Fear of COVID-19, psychological distress, general health and quality of life among baccalaureate nursing students at one year into the COVID-19 pandemic: a mixed method study

Fear of COVID-19, psychological distress, general health and quality of life among baccalaureate nursing students at one year into the COVID-19 pandemic: a mixed method study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Fear of COVID-19, psychological distress, general health and quality of life among baccalaureate nursing students at one year into the COVID-19 pandemic: a mixed method study Gudrun Rohde, Berit Johannessen, Markus Maaseide, Sylvi Flateland, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1803383/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Mar, 2023 Read the published version in BMC Nursing → Version 2 posted 11 You are reading this latest preprint version Show more versions Abstract Background : The COVID-19 pandemic led to major changes in people’s lives via protective strategies aimed at limiting the transmission of COVID-19, including social distancing, lockdowns, cancelled or limited leisure activities and tutorials and supervision for students taking place digital. All of these changes may have influenced students’ health and quality of life (QOL). Aim : To describe and explore fear of COVID-19 and psychological distress, as well as general health and QOL, among baccalaureate nursing students at 1 year into the COVID-19 pandemic. Method : We used a mixed method study design, including quantitative data from one university in southern Norway that was a part of a national survey of baccalaureate nursing students and qualitative data from focus group interviews from the same university. The quantitative data were collected using well-validated measures of fear of COVID-19, psychological distress, general health and QOL, and the data were analysed using the ANOVA-tests for continuous data and chi-square tests for categorical data. The qualitative data were analysed using systematic text condensation. Results : The quantitative survey included 396 baccalaureate nursing students (response rate: 46%). The mean score (standard deviation [SD]) for fear of COVID-19 was 2.32 (0.71), for psychological distress was 1.53 (1.00), for general health was 3.51 (0.96) and for overall QOL was 6.01 (2.06). Five focus group interviews were conducted with a total of 23 students (7 men, 16 women). In the qualitative data, we identified the overarching theme effect of COVID-19 on students’ QOL and the three main themes; importance of personal relations, physical health challenges and mental health challenges. Conclusion : The COVID-19 pandemic influenced negatively nursing students’ QOL and physical and mental health, and they often felt lonely. However, most of the participants also adapted strategies and resilience factors to cope with the situation. Via the pandemic situation, the students learned additional skills and mental mindsets that may be useful in their future professional lives. COVID-19 nursing students general health psychological distress QOL mixed methods Figures Figure 1 Introduction The United Nations third Sustainable Development Goal is to ensure healthy lives and to promote quality of life (QOL) for all people of all ages [ 1 ]. This goal has been incorporated into national guidelines and goals, healthcare practices and public awareness. QOL is increasingly used as an outcome measure in different research settings, including clinical practice and student population surveys. In this context, QOL is defined as individuals’ perception of their position in life in the context of the culture in which they live and in relation to their goals, expectations, standards and concerns [ 2 ]. When the COVID-19 pandemic hit in March 2020, it led to major changes in people’s lives through protective strategies aimed at limiting the transmission of COVID-19. Such strategies included social distancing, lockdowns, cancelled or limited leisure activities and digital rather than in-person tutorials for students [ 3 – 5 ], which may all have influenced people’s health and QOL. The consequences of COVID-19 restrictions and lockdown especially influenced young people and students. Nursing students may have been particularly vulnerable during the COVID-19 pandemic because of both their status as young adults being and their practical training during their nursing programmes as a part of the healthcare system [ 5 – 8 ]. Previous studies on nursing students during the COVID-19 pandemic revealed that stress increased substantially during lockdown. Stress and anxiety could be triggered by students’ personal problems [ 8 – 10 ]. Studies also showed that during the pandemic nursing students experienced loneliness and mental health problems, sleeplessness, problems with concentration and learning efficiency and fear of infection, as well as anxiety regarding grades, passing exams and final graduation [ 10 – 13 ]. Moreover, according to some research, nursing students have reported reduced health and QOL during the pandemic compared with the results of surveys of nursing students carried out the pandemic [ 14 , 15 ]. Statistics indicate that Norwegian society has handled the COVID-19 pandemic rather well. Most inhabitants have followed governmental rules, the transmission rate has been low and there have been relatively few hospital admissions and few deaths compared with the rates in other countries [ 16 ]. However, adolescents and young adults have seemed to suffer, and COVID-19 restrictions may have had negative effects on their QOL [ 17 ]. In a survey administered during the second wave of the pandemic (January – March 2021), Norwegian baccalaureate nursing students reported worse outcomes during the pandemic in terms of general health, psychological distress and overall QOL compared with a student reference student population the year before the pandemic [ 18 ]. However, the level of fear of COVID-19 accounted for few of these differences, indicating that other factors related to the pandemic may have reduced nursing students’ QOL [ 19 ]. For students involved in clinical practice during the pandemic, concern about infecting others was an additional factor that influenced psychological distress [ 19 ]. Results of a Norwegian national survey was recently published; the survey looked at baccalaureate nursing students’ experiences of fear of COVID-19, general health, psychological distress and overall QOL, with samples from five universities [ 19 ]. However, in-depth knowledge alongside the survey data seems to be lacking in this case. Thus, we aimed to describe and explore fear of COVID-19, psychological distress, general health and QOL among baccalaureate nursing students at 1 year into the COVID-19 pandemic. Methods Design and sample We used a mixed-method design comprising quantitative data from one of the five universities in Southern Norway from the national survey [19], combined with qualitative data from students at the same university. In the southern part of Norway, the transmission rate was rather low, and the university could offer the students clinical placement nearly as normal. This was not the case for several of the other universities. Between 27 January and 28 February 2021, full- and part-time baccalaureate nursing students > 18 years of age from the two campuses at the university in southern Norway took part in the web-based cross-sectional survey, as did students at four other universities in Norway. Baccalaureate nursing students from the same university were invited by the student representatives and the learning portal to participate in focus group interviews on campus. The focus group interviews took place between 26 April and 6 May 2021. The interviews were arranged in the afternoons and lasted for 50–90 minutes. The interviews were moderated by the first author (GR; four groups) or the last author (KH; one group), who are both nurses and professors in health sciences. Quantitative data Measures The survey included questions related to students’ demographics, personal health and study situation during the pandemic; these questions were specifically developed for the national survey by nursing students (including MM), university staff and researchers. Additional measures included four well-validated (nationally and internationally) instruments for assessing fear of COVID-19, psychological distress, general health and overall QOL. Characteristics of the respondents included study site, household status, year of study and age (<25, 25–29, ≥30 years) [19]. COVID-19 specific questions related to personal health were developed for the national survey [19] and included quarantine history (never, previous, present); feelings of loneliness because of COVID-19 (rated from 1 [strongly disagree] to 5 [strongly agree]); perceived risk for complications of COVID-19 (no, uncertain, yes); and history of suspected, possible or confirmed COVID-19 infection. In the analysis, responses of ‘agree’ and ‘strongly agree’ were pooled under ‘agree.’ The questions were piloted with nine nursing students (including MM, one of the authors of this study). After minor adjustments, a digital pilot study was conducted with 90 physiotherapy students [20]. No adjustments were made after the digital pilot. The Fear of COVID-19 Scale (FCV-19S) [21] was used to assess fear of coronavirus infection [21, 22]. Seven items (e.g. ‘I am most afraid of the coronavirus’) were rated on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree), with a total score ranging from 7 to 35. On this scale, higher scores indicate a greater fear of COVID-19. In the present study, the average item score was used; it was calculated by dividing the total score by the number of items. The Hopkins Symptom Checklist (SCL-5) [23] is available as a Norwegian translation. It includes five items measuring psychological distress (anxiety and depression) that are rated on a 5-point scale from 1 (not at all) to 5 (extremely). We calculated the average item score by dividing the total score by the number of items on the list [24]. Higher scores indicate greater psychological distress. General health was assessed using one item from the 36-Item Short-Form Health Survey (SF-36) [25, 26]: ‘In general, would you say your health is: excellent, very good, good, fair or poor? ’ Responses were rated on a 5-point scale ranging from 1 (excellent) to 5 (poor) [27]. Consistent with the SF-36 scoring algorithm, the scale was reverse scored. Thus, higher scores reflect better general health as perceived by respondents. The item was found to be as valid and reliable as multi-item scales [27]. Overall QOL was rated on an adapted version of the Cantril Ladder on a scale from 0 (not at all satisfied) to 10 (highly satisfied). A score of 6 or more indicates high life satisfaction. The question, ‘All in all, how satisfied are you with your life at this time?’, has been widely used in various populations and in different settings; it is considered a reliable and valid measure of overall QOL [28]. Qualitative data We used a semi-structured interview guide to ensure inclusion of the issues in focus, and the students were asked such questions as the following: How has the COVID-19 pandemic influenced your social life? How has the COVID-19 pandemic influenced your health? How has the COVID-19 pandemic influenced your QOL? Analysis The mixed-method analysis strategy represents a parallel mixed data analysis, with separate quantitative and qualitative strands implemented to address related aspects of the research questions regarding the same phenomenon [29]. The findings from both the quantitative and qualitative data collection are integrated in the discussion section. Statistical analysis Descriptive statistics are presented for all students and by year of education. Categorical variables as counts and percentages and continuous variables are described as means (SD). We used the chi-square test for categorical data to reveal associations between categorical variables and analysis of variance (ANOVA) tests for the continuous variables [30]. The analyses were considered exploratory, so no correction for multiple testing was performed. All tests were two-sided, and p -values < 0.05 were considered statistically significant. The analyses were performed using IBM SPSS Statistics (version 26) [30]. Qualitative analyses We audiotaped the interviews and transcribed them verbatim. The interviews were transferred to NVivo (version 12) software to organise the transcripts into codes and units of meaning. In the analyses, we used a systematic text condensation analysis style [31]. Two researchers (GR and KH) independently read all the material searching for an overall impression and established preliminary sub-themes; the rest of the group read one interview each, gave input and wrote a summary of the overall impression. We then examined the text for units of meaning representing the students’ experiences. In an iterative process, we coded and grouped these units; contrasted and abstracted the content in each group; and finally, discussed and summarised the content of each group into generalised descriptions. To support the analysis, we created mind maps and discussed the analysis at each step to reach an agreement. Quotations were used to illustrate and support the findings [31]. User involvement A second-year student (MM) took part in the design and guided the questions for the study. This student is also a co-author of this paper. Ethics The study was conducted according to research ethics guidelines set up in the Helsinki Declaration. The application was approved by the head of department at the university, the Norwegian Center for Research (NSD; Project No 973745) and the research ethics committee at the faculty of health- and sport sciences (FEK). The students received oral and written information about the study and gave their written consent to participate. Results Quantitative data In total, 396 baccalaureate nursing students at a university in southern Norway participated in the survey. Most were living with someone (84%), and 70% were younger than 25 years. Fifty-six per cent reported having felt lonely because of the pandemic. Sixty-two per cent had been engaged in clinical placement during the pandemic, and 83% of the students who had been in clinical practice had cared for patients with confirmed COVID-19 or unclear COVID-19 status. Most students (72%) had trust in the way in which their governments and universities (57%) were handling the COVID-19 situation. Moreover, 70% of the students were concerned about the quality of their education (Table 1 ). Table 1 Student characteristics of the baccalaureate nursing students at University of Agder for all participants ( N = 396) and organised by school year Total N = 396 Year 1 n = 142 Year 2 n = 127 Year 3 n = 127 p -values Years in nursing school 1 2 3 142 (36%) 127 (32%) 127 (32%) Age, years <25 25–29 ≥ 30 278 (70%) 46 (12%) 72 (18%) 112 (79%) 11 (8%) 19 (13%) 86 (65) 26 (20%) 15 (12%) 80 (63%) 20 (16%) 27 (21%) 0.056 Living alone No Yes 332 (84%) 64 (16%) 120 (85%) 22 (15%) 108 (85%) 19 (15%) 104 (82%) 23 (18%) 0.764 Quarantine status related to COVID-19 Never Previous Now 236 (60%) 157 (39%) 3 (1%) 77(54%) 63 (44%) 2 (2%) 78 (61%) 48 (38%) 1 (1%) 81 (64%) 46 (36%) 0 0.383 At risk for COVID-19 complications No Uncertain Yes 49 (10%) 323 (82%) 33 (8%) 16 (11%) 114 (80%) 12 (9%) 16 (13%) 103 (81%) 8 (6%) 8 (6%) 106 (84%) 13 (10%) 0.397 Trust in governmental handling of the COVID-19 situation Strongly disagree/disagree Neither disagree nor agree Agree Strongly agree 36 (9%) 44 (18%) 200 (50%) 89 (22%) 14 (6%) 30 (21%) 67 (47%) 31 (22%) 4 (3%) 29 (23%) 68 (53%) 26 (20%) 18 (14%) 12 (9%) 65 (51%) 32 (25%) 0.016 Trust in universities’ handling of the COVID-19 situation Strongly disagree Disagree Neither disagree nor agree Agree Strongly agree 18 (4%) 44 (11%) 112 (28%) 180 (46%) 42 (11%) 5 (4%) 17 (12%) 37 (26%) 67 (47%) 16 (11%) 4 (3%) 17 (13%) 47 (37%) 50 (39%) 28 (22%) 9 (7%) 10 (8%) 28 (22%) 63 (50%) 17 (13%) 0.080 Concern about the quality of education Strongly disagree Disagree Neither disagree nor agree Agree Strongly agree 22 (5%) 34 (9%) 64 (16%) 142 (36%) 134 (34%) 3 (2%) 6 (4%) 17 (12%) 50 (35%) 66 (47%) 6 (5%) 13 (10%) 21 (17%) 40 (31%) 47 (37%) 13 (10%) 15 (12%) 26 (21%) 52 (41%) 21 (16%) < 0.001 2.3 (0.7) 2.5 (0.8) 2.3 (0.7) 2.2 (0.7) 0.026 Feeling lonely due to COVID-19 Strongly disagree Disagree Neither disagree nor agree Agree Strongly agree 33 (8%) 61 (15%) 80 (20%) 130 (32%) 92 (23%) 8 (6%) 16 (11%) 23 (16%) 53 (37%) 42 (30%) 10 (8%) 21 (16%) 28 (22%) 40 (32%) 28 (22%) 15 (12%) 24 (19%) 29 (23%) 37 (29%) 22 (17%) 0.096 Engagement in clinical practice during the pandemic Yes No 246 (62%) 150 (38%) 12 (9%) 130 (91%) 117 (92%) 10 (8%) 127 (92%) 10 (8%) < 0.001 Have you been in contact with patients in the following situations during the pandemic? Patients with unclear COVID-19 status Patients with confirmed COVID-19 infection Both (unclear and confirmed) None 148 (61%) 7 (3%) 35 (15%) 52 (21%) 3 1 0 6 64 (55%) 2 (2%) 11 (9%) 39 (34%) 81 (70%) 4 (3%) 24 (21%) 7 (6%) < 0.001 * Categorical data are presented as number (%) and continuous variables as mean (SD). Chi-square tests were used to compare differences in categorical variables and ANOVA tests for continuous data Table 1 about here When comparing students in the three different study years, the most striking differences by February 2021 were that the first-year student had not been in clinical placement, and more students in second year (66%) and third year 3 (94%) had been in contact with patients with confirmed or unclear COVID-19 status. Further, more first-year students (82%) were concerned about the quality of education compared with second-year (70%) and third-year students (62%; Table 1 ). Fear Of Covid-19, Psychological Distress, General Health And Qol For the entire student group, the mean score (SD) for fear of COVID-19 was 2.32 (0.71), that for psychological distress was 1.53 (1.00), that for general health was 3.51 (0.96) and that for QOL was 6.01 (2.06). When comparing first-year students with second- and third-year students, they reported more fear of COVID-19 (2.45 [0.79] vs. 2.28 [0.66] vs. 2.22 [0.70], p = 0.026), more psychological distress (1.83 [0.99] vs. 1.43 [0.99] vs. 1.21 [0.66], p < 0.001) and lower QOL (5.44 [2.16] vs. 6.19 [2.02] vs. 6.45 [1.86], p < 0.001), see Table 2 . Table 2 Self-reported fear of COVID-19, psychological distress, general health and overall quality of life among 396 baccalaureate nursing students at the University of Agder Variables All ( N = 396) mean (SD) 1 2 3 P-value e ‧ Fear of COVID (FCV-19) a (1–5) 2.32 (0.71) 2.45 (0.76) 2.28 (0.66) 2.22 (0.70) 0.026 General health b (1–5) 3.51 (0.96) 3.41 (0.98) 3.59 (1.01) 3.60 (0.96) 0.164 Psychological distress c (SCL-5) (1–5) 1.54 (1.00) 1.83 (0.99) 1.43 (0.99) 1.21 (0.06) < 0.001 Overall Quality of life d (0–10) 6.01 (2.06) 5.44 (2.16) 6.19 (2.02) 6.45 (1.86) < 0.001‧ a Higher score of FCV-19S reflect higher level of fear of COVID-19 b Higher score reflects better perceived general health. c Higher score on Hopkins Symptom Checklist (SCL-5) reflects more psychological distress d In line with the SF-36 scoring algorithm, the item was reversed. Higher score of overall quality of health reflects better perceived overall quality of life. e ANOVA tests Table 2 about here Qualitative Data Twenty-three students (7 men, 16 women) took part in the focus group interviews; their age was in the range of 19–32 years, with a mean age of 23 years. The students comprised 10 first-year students, 7 second-year students and 6 third-year students. Most students lived in shared accommodation or with a partner. We identified the overarching theme of effect of COVID-19 on students’ QOL and the three following main themes: importance of personal relations , physical health challenges and mental health challenges. Each of the main themes comprised two sub-themes, as listed in Fig. 1 . Effect Of Covid-19 On Students’ Qol Most of the students felt that the pandemic had influenced their QOL negatively; some suggested that it had reduced their QOL by 20–30%. One of the students commented: ‘I have been unable to do things that bring energy, which is important for my QOL’ (Focus group 3). In contrast, some students experienced high QOL both before and during the pandemic; the difference was the factors important for QOL. In the context of the pandemic, they had learned to focus and appreciate other things and values that they had previously taken for granted. Furthermore, some students organised their everyday lives to improve their QOL; for instance, they would tidy their dwelling or practice given routines. One even commented: ‘I have felt lucky this year. I feel a bit guilty saying I experience a better QOL despite the pandemic’ (Focus group 2). Importance of personal relations comprised the sub-themes of feelings of loneliness and desire for a social life. In general, the participating students described envisioning student life as a time with a socially active lifestyle; however, because of restrictions and lockdowns, this was impossible for them. Several of the students felt lonely; this was especially prominent among the new first-year students because many of them were new in town and had not established contact with other students on campus. It already takes courage, initiative and proactiveness to meet new friends at the university; because of the pandemic restrictions, the arenas for these meetings were different and limited for these students. Some students underlined their responsibility for making friends in due course, while others just continued to feel lonely: And now I have to—even if it might feel a bit uncomfortable—randomly ask other students during the programme for semester start if they would like to do something together. I have to dare. I have to work with my mindset, leave my comfort zone, be nice to everyone and make an effort to make friends early. (Focus group 1) The students missed meeting one another casually; going to parties; and feeling free, without responsibilities. They missed their extended group of friends. At the same time, a few found it acceptable to live a quieter life without the expectation of being socially active. Pandemic restrictions meant that factors important for QOL were lacking or diminished; for instance, respondents could not meet up with other students or feel free to gather in groups. In the autumn, when the transmission rate was rather low, the student organisation scheduled an alternative study programme for the beginning of the semester and buddy groups that met the given pandemic restrictions. The buddy groups were crucial to allow new students to become acquainted with others, and some of the new students felt lucky to be with their group or cohort. The importance of the buddy group was also confirmed and emphasised by the more experienced students. One commented, ‘I am a bit embarrassed to say it, but I think I would have felt lonelier if I had been a first-year student’ (Focus group 2). Another stated: ‘I have to say this about the buddy group. We have stuck together. I feel lucky’ (Focus group 1). Since the transmission rate increased during the winter, some of the students felt they had to select which friends or group they could be with. This was hard, and with changing rules, plans had to be changed or adjusted. Especially during clinical placement, the students felt a responsibility to avoid spreading the COVID-19 virus to patients and other students, which easily could influence their study progression. As a result, they did not see friends, for example, when they went home to visit their parents for weekends or holidays. The students emphasised how they had looked forward to the social part of the student life and recognised that they had lost a lot: ‘I feel like the COVID-19 pandemic has diminished my student life’ (Focus group 2). Most of the students lived in shared accommodations or with a partner, and they underlined that this was crucial for their social well-being. However, some expressed that it is possible to feel lonely even when living with someone else. This view was especially prominent among those who felt socially isolated due to fear of COVID-19 or limited contacts. They were eager for contact, and some even characterised feelings of desperation in this situation: ‘Most of the time, it is just me and my boyfriend in this apartment 24/7. I feel desperate to see more people’ (Focus group 4). The restrictions implied that students could only see their families to a limited extent during the semesters. Some students came from a region with a higher transmission rate, and these were especially vulnerable because they were unable to go home. The weeks engaged in clinical placement also meant that students had fewer opportunities to see family and friends. Still, family was important for most of the students’ QOL. Physical health challenges comprised the sub-themes influences on physical activity and influences on nutrition intake. It was found that physical activity was important for the student’s physical health. When the fitness centres closed, students used alternative arenas for exercise and spent a lot of time outdoors, spent time with their pets or went fishing: ‘It is very relaxing just to go fishing’ (Focus group 1). Planning to exercise and stick with a friend helped to fulfil their exercise goals. Some students felt they had developed a COVID body. They had put on weight, started eating more, developed a habit of eating during the day while attending Zoom tutorials in bed or started eating in a less healthy way. This influenced their body image and their mental health. The students recognised that it was their responsibility to be active and eat properly. In contrast to those who felt less healthy, one student experienced having healthier habits when it was her decision on what and when to eat: ‘I actually eat healthier because I can plan my own meals, deciding what to eat and when’ (Focus group 1). Mental health challenges comprised the sub-themes feelings of depression and fatigue and fear of COVID-19. Several of the students experienced decreased mental health and well-being. Some experienced depressive thoughts, for example, because of catching the virus, worry about spreading the virus or the restrictions the pandemic brought. Others expressed a feeling of fatigue and limited initiative. Students who had experienced mental challenges and depression before the pandemic experienced that the situation influenced their mental health negatively, and some found that it could be hard to get adequate help: ‘It doesn’t help to ask for help when you are unable to receive any’ (Focus group 3). The students found it exhausting to adapt and follow the changing restrictions and rules. As nursing students, they were more aware of the mental health in general and the mental health of their fellow students. One student reported that she had been more attentive towards friends, sending extra text messages or calling them. Some students expressed that the pandemic period was one of the worst times in their lives, and they hoped that the future would be better. When students engaged in regular physical activity, it positively influenced their mental health. The students spent time with their cohort, and when they were not allowed to meet indoors, they went outdoors and enjoyed nature together: ‘If you are active and use your body, it will positively influence your mental health’ (Focus group 5). Several of the students said they had worked with their mindset and mental approach to life during the pandemic. The pandemic had taught them to take care of their health, although it required discipline to manage their study and everyday activities. Discussion When we explored fear of COVID-19, general health, psychological distress and quality of life among baccalaureate nursing students at 1 year into the COVID-19 pandemic, we found that the pandemic influenced the students’ QOL. The pandemic reduced the students' opportunities to live an active (student) life; many felt lonely and missed having social relations. The students experienced that this negatively influenced their QOL, physical health, and especially, their mental health. The challenges were most prominent among first-year students. However, the students also developed strategies for maintaining a social life to increase their physical and mental health and QOL under the given COVID-19 restrictions. The quantitative data showed that the students reported general health and psychological distress at a level that was comparable with the pre-pandemic level, whereas their level of QOL differed during the pandemic [ 19 ]. Most students experienced their QOL was influenced negatively, mainly because their previously known factors for QOL were lacking or had changed [ 32 ]. Previous studies have identified increased stress, anxiety [ 8 – 10 ], loneliness and mental health problems among nursing students because of the COVID-19 pandemic [ 10 – 13 ]. However, some of our students also revealed resilience as the pandemic went by, for example, by focusing on other issues that brought better QOL. Resilience during the pandemic has been seen in longitudinal studies of the general population; it is characterised as a surprising ability to adapt [ 6 ]. In the region of the present university, the students have access to woodlands and outdoor spaces, and there are arenas available for all people (including students); this made it easier for them to choose alternative activities. Despite signs of resilience and adaptation among most students, as well as that QOL among the students at the studied university was higher than levels reported in other universities taking part in the national survey [ 19 ] (see also supplementary Table 2), most of the students experienced reduced QOL because of the pandemic. About 50% of the students in the present study felt lonely because of the pandemic. They missed personal relations because they were unable to meet with other students, their friends, or their families. A previous study identified a correlation between feelings of social isolation and mental health among nursing students [ 33 ]. It has also been found that students struggle to implement knowledge when they feel lonely [ 34 ]. Our first-year students reported being lonelier and more vulnerable thanthesecond-and third-year students did, probably because of their limited opportunities to establish an educational and social network. The yearly programme for starting the autumn semester at the university is an event most students look forward to. At this time, the students connect with one another, and the university arranges buddy groups focused on helping new students to meet other students. However, this annual event had to be arranged with restrictions and adaptations because of the pandemic, and some of the initial intentions could not be realized. The students conveyed that the feeling of missing personal relations with other students became a stressor for them. Social and academic isolation can have major consequences when acquiring professional knowledge [ 10 , 34 , 35 ]. Such findings were also reported in another study based on a national sample where the nursing students showed strong feelings of social and academic isolation during the pandemic [ 36 ]. In our study, some of the students seemed to develop coping strategies to feel less lonely in finding smaller groups or cohorts to support them. Furthermore, clinical placements were described as an important place to connect to other students during the pandemic, as well as helping them to establish structure in their everyday lives, which was good for implementing predictability. That the present university could provide clinical placement nearly as normal was beneficial for the students. Previous studies showed that students experienced uncertain and stressful environments and struggled with their learning outcomes during COVID-19 [ 34 ]. To support students during a crisis like the pandemic, it is important for the university to create options to maintain distance counselling services for all students. Moreover, universities should develop strategies for identifying students who need psychosocial support and facilitating contact with supervisors and space to unwind [ 34 ]. The students in our study reported more fear of COVID-19 than the general population did [ 22 ], and the qualitative data revealed worsened physical and mental health among some of the students[ 4 ], including depressive thoughts, fatigue and lack of energy. These findings were especially prominent among first-year students. Nursing students are most likely aware of general advice for better mental and physical health. Given the COVID-19 restrictions, the students had a greater extent to self be responsible and chose activities that bring better health. The free time that came about as a result of the restrictions may have given the students the opportunity (or forced them) to make more conscious choices and perhaps explore former underused or new ways to increase their physical and mental health. The students’ health seems to have been influenced by the COVID-19 restrictions, and this may have caused more stress and fear. Such findings have also been seen in other studies among nursing students, who report increased levels of stress, anxiety, health problems, sleeplessness, and fear about their study progression [ 5 , 8 – 11 ]. The results from a systematic review suggest that providing regular mental health assessments or online mental health services to students may increase their well-being in situations like a pandemic [ 37 ]. Ultimately, empowering students to cope with challenging emotions and thoughts might contribute to the development of both individual students and the profession as a whole [ 38 ]. Strengths And Limitations The strengths of the current study are the inclusion of both qualitative and quantitative methods. It is a strength that we used well-validated instruments to measure psychological distress, physical and mental health and QOL. The qualitative analysis was conducted by authors who are experienced nurse educators, which may ensure knowledge of the context; however, it may also represent a bias in the data analysis. All authors took part in the analysis process, which strengthened the credibility of the study. Thematic synthesis allowed different perspectives and contexts to be explored. To ensure transparency, the different steps of the analysis were specified and followed [ 31 ]. The discussion and reflection between the researchers about the analysis and findings of both data sources strengthened the trustworthiness of the insights gained. Further, user involvement and collaboration with students is a strength in this study. Students were involved in several stages of the process and validated the themes and findings. One limitation was the cross-sectional nature of the survey, which allowed it to reveal only statistically significant associations between the variables and did not allow conclusions to be drawn about causality. Furthermore, we have no information about the students who did not take part in the survey. Conclusion And Implications The COVID-19 pandemic negatively influenced nursing students’ QOL and physical and mental health, and it increased their feelings of loneliness. However, most students who participated in this study also adapted strategies and resilience factors to cope with the situation. The students may have learned additional skills and mental mindsets that can be useful in their future professional lives. In future pandemics, it might be considered important for universities to take on responsibilities for supporting students’ mental health, physical health and QOL. Declarations Ethics approval: All procedures performed in the study were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval was obtained from the ethics committee of the Faculty of Health and Sport Sciences at the University of Agder and from the Norwegian Centre for Research Data (NSD Reference 60981). Consent to participate: The students received written information and gave their informed consent. Data in the study were anonymized. Consent for publication: Not applicable. Data and materials availability: The datasets used and/or analyzed during the current study are not publicly available due to General Data Protection Regulation laws but are available from the corresponding author on reasonable request and with permission from the Norwegian Centre for Research Data. Competing interest: The authors declare that they have no competing interests. Funding: Faculty of Health and Sport Sciences, University of Agder. Authors’ contributions: GR and KH designed the study. MM gave input to the national survey. GR and KH were responsible for the recruitment and focus-group interviews. Quantitative data analysis was performed by GR. GR was main responsible for the qualitative analysis, but all authors gave input and contributed. The first draft of the manuscript was written by GR, and all authors commented on previous and current versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements : We would like to thank all the nursing students at University of Agder who participated in this study, thereby providing us with valuable research data. References Sustainable Goals [https://www.un.org/sustainabledevelopment/]. The World Health Organization Quality of Life Assessment (WHOQOL): Position Paper from the World Health Organization . Soc Sci Med 1995, 41 (10):1403-1409. Education Shift During COVID-19: Students’ Satisfaction with Emergency Distance Learning . International Journal of Nursing Education 2021. NOKUT National Student Survey 2020 [https://www.studiebarometeret.no/en/]. Ard N, Beasley SF, Nunn-Ellison K, Farmer S: Responding to the pandemic: Nursing education and the ACEN . Teach Learn Nurs 2021, 16 (4):292-295. Leigh J, Bolton M, Cain K, Harrison N, Bolton NY, Ratcliffe S: Student Experiences of Nursing on the Front Line During the COVID-19 Pandemic . British Journal of Nursing 2020, 29 (13):788-789. Lovrić R, Farčić N, Mikšić Š, Včev A: Studying During the COVID-19 Pandemic: A Qualitative Inductive Content Analysis of Nursing Students’ Perceptions and Experiences . Education Sciences 2020, 10 (7):188. Gallego-Gómez JI, Campillo-Cano M, Carrión-Martínez A, Balanza S, Rodríguez-González-Moro MT, Simonelli-Muñoz AJ, Rivera-Caravaca JM: The COVID-19 Pandemic and Its Impact on Homebound Nursing Students . Int J Environ Res Public Health 2020, 17 (20). Huang L, Lei W, Xu F, Liu H, Yu L: Emotional Responses and Coping Strategies in Nurses and Nursing Students During COVID-19 Outbreak: A Comparative Study . PLoS One 2020, 15 (8):e0237303. Savitsky B, Findling Y, Ereli A, Hendel T: Anxiety and Coping Strategies Among Nursing Students During the COVID-19 Pandemic . Nurse Educ Pract 2020, 46 :102809. Utvær BKS, Paulsby TE, Torbergsen H, Haugan G: Learning Nursing During the COVID-19 Pandemic: The Importance of Perceived Relatedness with Teachers and Sense of Coherence . 2021. Blix I, Birkeland MS, Thoresen S: Worry and Mental Health in the COVID-19 Pandemic: Vulnerability Factors in the General Norwegian Population . BMC Public Health 2021, 21 (1):928. Kochuvilayil T, Fernandez RS, Moxham LJ, Lord H, Alomari A, Hunt L, Middleton R, Halcomb EJ: COVID-19: Knowledge, Anxiety, Academic Concerns and Preventative Behaviours Among Australian and Indian Undergraduate Nursing Students: A Cross-sectional Study . J Clin Nurs 2021, 30 (5-6):882-891. Keener TA, Hall K, Wang K, Hulsey T, Piamjariyakul U: Quality of Life, Resilience, and Related Factors of Nursing Students During the COVID-19 Pandemic . Nurse Educ 2021, 46 (3):143-148. Middleton R, Fernandez R, Moxham L, Tapsell A, Halcomb E, Lord H, Alomari A, Hunt L: Generational Differences in Psychological Wellbeing and Preventative Behaviours Among Nursing Students During COVID-19: A Cross-sectional Study . Contemp Nurse 2021:1-11. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at John Hopkins University (JHU) [https://www.arcgis.com/apps/dashboards/bda7594740fd40299423467b48e9ecf6]. Riiser K, Helseth S, Haraldstad K, Torbjørnsen A, Richardsen KR: Adolescents' Health Literacy, Health Protective Measures, and Health-Related Quality of Life During the COVID-19 Pandemic . PLoS One 2020, 15 (8):e0238161. The Student Survey 2021 [https://studiebarometeret.no/en/student/studieprogram/1175_syplgr/.] Beisland EG, Gjeilo KH, Andersen JR, Bratås O, Bø B, Haraldstad K, Hjelmeland IHH, Iversen MM, Løyland B, Norekvål TM et al. : Quality of Life and Fear of COVID-19 in 2600 Baccalaureate Nursing Students at Five Universities: A Cross-sectional Study . Health Qual Life Outcomes 2021, 19 (1):198. Stensrud SR, KR; Aars, M; Riiser, K: Fysioterapeutstudenters bekymring for smitte under Covid-19 pandemien og opplevd utbytte av klinisk praksis. En tverrsnittstudie . Fysioterapeuten 2021, Online . Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH: The Fear of COVID-19 Scale: Development and Initial Validation . Int J Ment Health Addict 2020:1-9. Iversen MM, Norekvål TM, Oterhals K, Fadnes LT, Mæland S, Pakpour AH, Breivik K: Psychometric Properties of the Norwegian Version of the Fear of COVID-19 Scale . Int J Ment Health Addict 2021:1-19. Schmalbach B, Zenger M, Tibubos AN, Kliem S, Petrowski K, Brähler E: Psychometric Properties of Two Brief Versions of the Hopkins Symptom Checklist: HSCL-5 and HSCL-10 . Assessment 2021, 28 (2):617-631. Strand BH, Dalgard OS, Tambs K, Rognerud M: Measuring the Mental Health Status of the Norwegian Population: A Comparison of the Instruments SCL-25, SCL-10, SCL-5 and MHI-5 (SF-36) . Nord J Psychiatry 2003, 57 (2):113-118. Jacobsen EL, Bye A, Aass N, Fosså SD, Grotmol KS, Kaasa S, Loge JH, Moum T, Hjermstad MJ: Norwegian Reference Values for the Short-Form Health Survey 36: Development over Time . Qual Life Res 2018, 27 (5):1201-1212. Ware JE, Jr., Kosinski MA, Keller SD: SF-36 Physical and Mental health Summery Scale: A User's Manual . Boston, MA: New England Medical Centre, The Health Institute; 1994. Macias C, Gold PB, Öngür D, Cohen BM, Panch T: Are Single-Item Global Ratings Useful for Assessing Health Status? J Clin Psychol Med Settings 2015. Levin KA, Currie C: Reliability and Validity of an Adapted Version of the Cantril Ladder for Use with Adolescent Samples . Social Indicators Research 2014, 119 (2):1047-1063. Polit DF: Nursing Research: Principles and Methods . Philadelphia, PA: Lippincott Williams & Wilkins; 2004. Pallant J: SPSS Survival Manual : A Step by Step Guide to Data Analysis Using IBM SPSS , 6th edn. Maidenhead: McGraw Hill Education; 2016. Crabtree BF, Miller WL: Doing Qualitative Research . Thousand Oaks, CA: Sage; 1999. Wilson IB, Cleary PD: Linking Clinical Variables with Health-Related Quality of Life. A Conceptual Model of Patient Outcomes . JAMA 1995, 273 (1):59-65. Patelarou E, Galanis P, Mechili EA, Argyriadi A, Argyriadis A, Asimakopoulou E, Kicaj E, Bucaj J, Carmona-Torres JM, Cobo-Cuenca AI et al. : Assessment of COVID-19 Fear in Five European Countries Before Mass Vaccination and Key Predictors among Nurses and Nursing Students . Vaccines (Basel) 2022, 10 (1). Ulenaers D, Grosemans J, Schrooten W, Bergs J: Clinical Placement Experience of Nursing Students During the COVID-19 Pandemic: A Cross-sectional Study . Nurse Educ Today 2021, 99 :104746. Flateland SM, Pryce-Miller M, Skisland AV, Tønsberg AF, Söderhamn U: Exploring the Experiences of Being an Ethnic Minority Student Within Undergraduate Nurse Education: A Qualitative Study . BMC Nurs 2019, 18 :63. Michel A, Ryan N, Mattheus D, Knopf A, Abuelezam NN, Stamp K, Branson S, Hekel B, Fontenot HB: Undergraduate Nursing Students' Perceptions on Nursing Education During the 2020 COVID-19 Pandemic: A National Sample . Nurs Outlook 2021, 69 (5):903-912. Mulyadi M, Tonapa SI, Luneto S, Lin WT, Lee BO: Prevalence of Mental Health Problems and Sleep Disturbances in Nursing Students During the COVID-19 Pandemic: A Systematic Review and Meta-analysis . Nurse Educ Pract 2021, 57 :103228. Türkleş S, Boğahan M, Altundal H, Yaman Z, Yılmaz M: Diaries of Nursing Students During the COVID-19 Pandemic: A Qualitative Descriptive Study . Int J Environ Res Public Health 2021, 18 (16). Additional Declarations No competing interests reported. Supplementary Files 26.05.22suplementarytableart2.docx Cite Share Download PDF Status: Published Journal Publication published 03 Mar, 2023 Read the published version in BMC Nursing → Version 2 posted Editorial decision: Major revision 26 Dec, 2022 Reviews received at journal 18 Dec, 2022 Reviewers agreed at journal 24 Nov, 2022 Reviews received at journal 30 Oct, 2022 Reviewers agreed at journal 07 Oct, 2022 Reviewers agreed at journal 29 Sep, 2022 Reviewers invited by journal 16 Sep, 2022 Editor assigned by journal 16 Sep, 2022 Editor invited by journal 06 Sep, 2022 Submission checks completed at journal 06 Sep, 2022 First submitted to journal 06 Sep, 2022 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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10:44:22","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-1803383/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-1803383/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-023-01218-8","type":"published","date":"2023-03-03T19:29:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":26993563,"identity":"6bf9490c-9a14-4378-ad4a-aef503de38a7","added_by":"auto","created_at":"2022-09-27 01:06:10","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":89317,"visible":true,"origin":"","legend":"\u003cp\u003eResults from the qualitative analyses with main themes and sub-themes\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1803383/v2/d9de25d24fdee013534ea601.jpg"},{"id":44721416,"identity":"c63de156-fda6-4747-9f61-348cb0a90aea","added_by":"auto","created_at":"2023-10-16 19:33:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1238268,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1803383/v2/f31320fa-768a-41de-97ff-ca40a8baf0b4.pdf"},{"id":26993808,"identity":"6c9fef11-a91f-4f8e-9768-49ecb19954d1","added_by":"auto","created_at":"2022-09-27 01:11:10","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22526,"visible":true,"origin":"","legend":"","description":"","filename":"26.05.22suplementarytableart2.docx","url":"https://assets-eu.researchsquare.com/files/rs-1803383/v2/78e94af5e71635ca9c832e4d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fear of COVID-19, psychological distress, general health and quality of life among baccalaureate nursing students at one year into the COVID-19 pandemic: a mixed method study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe United Nations third Sustainable Development Goal is to ensure healthy lives and to promote quality of life (QOL) for all people of all ages [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This goal has been incorporated into national guidelines and goals, healthcare practices and public awareness. QOL is increasingly used as an outcome measure in different research settings, including clinical practice and student population surveys. In this context, QOL is defined as individuals\u0026rsquo; perception of their position in life in the context of the culture in which they live and in relation to their goals, expectations, standards and concerns [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. When the COVID-19 pandemic hit in March 2020, it led to major changes in people\u0026rsquo;s lives through protective strategies aimed at limiting the transmission of COVID-19. Such strategies included social distancing, lockdowns, cancelled or limited leisure activities and digital rather than in-person tutorials for students [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], which may all have influenced people\u0026rsquo;s health and QOL.\u003c/p\u003e \u003cp\u003eThe consequences of COVID-19 restrictions and lockdown especially influenced young people and students. Nursing students may have been particularly vulnerable during the COVID-19 pandemic because of both their status as young adults being and their practical training during their nursing programmes as a part of the healthcare system [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Previous studies on nursing students during the COVID-19 pandemic revealed that stress increased substantially during lockdown. Stress and anxiety could be triggered by students\u0026rsquo; personal problems [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Studies also showed that during the pandemic nursing students experienced loneliness and mental health problems, sleeplessness, problems with concentration and learning efficiency and fear of infection, as well as anxiety regarding grades, passing exams and final graduation [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, according to some research, nursing students have reported reduced health and QOL during the pandemic compared with the results of surveys of nursing students carried out the pandemic [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStatistics indicate that Norwegian society has handled the COVID-19 pandemic rather well. Most inhabitants have followed governmental rules, the transmission rate has been low and there have been relatively few hospital admissions and few deaths compared with the rates in other countries [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, adolescents and young adults have seemed to suffer, and COVID-19 restrictions may have had negative effects on their QOL [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a survey administered during the second wave of the pandemic (January \u0026ndash; March 2021), Norwegian baccalaureate nursing students reported worse outcomes during the pandemic in terms of general health, psychological distress and overall QOL compared with a student reference student population the year before the pandemic [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the level of fear of COVID-19 accounted for few of these differences, indicating that other factors related to the pandemic may have reduced nursing students\u0026rsquo; QOL [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. For students involved in clinical practice during the pandemic, concern about infecting others was an additional factor that influenced psychological distress [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResults of a Norwegian national survey was recently published; the survey looked at baccalaureate nursing students\u0026rsquo; experiences of fear of COVID-19, general health, psychological distress and overall QOL, with samples from five universities [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, in-depth knowledge alongside the survey data seems to be lacking in this case. Thus, we aimed to describe and explore fear of COVID-19, psychological distress, general health and QOL among baccalaureate nursing students at 1 year into the COVID-19 pandemic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDesign and sample\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used a mixed-method design\u0026nbsp;comprising quantitative data from one of the five universities in Southern Norway from the national survey\u0026nbsp;[19], combined with qualitative data from students at the same university. In the southern part of Norway, the transmission rate was rather low, and the university could offer the students clinical placement nearly as normal. This was not the case for several of the other universities.\u003c/p\u003e\n\u003cp\u003eBetween 27 January and 28 February 2021, full- and part-time baccalaureate nursing students \u0026gt; 18 years of age from the two campuses at the university in southern Norway took part in the web-based cross-sectional survey, as did students at four other universities in Norway. Baccalaureate nursing students from the same university were invited by the student representatives and the learning portal to participate in focus group interviews on campus. The focus group interviews took place between 26 April and 6 May 2021.\u0026nbsp;The interviews were arranged in the afternoons and lasted for 50–90 minutes. The interviews were moderated by the first author (GR; four groups) or the last author (KH; one group), who are both nurses and professors in health sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuantitative data\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMeasures\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe survey included questions related to students’ demographics, personal health and study situation during the pandemic; these questions were specifically developed for the national survey by nursing students (including MM), university staff and researchers. Additional measures included four well-validated (nationally and internationally) instruments for assessing fear of COVID-19, psychological distress, general health and overall QOL.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCharacteristics of the respondents\u003c/em\u003eincluded study site, household status, year of study and age (\u0026lt;25, 25–29, ≥30 years)\u0026nbsp;[19].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCOVID-19 specific questions related to personal health\u0026nbsp;\u003c/em\u003ewere developed for the national survey\u0026nbsp;[19]\u0026nbsp;and included quarantine history (never, previous, present); feelings of loneliness because of COVID-19 (rated from 1 [strongly disagree] to 5 [strongly agree]); perceived risk for complications of COVID-19 (no, uncertain, yes); and history of suspected, possible or confirmed COVID-19 infection. In the analysis, responses of ‘agree’ and ‘strongly agree’ were pooled under ‘agree.’ The questions were piloted with nine nursing students (including MM, one of the authors of this study). After minor adjustments, a digital pilot study was conducted with 90 physiotherapy students\u0026nbsp;[20]. No adjustments were made after the digital pilot.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe Fear of COVID-19 Scale (FCV-19S)\u003c/em\u003e[21]\u0026nbsp;was used to assess fear of coronavirus infection\u0026nbsp;[21, 22]. Seven items (e.g. ‘I am most afraid of the coronavirus’) were rated on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree), with a total score ranging from 7 to 35. On this scale, higher scores indicate a greater fear of COVID-19. In the present study, the average item score was used; it was calculated by dividing the total score by the number of items.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe Hopkins Symptom Checklist (SCL-5)\u003c/em\u003e[23]\u0026nbsp;is available as a Norwegian translation. It includes five items measuring psychological distress (anxiety and depression) that are rated on a 5-point scale from 1 (not at all) to 5 (extremely). We calculated the average item score by dividing the total score by the number of items on the list\u0026nbsp;[24]. Higher scores indicate greater psychological distress.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGeneral health\u003c/em\u003e was assessed using one item from the 36-Item Short-Form Health Survey (SF-36)\u0026nbsp;[25, 26]: ‘In general, would you say your health is: excellent, very good, good, fair or poor?\u003cem\u003e’\u003c/em\u003e Responses were rated on a 5-point scale ranging from 1 (excellent) to 5 (poor)\u0026nbsp;[27]. Consistent with the SF-36 scoring algorithm, the scale was reverse scored. Thus, higher scores reflect better general health as perceived by respondents. The item was found to be as valid and reliable as multi-item scales\u0026nbsp;[27].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOverall QOL\u003c/em\u003ewas rated on an adapted version of the Cantril Ladder on a scale from 0 (not at all satisfied) to 10 (highly satisfied). A score of 6 or more indicates high life satisfaction. The question, ‘All in all, how satisfied are you with your life at this time?’, has been widely used in various populations and in different settings; it is considered a reliable and valid measure of overall QOL\u0026nbsp;[28].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQualitative data\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used a semi-structured interview guide to ensure inclusion of the issues in focus, and the students were asked such questions as the following:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eHow has the COVID-19 pandemic influenced your social life?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHow has the COVID-19 pandemic influenced your health?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHow has the COVID-19 pandemic influenced your QOL?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mixed-method analysis strategy represents a parallel mixed data analysis, with separate quantitative and qualitative strands implemented to address related aspects of the research questions regarding the same phenomenon\u0026nbsp;[29]. The findings from both the quantitative and qualitative data collection are integrated in the discussion section.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDescriptive statistics are presented for all students and by year of education. Categorical variables as counts and percentages and continuous variables are described as means (SD). We used the chi-square test for categorical data to reveal associations between categorical variables and analysis of variance (ANOVA) tests for the continuous variables\u0026nbsp;[30].\u003c/p\u003e\n\u003cp\u003eThe analyses were considered exploratory, so no correction for multiple testing was performed. All tests were two-sided, and \u003cem\u003ep\u003c/em\u003e-values\u0026nbsp;\u0026lt;\u0026nbsp;0.05 were considered statistically significant. The analyses were performed using IBM SPSS Statistics (version 26)\u0026nbsp;[30].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative analyses\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe audiotaped the interviews and transcribed them verbatim.\u0026nbsp;The interviews were transferred to NVivo (version 12) software to organise the transcripts into codes and units of meaning.\u0026nbsp;In the analyses, we used a systematic text condensation analysis style\u0026nbsp;[31].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo researchers (GR and KH) independently read all the material\u0026nbsp;searching for an overall impression and established preliminary sub-themes;\u0026nbsp;the rest\u0026nbsp;of the group\u0026nbsp;read one interview each,\u0026nbsp;gave input\u0026nbsp;and wrote a summary of the overall impression. We then examined the text for units of meaning representing\u0026nbsp;the\u0026nbsp;students’ experiences.\u0026nbsp;In an iterative process, we coded and grouped these units; contrasted and abstracted the content in each group; and finally, discussed and summarised the content of each group into generalised descriptions. To support the analysis, we created mind maps and discussed the analysis at each step to reach an agreement. Quotations were used to illustrate and support the findings\u0026nbsp;[31].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUser involvement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA second-year student (MM) took part in the design and guided the questions for the study. This student is also a co-author of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to research ethics guidelines set up in the Helsinki Declaration. The application was approved by the head of department at the university, the Norwegian Center for Research (NSD; Project No 973745) and the research ethics committee at the faculty of health- and sport sciences (FEK). The students received oral and written information about the study and gave their written consent to participate.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative data\u003c/h2\u003e \u003cp\u003eIn total, 396 baccalaureate nursing students at a university in southern Norway participated in the survey. Most were living with someone (84%), and 70% were younger than 25 years. Fifty-six per cent reported having felt lonely because of the pandemic. Sixty-two per cent had been engaged in clinical placement during the pandemic, and 83% of the students who had been in clinical practice had cared for patients with confirmed COVID-19 or unclear COVID-19 status. Most students (72%) had trust in the way in which their governments and universities (57%) were handling the COVID-19 situation. Moreover, 70% of the students were concerned about the quality of their education (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudent characteristics of the baccalaureate nursing students at University of Agder for all participants (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;396) and organised by school year\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;396\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYear 1\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;142\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYear 2\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;127\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYear 3\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;127\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears in nursing school\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142 (36%)\u003c/p\u003e \u003cp\u003e127 (32%)\u003c/p\u003e \u003cp\u003e127 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003cp\u003e\u0026lt;25\u003c/p\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026nbsp;30\u0026nbsp;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e278 (70%)\u003c/p\u003e \u003cp\u003e46 (12%)\u003c/p\u003e \u003cp\u003e72 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (79%)\u003c/p\u003e \u003cp\u003e11 (8%)\u003c/p\u003e \u003cp\u003e19 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86 (65)\u003c/p\u003e \u003cp\u003e26 (20%)\u003c/p\u003e \u003cp\u003e15 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80 (63%)\u003c/p\u003e \u003cp\u003e20 (16%)\u003c/p\u003e \u003cp\u003e27 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving alone\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;No\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e332 (84%)\u003c/p\u003e \u003cp\u003e64 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 (85%)\u003c/p\u003e \u003cp\u003e22 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108 (85%)\u003c/p\u003e \u003cp\u003e19 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e104 (82%)\u003c/p\u003e \u003cp\u003e23 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuarantine status\u0026nbsp;related\u0026nbsp;to COVID-19\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Never\u003c/p\u003e \u003cp\u003ePrevious\u003c/p\u003e \u003cp\u003eNow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236 (60%)\u003c/p\u003e \u003cp\u003e157 (39%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77(54%)\u003c/p\u003e \u003cp\u003e63 (44%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78 (61%)\u003c/p\u003e \u003cp\u003e48 (38%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81 (64%)\u003c/p\u003e \u003cp\u003e46 (36%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.383\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt risk for COVID-19 complications\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;No\u003c/p\u003e \u003cp\u003eUncertain\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (10%)\u003c/p\u003e \u003cp\u003e323 (82%)\u003c/p\u003e \u003cp\u003e33 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (11%)\u003c/p\u003e \u003cp\u003e114 (80%)\u003c/p\u003e \u003cp\u003e12 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (13%)\u003c/p\u003e \u003cp\u003e103 (81%)\u003c/p\u003e \u003cp\u003e8 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (6%)\u003c/p\u003e \u003cp\u003e106 (84%)\u003c/p\u003e \u003cp\u003e13 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.397\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrust in governmental handling of the COVID-19 situation\u003c/p\u003e \u003cp\u003eStrongly disagree/disagree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Neither disagree nor agree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Agree\u003c/p\u003e \u003cp\u003eStrongly agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (9%)\u003c/p\u003e \u003cp\u003e44 (18%)\u003c/p\u003e \u003cp\u003e200 (50%)\u003c/p\u003e \u003cp\u003e89 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (6%)\u003c/p\u003e \u003cp\u003e30 (21%)\u003c/p\u003e \u003cp\u003e67 (47%)\u003c/p\u003e \u003cp\u003e31 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3%)\u003c/p\u003e \u003cp\u003e29 (23%)\u003c/p\u003e \u003cp\u003e68 (53%)\u003c/p\u003e \u003cp\u003e26 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (14%)\u003c/p\u003e \u003cp\u003e12 (9%)\u003c/p\u003e \u003cp\u003e65 (51%)\u003c/p\u003e \u003cp\u003e32 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrust in universities\u0026rsquo; handling of the COVID-19 situation\u003c/p\u003e \u003cp\u003eStrongly disagree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Disagree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Neither disagree nor agree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Agree\u003c/p\u003e \u003cp\u003eStrongly agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (4%)\u003c/p\u003e \u003cp\u003e44 (11%)\u003c/p\u003e \u003cp\u003e112 (28%)\u003c/p\u003e \u003cp\u003e180 (46%)\u003c/p\u003e \u003cp\u003e42 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4%)\u003c/p\u003e \u003cp\u003e17 (12%)\u003c/p\u003e \u003cp\u003e37 (26%)\u003c/p\u003e \u003cp\u003e67 (47%)\u003c/p\u003e \u003cp\u003e16 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3%)\u003c/p\u003e \u003cp\u003e17 (13%)\u003c/p\u003e \u003cp\u003e47 (37%)\u003c/p\u003e \u003cp\u003e50 (39%)\u003c/p\u003e \u003cp\u003e28 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (7%)\u003c/p\u003e \u003cp\u003e10 (8%)\u003c/p\u003e \u003cp\u003e28 (22%)\u003c/p\u003e \u003cp\u003e63 (50%)\u003c/p\u003e \u003cp\u003e17 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern about the quality of education\u003c/p\u003e \u003cp\u003eStrongly disagree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Disagree\u003c/p\u003e \u003cp\u003eNeither disagree nor agree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Agree\u003c/p\u003e \u003cp\u003eStrongly agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (5%)\u003c/p\u003e \u003cp\u003e34 (9%)\u003c/p\u003e \u003cp\u003e64 (16%)\u003c/p\u003e \u003cp\u003e142 (36%)\u003c/p\u003e \u003cp\u003e134 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003cp\u003e6 (4%)\u003c/p\u003e \u003cp\u003e17 (12%)\u003c/p\u003e \u003cp\u003e50 (35%)\u003c/p\u003e \u003cp\u003e66 (47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (5%)\u003c/p\u003e \u003cp\u003e13 (10%)\u003c/p\u003e \u003cp\u003e21 (17%)\u003c/p\u003e \u003cp\u003e40 (31%)\u003c/p\u003e \u003cp\u003e47 (37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (10%)\u003c/p\u003e \u003cp\u003e15 (12%)\u003c/p\u003e \u003cp\u003e26 (21%)\u003c/p\u003e \u003cp\u003e52 (41%)\u003c/p\u003e \u003cp\u003e21 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.3 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.3 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeeling lonely due to COVID-19\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Strongly disagree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Disagree\u003c/p\u003e \u003cp\u003eNeither disagree nor agree\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Agree\u003c/p\u003e \u003cp\u003eStrongly agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (8%)\u003c/p\u003e \u003cp\u003e61 (15%)\u003c/p\u003e \u003cp\u003e80 (20%)\u003c/p\u003e \u003cp\u003e130 (32%)\u003c/p\u003e \u003cp\u003e92 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6%)\u003c/p\u003e \u003cp\u003e16 (11%)\u003c/p\u003e \u003cp\u003e23 (16%)\u003c/p\u003e \u003cp\u003e53 (37%)\u003c/p\u003e \u003cp\u003e42 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (8%)\u003c/p\u003e \u003cp\u003e21 (16%)\u003c/p\u003e \u003cp\u003e28 (22%)\u003c/p\u003e \u003cp\u003e40 (32%)\u003c/p\u003e \u003cp\u003e28 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (12%)\u003c/p\u003e \u003cp\u003e24 (19%)\u003c/p\u003e \u003cp\u003e29 (23%)\u003c/p\u003e \u003cp\u003e37 (29%)\u003c/p\u003e \u003cp\u003e22 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngagement in clinical practice during the pandemic\u0026nbsp;\u003c/p\u003e \u003cp\u003e\u0026nbsp;Yes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e246 (62%)\u003c/p\u003e \u003cp\u003e150 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (9%)\u003c/p\u003e \u003cp\u003e130 (91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117 (92%)\u003c/p\u003e \u003cp\u003e10 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e127 (92%)\u003c/p\u003e \u003cp\u003e10 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHave you been in contact with patients in the following situations during the pandemic?\u003c/p\u003e \u003cp\u003ePatients with unclear COVID-19 status\u003c/p\u003e \u003cp\u003ePatients with confirmed COVID-19 infection\u003c/p\u003e \u003cp\u003eBoth (unclear and confirmed)\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (61%)\u003c/p\u003e \u003cp\u003e7 (3%)\u003c/p\u003e \u003cp\u003e35 (15%)\u003c/p\u003e \u003cp\u003e52 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 (55%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003cp\u003e11 (9%)\u003c/p\u003e \u003cp\u003e39 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81 (70%)\u003c/p\u003e \u003cp\u003e4 (3%)\u003c/p\u003e \u003cp\u003e24 (21%)\u003c/p\u003e \u003cp\u003e7 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* Categorical data are presented as number (%) and continuous variables as mean (SD). Chi-square tests were used to compare differences in categorical variables and ANOVA tests for continuous data\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here\u003c/p\u003e \u003cp\u003eWhen comparing students in the three different study years, the most striking differences by February 2021 were that the first-year student had not been in clinical placement, and more students in second year (66%) and third year 3 (94%) had been in contact with patients with confirmed or unclear COVID-19 status. Further, more first-year students (82%) were concerned about the quality of education compared with second-year (70%) and third-year students (62%; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eFear Of Covid-19, Psychological Distress, General Health And Qol\u003c/h2\u003e\n\u003cp\u003eFor the entire student group, the mean score (SD) for fear of COVID-19 was 2.32 (0.71), that for psychological distress was 1.53 (1.00), that for general health was 3.51 (0.96) and that for QOL was 6.01 (2.06). When comparing first-year students with second- and third-year students, they reported more fear of COVID-19 (2.45 [0.79] vs. 2.28 [0.66] vs. 2.22 [0.70], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026), more psychological distress (1.83 [0.99] vs. 1.43 [0.99] vs. 1.21 [0.66], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and lower QOL (5.44 [2.16] vs. 6.19 [2.02] vs. 6.45 [1.86], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-reported fear of COVID-19, psychological distress, general health and overall quality of life among 396 baccalaureate nursing students at the University of Agder\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;396)\u003c/p\u003e \u003cp\u003emean\u0026nbsp;(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003csup\u003ee\u003c/sup\u003e‧\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of COVID (FCV-19)\u003csup\u003ea\u003c/sup\u003e (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.32 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.45 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.28 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.22 (0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral health\u003csup\u003eb\u003c/sup\u003e (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.51 (0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.41 (0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.59 (1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.60 (0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.164\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological distress\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(SCL-5) (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.54 (1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.83 (0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.43 (0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.21 (0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Quality of life\u003csup\u003ed\u003c/sup\u003e\u0026nbsp;(0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.01 (2.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.44 (2.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.19 (2.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.45 (1.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001‧\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ea Higher score of FCV-19S reflect higher level of fear of COVID-19\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eb Higher score reflects better perceived general health.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ec Higher score on Hopkins Symptom Checklist (SCL-5) reflects more psychological distress\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ed In line with the SF-36 scoring algorithm, the item was reversed. Higher score of overall quality of health reflects better perceived overall quality of life.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ee ANOVA tests\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e about here\u003c/p\u003e\n\u003ch2\u003eQualitative Data\u003c/h2\u003e\n\u003cp\u003eTwenty-three students (7 men, 16 women) took part in the focus group interviews; their age was in the range of 19\u0026ndash;32 years, with a mean age of 23 years. The students comprised 10 first-year students, 7 second-year students and 6 third-year students. Most students lived in shared accommodation or with a partner. We identified the overarching theme of \u003cem\u003eeffect of COVID-19 on students\u0026rsquo; QOL\u003c/em\u003e and the three following main themes: \u003cem\u003eimportance of personal relations\u003c/em\u003e, \u003cem\u003ephysical health challenges\u003c/em\u003e and \u003cem\u003emental health challenges.\u003c/em\u003e Each of the main themes comprised two sub-themes, as listed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch2\u003eEffect Of Covid-19 On Students’ Qol\u003c/h2\u003e\n\u003cp\u003eMost of the students felt that the pandemic had influenced their QOL negatively; some suggested that it had reduced their QOL by 20\u0026ndash;30%. One of the students commented: \u003cem\u003e\u0026lsquo;I have been unable to do things that bring energy, which is important for my QOL\u0026rsquo;\u003c/em\u003e (Focus group 3). In contrast, some students experienced high QOL both before and during the pandemic; the difference was the factors important for QOL. In the context of the pandemic, they had learned to focus and appreciate other things and values that they had previously taken for granted. Furthermore, some students organised their everyday lives to improve their QOL; for instance, they would tidy their dwelling or practice given routines. One even commented: \u003cem\u003e\u0026lsquo;I have felt lucky this year. I feel a bit guilty saying I experience a better QOL despite the pandemic\u0026rsquo;\u003c/em\u003e (Focus group 2).\u003c/p\u003e \u003cp\u003e \u003cb\u003eImportance of personal relations\u003c/b\u003e comprised the sub-themes of feelings of loneliness and desire for a social life. In general, the participating students described envisioning student life as a time with a socially active lifestyle; however, because of restrictions and lockdowns, this was impossible for them. Several of the students felt lonely; this was especially prominent among the new first-year students because many of them were new in town and had not established contact with other students on campus. It already takes courage, initiative and proactiveness to meet new friends at the university; because of the pandemic restrictions, the arenas for these meetings were different and limited for these students. Some students underlined their responsibility for making friends in due course, while others just continued to feel lonely:\u003c/p\u003e \u003cp\u003e \u003cem\u003eAnd now I have to\u0026mdash;even if it might feel a bit uncomfortable\u0026mdash;randomly ask other students during the programme for semester start if they would like to do something together. I have to dare. I have to work with my mindset, leave my comfort zone, be nice to everyone and make an effort to make friends early.\u003c/em\u003e (Focus group 1)\u003c/p\u003e \u003cp\u003eThe students missed meeting one another casually; going to parties; and feeling free, without responsibilities. They missed their extended group of friends. At the same time, a few found it acceptable to live a quieter life without the expectation of being socially active. Pandemic restrictions meant that factors important for QOL were lacking or diminished; for instance, respondents could not meet up with other students or feel free to gather in groups.\u003c/p\u003e \u003cp\u003eIn the autumn, when the transmission rate was rather low, the student organisation scheduled an alternative study programme for the beginning of the semester and buddy groups that met the given pandemic restrictions. The buddy groups were crucial to allow new students to become acquainted with others, and some of the new students felt lucky to be with their group or cohort. The importance of the buddy group was also confirmed and emphasised by the more experienced students. One commented, \u003cem\u003e\u0026lsquo;I am a bit embarrassed to say it, but I think I would have felt lonelier if I had been a first-year student\u0026rsquo;\u003c/em\u003e (Focus group 2). Another stated: \u003cem\u003e\u0026lsquo;I have to say this about the buddy group. We have stuck together. I feel lucky\u0026rsquo;\u003c/em\u003e (Focus group 1).\u003c/p\u003e \u003cp\u003eSince the transmission rate increased during the winter, some of the students felt they had to select which friends or group they could be with. This was hard, and with changing rules, plans had to be changed or adjusted. Especially during clinical placement, the students felt a responsibility to avoid spreading the COVID-19 virus to patients and other students, which easily could influence their study progression. As a result, they did not see friends, for example, when they went home to visit their parents for weekends or holidays. The students emphasised how they had looked forward to the social part of the student life and recognised that they had lost a lot: \u003cem\u003e\u0026lsquo;I feel like the COVID-19 pandemic has diminished my student life\u0026rsquo;\u003c/em\u003e (Focus group 2).\u003c/p\u003e \u003cp\u003eMost of the students lived in shared accommodations or with a partner, and they underlined that this was crucial for their social well-being. However, some expressed that it is possible to feel lonely even when living with someone else. This view was especially prominent among those who felt socially isolated due to fear of COVID-19 or limited contacts. They were eager for contact, and some even characterised feelings of desperation in this situation: \u003cem\u003e\u0026lsquo;Most of the time, it is just me and my boyfriend in this apartment 24/7. I feel desperate to see more people\u0026rsquo;\u003c/em\u003e (Focus group 4).\u003c/p\u003e \u003cp\u003eThe restrictions implied that students could only see their families to a limited extent during the semesters. Some students came from a region with a higher transmission rate, and these were especially vulnerable because they were unable to go home. The weeks engaged in clinical placement also meant that students had fewer opportunities to see family and friends. Still, family was important for most of the students\u0026rsquo; QOL.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhysical health challenges\u003c/b\u003e comprised the sub-themes influences on physical activity and influences on nutrition intake. It was found that physical activity was important for the student\u0026rsquo;s physical health. When the fitness centres closed, students used alternative arenas for exercise and spent a lot of time outdoors, spent time with their pets or went fishing: \u003cem\u003e\u0026lsquo;It is very relaxing just to go fishing\u0026rsquo;\u003c/em\u003e (Focus group 1). Planning to exercise and stick with a friend helped to fulfil their exercise goals.\u003c/p\u003e \u003cp\u003eSome students felt they had developed a COVID body. They had put on weight, started eating more, developed a habit of eating during the day while attending Zoom tutorials in bed or started eating in a less healthy way. This influenced their body image and their mental health. The students recognised that it was their responsibility to be active and eat properly. In contrast to those who felt less healthy, one student experienced having healthier habits when it was her decision on what and when to eat: \u003cem\u003e\u0026lsquo;I actually eat healthier because I can plan my own meals, deciding what to eat and when\u0026rsquo;\u003c/em\u003e (Focus group 1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eMental health challenges\u003c/b\u003e comprised the sub-themes feelings of depression and fatigue and fear of COVID-19. Several of the students experienced decreased mental health and well-being. Some experienced depressive thoughts, for example, because of catching the virus, worry about spreading the virus or the restrictions the pandemic brought. Others expressed a feeling of fatigue and limited initiative. Students who had experienced mental challenges and depression before the pandemic experienced that the situation influenced their mental health negatively, and some found that it could be hard to get adequate help: \u003cem\u003e\u0026lsquo;It doesn\u0026rsquo;t help to ask for help when you are unable to receive any\u0026rsquo;\u003c/em\u003e (Focus group 3).\u003c/p\u003e \u003cp\u003eThe students found it exhausting to adapt and follow the changing restrictions and rules. As nursing students, they were more aware of the mental health in general and the mental health of their fellow students. One student reported that she had been more attentive towards friends, sending extra text messages or calling them. Some students expressed that the pandemic period was one of the worst times in their lives, and they hoped that the future would be better.\u003c/p\u003e \u003cp\u003eWhen students engaged in regular physical activity, it positively influenced their mental health. The students spent time with their cohort, and when they were not allowed to meet indoors, they went outdoors and enjoyed nature together: \u003cem\u003e\u0026lsquo;If you are active and use your body, it will positively influence your mental health\u0026rsquo;\u003c/em\u003e (Focus group 5).\u003c/p\u003e \u003cp\u003eSeveral of the students said they had worked with their mindset and mental approach to life during the pandemic. The pandemic had taught them to take care of their health, although it required discipline to manage their study and everyday activities.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhen we explored fear of COVID-19, general health, psychological distress and quality of life among baccalaureate nursing students at 1 year into the COVID-19 pandemic, we found that the pandemic influenced the students\u0026rsquo; QOL. The pandemic reduced the students' opportunities to live an active (student) life; many felt lonely and missed having social relations. The students experienced that this negatively influenced their QOL, physical health, and especially, their mental health. The challenges were most prominent among first-year students. However, the students also developed strategies for maintaining a social life to increase their physical and mental health and QOL under the given COVID-19 restrictions.\u003c/p\u003e \u003cp\u003eThe quantitative data showed that the students reported general health and psychological distress at a level that was comparable with the pre-pandemic level, whereas their level of QOL differed during the pandemic [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Most students experienced their QOL was influenced negatively, mainly because their previously known factors for QOL were lacking or had changed [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Previous studies have identified increased stress, anxiety [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], loneliness and mental health problems among nursing students because of the COVID-19 pandemic [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, some of our students also revealed resilience as the pandemic went by, for example, by focusing on other issues that brought better QOL. Resilience during the pandemic has been seen in longitudinal studies of the general population; it is characterised as a surprising ability to adapt [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the region of the present university, the students have access to woodlands and outdoor spaces, and there are arenas available for all people (including students); this made it easier for them to choose alternative activities. Despite signs of resilience and adaptation among most students, as well as that QOL among the students at the studied university was higher than levels reported in other universities taking part in the national survey [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] (see also supplementary Table\u0026nbsp;2), most of the students experienced reduced QOL because of the pandemic.\u003c/p\u003e \u003cp\u003eAbout 50% of the students in the present study felt lonely because of the pandemic. They missed personal relations because they were unable to meet with other students, their friends, or their families. A previous study identified a correlation between feelings of social isolation and mental health among nursing students [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. It has also been found that students struggle to implement knowledge when they feel lonely [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our first-year students reported being lonelier and more vulnerable thanthesecond-and third-year students did, probably because of their limited opportunities to establish an educational and social network. The yearly programme for starting the autumn semester at the university is an event most students look forward to. At this time, the students connect with one another, and the university arranges buddy groups focused on helping new students to meet other students. However, this annual event had to be arranged with restrictions and adaptations because of the pandemic, and some of the initial intentions could not be realized.\u003c/p\u003e \u003cp\u003eThe students conveyed that the feeling of missing personal relations with other students became a stressor for them. Social and academic isolation can have major consequences when acquiring professional knowledge [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Such findings were also reported in another study based on a national sample where the nursing students showed strong feelings of social and academic isolation during the pandemic [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, some of the students seemed to develop coping strategies to feel less lonely in finding smaller groups or cohorts to support them. Furthermore, clinical placements were described as an important place to connect to other students during the pandemic, as well as helping them to establish structure in their everyday lives, which was good for implementing predictability. That the present university could provide clinical placement nearly as normal was beneficial for the students. Previous studies showed that students experienced uncertain and stressful environments and struggled with their learning outcomes during COVID-19 [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. To support students during a crisis like the pandemic, it is important for the university to create options to maintain distance counselling services for all students. Moreover, universities should develop strategies for identifying students who need psychosocial support and facilitating contact with supervisors and space to unwind [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe students in our study reported more fear of COVID-19 than the general population did [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and the qualitative data revealed worsened physical and mental health among some of the students[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], including depressive thoughts, fatigue and lack of energy. These findings were especially prominent among first-year students. Nursing students are most likely aware of general advice for better mental and physical health. Given the COVID-19 restrictions, the students had a greater extent to self be responsible and chose activities that bring better health. The free time that came about as a result of the restrictions may have given the students the opportunity (or forced them) to make more conscious choices and perhaps explore former underused or new ways to increase their physical and mental health.\u003c/p\u003e \u003cp\u003eThe students\u0026rsquo; health seems to have been influenced by the COVID-19 restrictions, and this may have caused more stress and fear. Such findings have also been seen in other studies among nursing students, who report increased levels of stress, anxiety, health problems, sleeplessness, and fear about their study progression [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The results from a systematic review suggest that providing regular mental health assessments or online mental health services to students may increase their well-being in situations like a pandemic [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Ultimately, empowering students to cope with challenging emotions and thoughts might contribute to the development of both individual students and the profession as a whole [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e"},{"header":"Strengths And Limitations","content":"\u003cp\u003eThe strengths of the current study are the inclusion of both qualitative and quantitative methods. It is a strength that we used well-validated instruments to measure psychological distress, physical and mental health and QOL. The qualitative analysis was conducted by authors who are experienced nurse educators, which may ensure knowledge of the context; however, it may also represent a bias in the data analysis. All authors took part in the analysis process, which strengthened the credibility of the study. Thematic synthesis allowed different perspectives and contexts to be explored. To ensure transparency, the different steps of the analysis were specified and followed [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The discussion and reflection between the researchers about the analysis and findings of both data sources strengthened the trustworthiness of the insights gained. Further, user involvement and collaboration with students is a strength in this study. Students were involved in several stages of the process and validated the themes and findings.\u003c/p\u003e \u003cp\u003eOne limitation was the cross-sectional nature of the survey, which allowed it to reveal only statistically significant associations between the variables and did not allow conclusions to be drawn about causality. Furthermore, we have no information about the students who did not take part in the survey.\u003c/p\u003e"},{"header":"Conclusion And Implications","content":"\u003cp\u003eThe COVID-19 pandemic negatively influenced nursing students\u0026rsquo; QOL and physical and mental health, and it increased their feelings of loneliness. However, most students who participated in this study also adapted strategies and resilience factors to cope with the situation. The students may have learned additional skills and mental mindsets that can be useful in their future professional lives. In future pandemics, it might be considered important for universities to take on responsibilities for supporting students\u0026rsquo; mental health, physical health and QOL.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e All procedures performed in the study were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval was obtained from the ethics committee of the Faculty of Health and Sport Sciences at the University of Agder and from the Norwegian Centre for Research Data (NSD Reference 60981).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eThe students received written information and gave their informed consent. Data in the study were anonymized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData and materials availability:\u003c/strong\u003e The datasets used and/or analyzed during the current study are not publicly available due to General Data Protection Regulation laws but are available from the corresponding author on reasonable request and with permission from the Norwegian Centre for Research Data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eFaculty of Health and Sport Sciences, University of Agder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eGR and KH designed the study. MM gave input to the national survey.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eGR and KH were responsible for the recruitment and focus-group interviews. Quantitative data analysis was performed by GR. GR was main responsible for the qualitative analysis, but all authors gave input and contributed. The first draft of the manuscript was written by GR, and all authors commented on previous and current versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: We would like to thank all the nursing students at University of Agder who participated in this study, thereby providing us with valuable research data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cstrong\u003eSustainable Goals \u003c/strong\u003e[https://www.un.org/sustainabledevelopment/].\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eThe World Health Organization Quality of Life Assessment (WHOQOL): Position Paper from the World Health Organization\u003c/strong\u003e. \u003cem\u003eSoc Sci Med \u003c/em\u003e1995, \u003cstrong\u003e41\u003c/strong\u003e(10):1403-1409.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eEducation Shift During COVID-19: Students’ Satisfaction with Emergency Distance Learning\u003c/strong\u003e. \u003cem\u003eInternational Journal of Nursing Education 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Boston, MA: New England Medical Centre, The Health Institute; 1994.\u003c/li\u003e\n\u003cli\u003eMacias C, Gold PB, Öngür D, Cohen BM, Panch T: \u003cstrong\u003eAre Single-Item Global Ratings Useful for Assessing Health Status?\u003c/strong\u003e \u003cem\u003eJ Clin Psychol Med Settings \u003c/em\u003e2015.\u003c/li\u003e\n\u003cli\u003eLevin KA, Currie C: \u003cstrong\u003eReliability and Validity of an Adapted Version of the Cantril Ladder for Use with Adolescent Samples\u003c/strong\u003e. \u003cem\u003eSocial Indicators Research \u003c/em\u003e2014, \u003cstrong\u003e119\u003c/strong\u003e(2):1047-1063.\u003c/li\u003e\n\u003cli\u003ePolit DF: \u003cstrong\u003eNursing Research: Principles and Methods\u003c/strong\u003e. Philadelphia, PA: Lippincott Williams \u0026amp; Wilkins; 2004.\u003c/li\u003e\n\u003cli\u003ePallant J: \u003cstrong\u003eSPSS Survival Manual : A Step by Step Guide to Data Analysis Using IBM SPSS\u003c/strong\u003e, 6th edn. Maidenhead: McGraw Hill Education; 2016.\u003c/li\u003e\n\u003cli\u003eCrabtree BF, Miller WL: \u003cstrong\u003eDoing Qualitative Research\u003c/strong\u003e. Thousand Oaks, CA: Sage; 1999.\u003c/li\u003e\n\u003cli\u003eWilson IB, Cleary PD: \u003cstrong\u003eLinking Clinical Variables with Health-Related Quality of Life. A Conceptual Model of Patient Outcomes\u003c/strong\u003e. \u003cem\u003eJAMA \u003c/em\u003e1995, \u003cstrong\u003e273\u003c/strong\u003e(1):59-65.\u003c/li\u003e\n\u003cli\u003ePatelarou E, Galanis P, Mechili EA, Argyriadi A, Argyriadis A, Asimakopoulou E, Kicaj E, Bucaj J, Carmona-Torres JM, Cobo-Cuenca AI\u003cem\u003e et al.\u003c/em\u003e: \u003cstrong\u003eAssessment of COVID-19 Fear in Five European Countries Before Mass Vaccination and Key Predictors among Nurses and Nursing Students\u003c/strong\u003e. \u003cem\u003eVaccines (Basel) \u003c/em\u003e2022, \u003cstrong\u003e10\u003c/strong\u003e(1).\u003c/li\u003e\n\u003cli\u003eUlenaers D, Grosemans J, Schrooten W, Bergs J: \u003cstrong\u003eClinical Placement Experience of Nursing Students During the COVID-19 Pandemic: A Cross-sectional Study\u003c/strong\u003e. \u003cem\u003eNurse Educ Today \u003c/em\u003e2021, \u003cstrong\u003e99\u003c/strong\u003e:104746.\u003c/li\u003e\n\u003cli\u003eFlateland SM, Pryce-Miller M, Skisland AV, Tønsberg AF, Söderhamn U: \u003cstrong\u003eExploring the Experiences of Being an Ethnic Minority Student Within Undergraduate Nurse Education: A Qualitative Study\u003c/strong\u003e. \u003cem\u003eBMC Nurs \u003c/em\u003e2019, \u003cstrong\u003e18\u003c/strong\u003e:63.\u003c/li\u003e\n\u003cli\u003eMichel A, Ryan N, Mattheus D, Knopf A, Abuelezam NN, Stamp K, Branson S, Hekel B, Fontenot HB: \u003cstrong\u003eUndergraduate Nursing Students' Perceptions on Nursing Education During the 2020 COVID-19 Pandemic: A National Sample\u003c/strong\u003e. \u003cem\u003eNurs Outlook \u003c/em\u003e2021, \u003cstrong\u003e69\u003c/strong\u003e(5):903-912.\u003c/li\u003e\n\u003cli\u003eMulyadi M, Tonapa SI, Luneto S, Lin WT, Lee BO: \u003cstrong\u003ePrevalence of Mental Health Problems and Sleep Disturbances in Nursing Students During the COVID-19 Pandemic: A Systematic Review and Meta-analysis\u003c/strong\u003e. \u003cem\u003eNurse Educ Pract \u003c/em\u003e2021, \u003cstrong\u003e57\u003c/strong\u003e:103228.\u003c/li\u003e\n\u003cli\u003eTürkleş S, Boğahan M, Altundal H, Yaman Z, Yılmaz M: \u003cstrong\u003eDiaries of Nursing Students During the COVID-19 Pandemic: A Qualitative Descriptive Study\u003c/strong\u003e. \u003cem\u003eInt J Environ Res Public Health \u003c/em\u003e2021, \u003cstrong\u003e18\u003c/strong\u003e(16).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, nursing students, general health, psychological distress, QOL, mixed methods","lastPublishedDoi":"10.21203/rs.3.rs-1803383/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1803383/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e:\u003cstrong\u003e \u003c/strong\u003eThe COVID-19 pandemic led to major changes in people’s lives via protective strategies aimed at limiting the transmission of COVID-19, including social distancing, lockdowns, cancelled or limited leisure activities and tutorials and supervision for students taking place digital. All of these changes may have influenced students’ health and quality of life (QOL).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: To describe and explore fear of COVID-19 and psychological distress, as well as general health and QOL, among baccalaureate nursing students at 1 year into the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: We used a mixed method study design, including quantitative data from one university in southern Norway that was a part of a national survey of baccalaureate nursing students and qualitative data from focus group interviews from the same university. The quantitative data were collected using well-validated measures of fear of COVID-19, psychological distress, general health and QOL, and the data were analysed using the ANOVA-tests for continuous data and chi-square tests for categorical data. The qualitative data were analysed using systematic text condensation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e:\u003cstrong\u003e \u003c/strong\u003eThe quantitative survey included 396 baccalaureate nursing students (response rate: 46%). The mean score (standard deviation [SD]) for fear of COVID-19 was 2.32 (0.71), for psychological distress was 1.53 (1.00), for general health was 3.51 (0.96) and for overall QOL was 6.01 (2.06).\u003c/p\u003e\n\u003cp\u003eFive focus group interviews were conducted with a total of 23 students (7 men, 16 women). In the qualitative data, we identified the overarching theme \u003cem\u003eeffect of COVID-19 on students’ QOL\u003c/em\u003e and the three main themes; \u003cem\u003eimportance of personal relations, physical health challenges \u003c/em\u003eand\u003cem\u003emental health challenges.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e:\u003cstrong\u003e \u003c/strong\u003eThe COVID-19 pandemic influenced negatively nursing students’ QOL and physical and mental health, and they often felt lonely. However, most of the participants also adapted strategies and resilience factors to cope with the situation. Via the pandemic situation, the students learned additional skills and mental mindsets that may be useful in their future professional lives.\u003c/p\u003e","manuscriptTitle":"Fear of COVID-19, psychological distress, general health and quality of life among baccalaureate nursing students at one year into the COVID-19 pandemic: a mixed method study","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2022-09-27 01:06:08","doi":"10.21203/rs.3.rs-1803383/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-12-26T12:40:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-12-18T09:46:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8c49109f-d4db-4419-8617-bc2a5ff686c3","date":"2022-11-24T12:56:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-10-30T05:59:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"fd3e6d59-d600-4ff0-9e93-44c360e8c493","date":"2022-10-07T13:32:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28ededc6-4448-44dd-a76b-f6a6088d20f2","date":"2022-09-29T22:47:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-09-16T13:58:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-09-16T13:48:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-09-06T10:48:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-09-06T10:41:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2022-09-06T06:18:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"288ce480-5ece-4f25-b877-6ceef5ae6a18","owner":[],"postedDate":"September 27th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T19:32:49+00:00","versionOfRecord":{"articleIdentity":"rs-1803383","link":"https://doi.org/10.1186/s12912-023-01218-8","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2023-03-03 19:29:36","publishedOnDateReadable":"March 3rd, 2023"},"versionCreatedAt":"2022-09-27 01:06:08","video":"","vorDoi":"10.1186/s12912-023-01218-8","vorDoiUrl":"https://doi.org/10.1186/s12912-023-01218-8","workflowStages":[]},"version":"v2","identity":"rs-1803383","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1803383","identity":"rs-1803383","version":["v2"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}