INTRODUCTION
Since the first case of COVID-19 (coronavirus disease 19) was reported three years ago, and until now, when the World Health Organization identified the first variants of the virus, COVID-19 has affected various aspects of life not only the general population but also healthcare professionals. The impact of the COVID-19 pandemic on nurses is particularly significant because the increased levels of work-related stress among nurses during the pandemic cause psychological distress and bring about nurses' desire to leave the profession [1]. In particular, over half of the participants had severe psychological distress and their psychological distress has increased during the COVID-19 pandemic according to a study on the prevalence of psychological distress in nursing students [2].
It is important to look into psychological well-being among nursing students because literature suggested that it is negatively related to their risk perception of COVID-19 [3] and psychological distress among nursing students was found to be negatively associated with self-care practices during the pandemic [4]. Besides, a qualitative study on nursing students' perceptions of the pandemic claimed that most of the nursing students apply protective measures as they are afraid of infection and concerned about the well-being of their families, even though they recognize their responsibility to the community as well as the importance and risks of the nursing profession, but they are still afraid of the fear of possible infection in clinical settings [5]. And it is worth noticing that women perceived risks more strongly, and adhered to government regulations more than men in response to COVID-19 [6] as the majority of nursing students are women. Also, according to one Korean study belief in misinformation was negatively correlated with COVID-19-related knowledge and preventative practices because young people, including university students, lacked the skills to evaluate health resources or apply acquired information from online resources to health-related decisions [7].
Meanwhile, the COVID-19 pandemic has also provided a unique opportunity for the nursing profession, as nurses have received widespread respect and recognition from society for their services during this time, and these positive societal views have been shown to strengthen the professional values of nursing students [8]. The devotion of nurses in dealing with COVID-19 was shown to have positively influenced the professional values of nursing students after their first clinical practice during the pandemic [9]. However, where nursing professional values may have increased, evidence also demonstrates that globally, nursing students may be more prone to psychological suffering [4]. That is, nursing students' favorable perceptions of the nursing profession decreased as their anxiety levels increased, and students who were shown to have negative views of their profession due to the pandemic were prone to high anxiety levels and were unlikely to practice as nurses in the future [10]. Considering that nursing students are the future workforce of the nursing profession [8], it is necessary to be concerned with the psychological distress that nursing students experience during the prolonged pandemic.
Along these lines, we’ d like to identify the factors influencing COVID-19-related psychological distress of nursing students within the context of COVID-19-related knowledge, preventive behaviors, and risk perception, with the inclusion of nursing professional values. We especially take note of senior nursing students in their 4th year with clinical practicums as we noticed that nursing students' stress levels have increased, as did their anxiety and fear levels, especially among females or fourth-year nursing students [11,12]. Also, senior nursing students are considered to be mature in terms of understanding nursing science since they have experienced most of the major courses and clinical practicums [13]. Because it says that nursing education has a significant impact on the development of professional values, and students in the final year of their nursing programs had a higher score for professional identity in the previous study [14]. In addition, clinical practice plays an important role in developing professional attitudes as their experience in clinical situations can assist students in developing positive attitudes and professional values of nursing to establish the foundation for a future nursing career [15].
In summary, this study aimed to investigate the levels of psychological distress experienced by senior nursing students and to uncover factors influencing this distress, including whether recent positive societal views of nurses and attitudes toward increased professional values in the workforce have influenced students' psychological distress. We believe that this evidence will provide a basis for nursing educators to prepare better education programs, especially now that the COVID-19 pandemic has entered a new phase.
METHODS
1. Aim
This study aimed to determine the relationship between COVID-19-related knowledge, preventive behaviors, risk perception, nursing professional values, and COVID-19 psychological distress among senior nursing students, and to identify factors associated with COVID-19 Psychological distress.
3. Participants
Participants were recruited from multiple online university communities that are widely used by nursing students in South Korea. The eligibility criteria for this study were (1) fourth-year students in nursing college and (2) students with experience in face-to-face clinical practicums for at least one semester. Those with only online curriculum experience in clinical practice were excluded. We included these criteria because fourth-year students are considered to be mature in terms of understanding nursing science since they have experienced most of the major courses and clinical practicums [13]. It says that nursing education has a significant impact on the development of professional values and students in the final year of their nursing programs had a higher score for professional identity in the previous study [14]. In addition, clinical practice plays an important role in developing professional attitudes as their experience in clinical situations can assist students in developing positive attitudes and professional values of nursing to establish the foundation for a future nursing career [15].
The sample size was calculated to be 160 using the G* power 3.1.9.4 program with a significance level of .05, an effect size of .15 [3], a statistical power of .80, and a number of predictors of 20. A total of 193 students answered the questionnaire, which was satisfactory. Ten were ineligible (not in the senior year) and were excluded from the analysis.
4. Measurements
1) General characteristics
Details regarding general characteristics of the sample were collected, including gender, age, level of academic performance, religion, presence of siblings or medical staff in family members, career intention after graduation, history of confirmatory diagnosis of COVID-19, and level of satisfaction with clinical practicum or nursing major.
Verification validity of the instruments
To assess the content validity of both instruments, we first translated items of COVID-19-related knowledge, preventive behaviors, risk perception, and the COVID-19 Peritraumatic Distress Index (CPDI) into Korean, and subsequently, two medical-based bilingual Koreans performed back translation to English. Three medical-based bilingual experts reviewed the original and back-translated versions and determined the accuracy and equivalence of the translation process. A comparison was made between the original and back-translated versions and no substantial differences were found.
We then asked a panel of experts, including five nursing professors and one medical doctor, to evaluate each item of the scale and rate them based on relevance, clarity, and ambiguity using a 4-point content validity index (CVI). The content validity of an item was determined as suitable for selection if the score of the I-CVI was ≥.78 and the S-CVI/Ave was ≥.90 [16]. The CVI for each item of COVID-19-related knowledge, prevented behaviors and risk perception ranged from .83 to 1.00, with two items being excluded from the knowledge questions because their item-level CVI was .66. The I-CVI for each item of the CPDI ranged from .90 to 1.00 except for two items. We deleted two items with an I-CVI value less than .78. The item-level CVI for both scales was .80 and above, which means that the average proportion of items was rated as 3 or 4 by our six experts. These values met the recommended values, and both scales were subsequently included in our study [16].
We conducted a pilot study with 10 senior nursing students. The pilot study was conducted from April 1, 2022, to April 5, 2022. The results of the pilot study indicated that none of the items were considered difficult to answer by the participants. The items were also not considered to be confusing, difficult to understand, upsetting, or offen-sive, and no participant responded that they would ask a question differently.
The exploratory factor analysis (EFA) of the COVID-19-related psychological distress measuring instrument consisting of 22 items on a 5-point Likert scale confirmed through CVI verification was performed. The EFA using an eigenvalue curve indicated three eigenvalues in the scree plot above the mean; these three subfactors were retained the same as the original instrument. In addition, the factors showing ≥50.0% cumulative percentage of the distribution that was accounted for by the variables were selected at factor loading ≥.50. The value of KMO was .91, which satisfied the general criteria of ≥.70. Further, the result of Bartlett's sphericity test showed statistical significance (p<.001). Thus, the Varimax rotation and the principal components analysis (PCA) were used for factor extraction to derive four subfactors from 22 items. We used the PCA as a factor extract model, which is primarily used to minimize information loss with the least number of factors aiming at the forecast, and we used Varimax rotation to classify the factors by maximizing the sum of factor loading variance and clearing the factor property to the greatest extent possible. The cumulative explanatory variance was 54.8% and all 22 items had eigenvalues≥1.0(range 8.23~1.47), at a factor loading between .53~.80 to satisfy the criteria. And also, the commonality was .48~.71. The three subfactors were named as negative mood, cognitive and behavior change, and irritability and hyperarousal as in the original tool.
3) COVID-19-related knowledge, preventive behaviors, and risk perception
A questionnaire by Taghrir, Borazjani, and Shiraly [17] was used to assess COVID-19-related knowledge, preventive behaviors, and risk perception, which consisted of 15, 9, and 2 items, respectively. For the COVID-19-related knowledge, questions were modified to reflect recent updates regarding COVID-19, as recommended by the developers. The 14 items include etiology, symptoms, transmission, incubation period, diagnosis, prevention, vaccination, and treatment. Each item of knowledge asked participants to answer ‘yes’, ‘no’, or ‘I do not know’. One point was given for a correct answer, and 0 points were designated for incorrect answers or ‘I do not know’ answers. The total score was then converted to a percentile. The final scores were classified as high (75% and above), moderate (50~75%), and low (50% and below) levels of knowledge. Cronbach's ⍺ for the scale was .80 in the original study [17], and .61 for KR-20 in this study.
Nine items were used to assess preventive behaviors, including reducing daily use of public places, preventive behavior during coughing, handwashing and surface disinfection, and talking about prevention. Within the questionnaire on COVID-19 preventive behaviors, each item asked participants to answer ‘yes’ or ‘no’. Each appropriate behavior received one point, whereas inappropriate behaviors received 0 points. The total score was converted into a percentile, with scores of 75% and above reflecting a higher level of preventive behavior. Cronbach's ⍺ for the scale was .81 in the original study [17], and .62 in this study. The questionnaire on COVID-19 risk perception consisted of two items rated on a 5-point Likert scale, with total scores ranging from 2 to 10. Higher scores indicated higher COVID-19-related risk perceptions. Cronbach's ⍺ for the scale was .79 in the original study [17], and .63 in this study.
4) Nursing professionalism
We used the Korean nursing professional value scale (K-NPV) [18] to assess nursing professionalism. The scale consists of 29 items questioning participants’ self-concept of the profession, social awareness, professionalism of nursing, views on the roles of nursing services, and originality of nursing. Each item is scored on a 5-point Likert scale, and the total score ranges from 29 to 145, with a higher score indicating a higher level of professional attitude. Cronbach's ⍺ for the scale was .92 in the original study [18] and .92 in this study.
5) COVID-19-related psychological distress
The COVID-19 Peritraumatic Distress Index [19] was used to assess COVID-19-related psychological distress. The CPDI questionnaire registered details including anxiety, depression, specific phobias, cognitive change, avoidance, and compulsive behavior, physical symptoms and loss of social functioning in the past week. This scale originally consisted of 24 items with three subfactors: negative mood, cognitive and behavioral change, and irritability and hyperarousal, and was scored on a 5-point Likert scale (never-0, occasionally-1, sometimes-2, often-3, always-4), with total scores ranging from 0 to 96. In this study, a tool consisting of a total of 22 items and 3 subfactors (negative mood, cognitive and behavior change, and irritability and hyperarousal) was used through EFA. The measurable score for this tool ranges from a low of 0 to a high of 88. Cronbach's ⍺ for the scale was .95 in the original study [19]. In this study, Cronbach's ⍺ for the total was .92, and the range for each subfactor was .89 to 93.
5. Ethical Considerations
The Institutional Review Board (IRB) of Jeonbuk university approved this study (IRB No. 2022-02-004-001). The consent form explained the study's purpose and procedures as well as the guidelines for data confidentiality, voluntary participation, and participants' right to withdraw from the study at any time. The participants were required to provide written consent before completing the survey to confirm their willingness to participate.
6. Data Collection
Data were collected online between May 1 and June 13, 2022, using the aforementioned structured questionnaires. Survey invitations, including a brief description of the surveys, were uploaded to online communities to encourage senior students to voluntarily participate. A participation incentive was provided upon the completion of the questionnaire. The questionnaires took approximately 10 min to complete.
7. Data Analysis
The collected data were analyzed using the IBM SPSS version 27.0 software (IBM Corp., Armonk, NY, USA). Participants’ demographic characteristics and research variables were analyzed using frequency and percentage, mean and standard deviation, and minimum and maximum range. The normality of the samples was tested based on skewness and kurtosis. Differences in COVID-19-related psychological distress scores according to general characteristics were assessed using independent t- tests, one-way analysis of variance (ANOVA), and post- hoc Scheffé tests. Pearson's correlation coefficients were used to calculate correlations between the variables. Linear multiple regression analysis was performed to identify the factors affecting COVID-19-related psychological distress in senior nursing students. Two-tailed p values were used, which were significant at < .05.
RESULTS
1. General Characteristics of the Participants and COVID-19-related Psychological Distress according to General Characteristics
The general characteristics of the participants are summarized in Table 1. Most participants (88.5%) were women, with a mean age of 23.85 years. The majority (65.0%) of participants reported their academic performance in GPA between 3 and 3.9 and did not have a religion (61.7%). Most had siblings (94.0%) and no family members working as medical staff (66.1%), with most participants also considering working in a hospital (89.1%). A total of 33.3% of the participants had a history of confirmative diagnosis of COVID-19. The mean scores of clinical practicum satisfaction and major satisfaction were 3.82±0.98 (range 1~5) and 4.06±0.93 (range 1~5), respectively. Based on general characteristics, COVID-19-related psychological distress was negatively correlated with major satisfaction (r=-.17, p=.025) (Table 1).
Table 1.
General Characteristics of the Participants and COVID-19-related Psychological Distress according to General Characteristics (N=183)
| Characteristics | Categories | n (%) or M± SD | Range | COVID-19-related psychological distress | |
|---|---|---|---|---|---|
| M± SD | t or F or r (p) Scheffé | ||||
| Gender | Men | 21 (11.5) | 28.38±16.47 | -0.41 (.627) | |
| Women | 162 (88.5) | 30.20±16.05 | |||
| Age (year) | 21~22 | 119 (65.0) | 29.02±15.23 | -1.12 (.265) | |
| ≥23 | 64 (35.0) | 31.80±17.47 | |||
| 23.85±4.96 | |||||
| Grade (GPA) | 4~4.5 | 53 (29.0) | 26.87±15.38 | 1.47 (.232) | |
| 3~3.9 | 119 (65.0) | 31.12±16.54 | |||
| ＜3 | 11 (6.0) | 32.82±12.67 | |||
| Religion | Yes | 70 (38.3) | 32.10±16.81 | 1.40 (.162) | |
| No | 113 (61.7) | 28.68±15.50 | |||
| Siblings | Yes | 172 (94.0) | 29.52±16.06 | -1.58 (.116) | |
| No | 11 (6.0) | 36.36±14.73 | |||
| Medical staff in the family | Yes | 62 (33.9) | 33.15±16.66 | 1.92 (.057) | |
| No | 121 (66.1) | 28.37±15.57 | |||
| Career after graduation | Clinical nurse | 163 (89.1) | 29.90±16.00 | -0.13 (.895) | |
| Other | 20 (10.9) | 28.67±18.58 | |||
| COVID-19 confirmed | Yes | 61 (33.3) | 29.75±16.01 | -0.02 (.983) | |
| No | 122 (66.7) | 29.79±16.24 | |||
| Clinical practicum satisfaction | 3.82±0.98 | 1~5 | -.10† (.199) | ||
| Major satisfaction | 4.06±0.93 | 1~5 | -.17† (.025) | ||
2. Descriptive Statistics of the Variables
Table 2 summarizes the descriptive statistics of the variables. The mean scores of COVID-19-related knowledge, preventive behavior, risk perception, nursing professional values, and COVID-19-related psychological distress were 10.83±1.48, 7.89±1.23, 4.71±1.56, 93.96±14.43, and 29.99 ±16.06, respectively. As a result of checking the skewness and kurtosis before analyzing the data, it was confirmed that both the skewness and kurtosis were normally distributed with values within a range of -2 to +2 [20].
Table 2.
Descriptive Statistics of the Variables (N=183)
| Variables | Level | n (%) | Min. | Max. | M± SD | Skewness† | Kurtosis† |
|---|---|---|---|---|---|---|---|
| COVID-19 knowledge (range: 0~13) |
High (＞75%) Moderate (50~75%) |
145 (79.1) 38 (20.9) |
7 | 13 | 10.83±1.48 | -0.33 | -0.48 |
| COVID-19 preventive behavior (range: 0~9) |
High (≥75%) Low (＜75%) |
156 (85.2) 27 (14.8) |
4 | 9 | 7.89±1.23 | -0.84 | -0.36 |
| COVID-19 risk perception (range: 2~8) | 2 | 8 | 4.71±1.56 | 0.17 | -0.28 | ||
| NPV (range: 29~145) | 78 | 141 | 93.96±14.43 | -0.28 | -0.51 | ||
| COVID-19-related psychological distress (range: 0~88) | 0 | 71 | 29.99±16.06 | 0.59 | -0.27 |
3. Correlations among Main Variables
The correlations between COVID-19-related psychological distress and the main variables are shown in Table 3. The COVID-19-related psychological distress was significantly correlated with COVID-19 knowledge (r=.33, p< .001), COVID-19 preventive behavior (r=-.24, p <.001), COVID-19 risk perception (r=.36, p<.001). In addition, COVID-19 risk perception was correlated with COVID-19 preventive behavior (r=.26, p<.001), and COVID-19 preventive behavior was correlated with COVID-19 knowledge (r=.22, p=.003).
Table 3.
Correlations between the Research Variables (N=183)
4. Factors affecting COVID-19-related Psychological Distress
The factors influencing the COVID-19-related psychological distress of the participants are summarized in Table 4. The Durbin-Watson index was 1.84, which was close to the reference value of 2; therefore, there was no problem with the autocorrelation of the dependent variables used to verify the assumption of linear regression. The variance inflation factor ranged from 1.01 to 1.12, and all values were less than 10, confirming that there was no multicollinearity between the measured variables. Tolerance ranged from .89 to .99, which was .10 or more, indicating no multicollinearity. As a result of verifying the normal distribution of the residuals in the P-P plot, the residuals showed normality as they were close to 45 degrees. In addition, as a result of checking the scatter plot, the residuals were all evenly distributed around 0, so the linearity and equal variance were satisfied.
Table 4.
Factors Influencing COVID-19-related Psychological Distress in Nursing Students (N=183
An analysis of the factors influencing participants' COVID-19-related psychological distress showed that COVID-19 risk perception (β=.39, t=5.91, p<.001), COVID -19 knowledge (β=.37, t=5.58, p<.001), major satisfaction (β=-.19, t=-2.89, p=.004), and COVID-19 preventive behavior (β=-.16, t=-2.30, p=.023) were identified to be influencing factors. This indicated that COVID-19-related psychological distress decreased as knowledge and risk perception levels decreased, and COVID-19-related psycho-logical distress tended to be higher for those with low levels of COVID-19 preventive behavior and major satisfaction. The regression model was satisfactory according to the goodness-of-fit test (F=14.56, p<.001), with an explanatory power of approximately 27%.
DISCUSSION
The current pandemic had a significant impact on nursing students [21]. Thus, this study assessed nursing students’ psychological distress caused by COVID-19 and discovered that factors such as COVID-19-related risk perception, knowledge, preventive behavior, and satisfaction with nursing majors had influenced COVID-19-related psychological distress.
Our participants' average score of nursing professional values was 3.88±0.43 which was relatively lower than the scores of 4.05±0.54 and 3.90±0.52 that were previously measured using the same instruments during the early stage of the COVID-19 pandemic [22,23], but were higher than 3.60±0.45 which was measured before pandemic [13]. This supports the results of a previous study that showed that the present pandemic offers nursing students an opportunity to improve their positive professional attitudes [6,22]. However, contrary to our expectation, the nursing professional value was not found to be an influencing factor for COVID-19-related psychological distress among senior nursing students in this study. Our participants may not yet be mature in developing professional values in nursing because professional value development is a continuous process influenced by various factors such as clinical and educational experiences [14].
In this study, the mean COVID-19-related Psychological distress score of the participants was 29.99 (based on an average rating: 0.96 points, range 0~4). This result demonstrates that the COVID-19-related psychological distress that senior nursing students experience is greater than the levels (23.00, based on an average rating: 0.96 points) experienced by Korean adults [24] and by Chinese adults (23.65, based on an average rating: 0.99 points)[19], even after experiencing the prolonged two-year period of the COVID-19 pandemic. Perhaps this increased distress in our population is related to the majority of our participants having never been confirmed to have COVID-19, as their lack of personal experience with the disease increases the anticipatory dread of getting infected in the future. In previous similar studies conducted in different countries, concerns regarding getting infected with the virus and news about the pandemic affected the level of stress of nursing students in eastern Turkey [2]. Students also reported feeling isolated from classmates, difficulty connecting with instructors online, and an increased level of anxiety from ever-changing school clinical guidelines [25], such that interventions to reduce anxiety and fear of COVID-19 among nursing students are needed [3]. Thus, nursing educators should not underestimate the psychological distress of nursing students as a result of the pandemic, and should work to develop measures to evaluate it and act accordingly.
COVID-19 risk perception was an important factor in explaining COVID-19-related psychological distress in the present study. This result is similar to a previous study, which showed that health workers who work closer to the risk of infection show a higher risk of acute psychological distress, especially women [26]. This study also deduced that COVID-19-related knowledge can increase risk perception. The results of this study are quite coherent with our results if one considers that the majority of our participants were also female with close proximity to the COVID -19 infection and with an overall high level of COVID-19 knowledge.
In this study, COVID-19 knowledge was a second affecting factor explaining COVID-19-related psychological distress of nursing students. This result was also found in a previous study in which those with higher levels of education typically experienced more distress because they were more self-aware of their health [19]. The average score of COVID-19 knowledge was 10.73±1.56, which is approximately 79%, meaning that the majority of our participants demonstrated a high level of knowledge. The high level of knowledge among our participants was another important factor affecting COVID-19-related Psychological distress. Educators keep in mind to provide reasonable assurance when they structure education programs on COVID-19 as one study claims that psychological distress levels were also influenced by the availability of medical resources and control measures taken against the epidemic situation [19].
In this study, satisfaction with the nursing major was another factor that influenced COVID-19-related psychological distress among senior nursing students. This is in line with results from previous studies, which showed that in the case of Norwegian Baccalaureate nursing students, the higher their satisfaction with their educational curriculum, could then be positively associated with the overall quality of life [27]. More specifically, satisfaction with the nursing major of students is associated with psychological distress during the COVID-19 pandemic and a student's overall quality of life and well-being. Additionally, for senior students, the greater their satisfaction with their nursing major, the greater their social responsibility [28]. However, in this study, only 24.6% of our participants were highly satisfied with their clinical practice. This result may be in line with a previous study that claimed that nursing students are faced with increased diffi-culties in finding placements in clinical practice because of the various changes implemented during the COVID-19 pandemic, even though clinical practicum is essential for their professional development [21]. Thus, nursing educators should consider this and develop plans to enhance nursing students' major satisfaction by improving the clinical practicum suited to nursing students' needs.
Lastly, COVID-19 preventive behavior was another affecting factor explaining COVID-19-related psychological distress. This finding is consistent with the fact that the psychological distress of nursing students during the COVID -19 pandemic was negatively correlated with self- care practices [5]. Besides, the average score for COVID-19 preventive behaviors was 7.89±1.23, which is approximately 85%, representing a high level of conduct of preventive acts among our participants. Furthermore, our study showed a positive correlation between preventive behaviors and COVID-19 risk perception. This result is in line with the results of a national survey in which it was shown that those who perceived increased COVID-19 in-fections or a higher fatality risk implemented more protective behaviors to avoid COVID-19 [29].
The limitations of this study are as follows. First, the participants were mainly from one province, despite our efforts to collect data from multiple online communities with participants from various nursing schools across the country. Therefore, the generalization of our results may be limited. Second, as a cross-sectional study, the COVID-19 pandemic has changed since the online survey for this study took place. Future studies with a longitudinal design should be conducted to evaluate psychological distress according to changes in circumstances. Third, in this study, translation, panel discussion, back-translation, pilot test, and CVI verification were performed to verify the cultural fit of the English version of the COVID-19-related knowledge, preventive behavior, and risk perception measurement tool to the Korean version. Therefore, sys-tematic validation of this tool is required in future studies. Finally, Cronbach's ⍺ values of the COVID-19 knowledge, preventive behaviors, and risk perception measurement tools used in this study were .61, .62, and .63, respectively. A generally accepted rule is that Cronbach's ⍺ of .60~.70 indicates an acceptable level of reliability [30], and .70 or greater is a good level [31]. Therefore, it is necessary to verify the reliability of the tool again in the future.
Nevertheless, it is worth recognizing that the present study had several strengths. First, this study provided an outlook on pandemic-related psychological distress experienced by the future nursing workforce, by evaluating the COVID-19-related psychological distress of nursing students who were in their 4th year and who had experience in face-to-face clinical practicums. Furthermore, this study indicates that not only COVID-19-related knowledge or risk perception, but also individual characteristics such as satisfaction with the nursing major could affect COVID -19-related psychological distress in senior nursing students. Lastly, to the best of our knowledge, this is the first study to identify the factors influencing COVID-19-related psychological distress that included professional nursing values within the COVID-19-related variables.
CONCLUSION
Evaluation of nursing students’ COVID-19-related psychological distress is necessary. To develop interventions to reduce COVID-19-related psychological distress in nursing education settings, COVID-19 knowledge, COVID-19 risk perception, COVID-19 preventive behavior, and satisfaction with nursing majors for nursing students should be considered. Conducting a future study with a longitudinal design to evaluate psychological distress according to changes in COVID-19-related circumstances is suggested, as well as comparing the COVID-19-related psychological distress of students who did not experience a clinical practicum with that of students who did.
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