias and the internet, and change their behaviors or make corresponding reactions . It is also a convenient and quick way to obtain necessary information or knowledge rather than bother their instructors. The COVID-19 epidemic began during the Chinese traditional Spring Festival holiday, 220 (92.8%) of the 237 nursing interns went back hometown for vacation, and the rest of the interns remained on duty or did not went back to hometown due other reasons. Therefore, there are more nursing interns who selected seeking for advices/help online or from family or friends. But we should be aware of that there are many fake news and wrong information about COVID-19 on the internet, the instructors and teachers should teach the nursing interns how to distinguish between true and false information.
Because the nursing interns have certain medical knowledge, they pay more attention to preventive measures, the number of suspected patients and patients instead of other information (Table 3). When the local and national governments advocate and require all the people to stay at home, which will help the medical professional fight against the epidemic, at the same time, the governments have only taken measures to maintain the basic daily life of the people, for example, people can apply for medical masks and buy various living necessities through official online shops or platforms. For all these reasons, some nursing interns worry about probably rising prices and shortages of daily necessities in the future.
Regarding COVID-19-related knowledge, the nursing interns participating in the survey have a good grasp of the prevention, followed by sources of infection and routes of transmission, clinical manifestations, test/diagnosis, the guidelines for patient care, however have relative less knowledge on disease epidemiological characteristics of COVID-19 and treatment (Table 4). In order to find every suspicious patients, provide accurate treatment to every confirmed or suspected patients, and avoid the spreading of infection in medical institutions, for each latest updating of the diagnosis and treatment guidelines, the medical institutions provide relevant training to all the staff including both the nursing interns on duty and on vacation through various on-line, off-line, or on-site forms, and take immediate implementation and supervision . However, there are still some nursing interns who took vacation at hometown and did not timely attend the latest training on the updated diagnosis and treatment guidelines issued by the National Health Commission of China.
We are glad to see that the nursing interns show a relative good score (84.6% recommended measures were adopted) for preventive behaviors (Table 5), which indicates that they had high compliance, and took good prevention and control measures during the COVID-19 epidemic. The research team believes that this is related to the national propaganda campaign and policies . When the epidemic emerged, people were required to wear masks when going out and wash their hands when entering home. In residential communities and public places, there are volunteers who check and remind people to wear mask. Supermarkets and shops have set temporary regulation that customers should wear mask and those who did not follow the regulation would be rejected to enter . The hospital (and other hospital also) requires washing hands with seven-step method and daily disinfection of floors and object surfaces, such as door handles, using chlorine-containing disinfectants or 75% alcohol . Although the interns may conduct routine clearing when they stay at home, they cannot conduct disinfection as frequent as what they do in hospital. It might be the reason that the percentage of “Every time when I wash my hands I follow the recommended seven-step method.” and “I disinfect door handles and object surfaces frequently.” are low. In addition, because many nursing interns live at home, they may not have an appropriate place and venue to exercise, it might be the reason the percentage of “I exercise at home to increase immunity.” is also low.
Limitation and strength
There are several advantages in our study. First, to our knowledge, this is the first KAP survey that investigated the psychological and behavioral responses of the nursing interns working during the COVID-19 epidemic, which provides first-hand information regarding the psychological and educational intervention for the nursing interns to both improve their caring for the COVID-19 patients and protect themselves. Second, although the survey used a convenience sample, the nursing interns are from 12 universities in China, which to some extent may be representative of CONVID-19-related KAP of nursing interns at least at a regional level. Third, the study was conducted in the country where COVID-19 epidemic broke out first and has a large amount of confirmed patients, therefore its results may provide references for other countries.
However, there are also limitations in our study. First, considering the efficiency and response rate of the survey, we only investigated 2 of 9 psychological symptoms in the SCL-90, which cannot reflect the overall psychological responses of the nursing interns. Second, because the study was only limited within nursing interns due to the pedagogy-driven objectives, which cannot reflect the situation among the general nurse practitioners. Last but not least, the inherent limitation in the study design hinders the generalization of the results. A follow-up study using a representative sample with larger sample size is needed to provide deeper insights in this field.