Examining the Long-Term Impact of COVID-19-Induced Clinical Practice Changes on Problem-Solving Behaviors Among Newly Graduated Nurses: A Longitudinal Study

Abstract

Objective

This study aimed to longitudinally examine how the cancellation or modification of the clinical practicum due to COVID-19 affected the nursing practice competence of newly graduated nurses in Japan.

Methods

A survey was conducted across three periods—June, September, and December 2022—to seek responses from participants. A total of 73 participants (two men and 71 women) who responded in all periods were included in the analysis. The survey included questions on the impact of the integrated and specific clinical practicums, including a self-assessment scale for nursing problem-solving behaviors.

Results

During all response periods, those whose practicums were entirely clinical scored significantly higher in nursing problem-solving behaviors. Furthermore, by December, “psychological support to patients for overcoming challenges” improved alongside the clinical experience of newly graduated nurses. However, their practical skills related to aggregating information, identifying improvements in nursing problems, facilitating smooth patient interactions, and individualizing assistance were challenging to improve along with clinical experience.

Conclusion

This study revealed that canceling or modifying the clinical practicum owing to COVID-19 impacted the problem-solving behaviors of newly graduated nurses.

Keywords

COVID-19 clinical practice newly graduated nurses nursing practice skills longitudinal study

Introduction

In December 2019, pneumonia cases caused by the novel coronavirus disease 2019 (COVID-19) were first reported in Wuhan, China, leading to the declaration of a “public health emergency of international concern” by the World Health Organization (2020). Consequently, nursing education, including clinical practice in hospitals worldwide, was also affected (Dewart et al., 2020). In response to the nationwide spread of COVID-19, many hospitals in Japan were reluctant to accept clinical trainees owing to the risk of nosocomial infection. Therefore, significant changes were made to university practicum methods, such as shortened clinical placements and substituted internal simulations (Japan Association of Nursing Programs in Universities, 2021; Sugawara et al., 2020). Clinical nursing practice is designed for students to integrate, deepen, and validate their nursing knowledge, skills, and attitudes acquired through general and specialized courses during their bachelor's degrees (Ministry of Education, Culture, Sports, Science and Technology, 2019).

During the COVID-19 pandemic, nursing education in Japan experienced significant changes. Many nursing schools temporarily suspended clinical placements to protect students and patients, leading to a rapid shift toward online education and virtual learning environments (Kenmotsu & Kameoka, 2023). Moreover, simulation-based learning was widely implemented in response to the lack of in-person clinical training. This method provided realistic scenarios for practicing infection control and emergency response, proving to be an effective learning tool during this period.

Hybrid learning models that combined virtual classes with limited face-to-face clinical training emerged as practical solutions for the modified Japanese nursing education. These models offered a flexible approach to learning, allowing students to acquire theoretical knowledge and essential practical skills. However, the abrupt shift in the educational environment resulted in increased stress and anxiety among nursing students. Concerns about exposure to the virus and difficulties in adapting to online learning were major factors contributing to their psychological burden.

Therefore, the reduction in opportunities to acquire practical skills due to COVID-19 raised concerns about its impact on the nursing practice abilities of newly graduated nurses.

Review of Literature

The COVID-19 pandemic significantly disrupted nursing education worldwide, particularly clinical practice, which is a critical component of developing nursing competencies. Existing literature has explored the impact of these disruptions on nursing students and newly graduated nurses.

Impact of Reduced Clinical Practice on Learning Outcomes

Ohue and Shiragami (2023) conducted a comparative analysis of nursing students who experienced only 1 week of clinical practice due to COVID-19-related restrictions, compared with those who underwent exclusively simulation-based training. Their study revealed that students with limited clinical practice gained more knowledge and skills in problem-solving customization and psychological support for patients than those exposed solely to simulation-based training. This finding suggests that even a brief period of direct clinical exposure has distinct advantages over simulated environments. This study underscores the importance of real-world clinical practice in developing critical problem solving and patient care skills.

Contrasting Findings on General Nursing Competence

However, Palese et al. (2022) found no significant differences in general nursing abilities—such as job roles and skills—between newly graduated nurses who completed their education under clinical practice restrictions due to COVID-19 and those from prior years without such restrictions. These findings indicate that general nursing competencies may be less sensitive to disruptions in clinical training, possibly due to adaptations in curriculum design or the inherent resilience of foundational nursing education.

Mixed Outcomes in Practical Nursing Abilities

Matsumoto and Nishiue reported that some nursing practice abilities of newly graduated nurses affected by COVID-19 showed partial improvement compared with those of the previous year. However, this improvement was not consistent across all domains. The authors emphasized that changes in the structure and delivery of nursing education during the pandemic might have contributed to these mixed outcomes. For example, an increased emphasis on theoretical knowledge or alternative training methods could explain the observed improvements in certain areas, while practical skill development may have been hindered by the lack of hands-on experience.

Limitations of Existing Studies

These studies share a significant limitation: the reliance on cross-sectional surveys of different participants groups. Comparing distinct cohorts, particularly when initial competencies and postgraduate training opportunities vary, introduces variability that complicates the interpretation of results. Factors such as individual aptitude, the content and quality of alternative training methods, and the availability of mentorship after graduation could all influence outcomes, making it difficult to isolate the effects of reduced clinical practice due to COVID-19.

Contextual Variations in Education and Training

The timeline of educational disruptions also played a critical role. For instance, nursing students in the academic year 2020 experienced significant alterations to their integration training, while those in 2021 faced widespread reductions in practical training. In contrast, the cohort of newly graduated nurses in 2022 experienced more targeted disruptions, particularly in practical training for nursing integration. These variations necessitate a nuanced understanding of how the timing and type of disruption impacted nursing competencies.

Current Study Rationale

Building on these insights, this study focuses on the problem-solving behaviors of newly graduated nurses from the 2022 cohort. The primary objective is to investigate how reductions or changes in clinical practice due to COVID-19 have influenced these behaviors. Moreover, the longitudinal design aims to track how these problem-solving behaviors evolve with postgraduate clinical experience. By addressing the limitations of previous cross-sectional studies, this research seeks to provide a more comprehensive understanding of the long-term impact of COVID-19-related changes on nursing practice competencies.

Methods

Design

A quantitative research design was used, and a longitudinal survey was conducted across three periods (June, September, and December 2022).

Research Question

In this study, the researchers longitudinally examined how the cessation or alteration of clinical training due to COVID-19 affected the problem-solving behaviors of newly graduated nurses in 2022.

Sample

The study targeted 225 nurses who graduated from basic nursing education in the fiscal year 2022. The participants were employed for the first time within a year after their graduation from 39 hospitals in Hyogo Prefecture that granted consent from 336 hospitals.

The initial sample size was set at 336 participants, considering an anticipated response rate of 60% and a dropout rate of 20% across the study period. Data were collected at three time points: baseline (T1: June 2022), three months (T2: September 2022), and six months (T3: December 2022). At T1, 225 participants completed the survey. At T2, 140 participants remained, and at T3, 73 participants completed the final survey. Overall, 73 participants were included in the final analysis, with a confidence level of 95% and margin of error of 5%.

Inclusion and Exclusion Criteria

The inclusion criterion for participation in this study was newly graduated nurses who had their clinical training during the COVID-19 pandemic. Nurses with mental disorders were excluded.

Instrument

Basic demographics, such as sex, age, years of experience, and department, were assessed. The impact of clinical training was evaluated subjectively on a 5-point scale ranging from “considerable effect” (5) to “no effect at all” (1) for each specific clinical training area (adult, geriatric, psychiatric, pediatric, and maternal nursing), as well as on the integration of nursing and practical training. Additionally, the participants were asked about the specific changes in clinical training, including “all clinical training,” “partial use of in-house training for clinical training,” “partial use of online training for clinical training,” “all in-house training,” and “all online training.”

Nursing problem-solving behaviors were measured using the Self-Evaluation Scale of Oriented Problem-Solving Behavior in Nursing Practice (OPSN; Funashima, 2015; Sadahiro & Yamashita, 2002). This scale comprises 25 items categorized into five subdimensions: “exploration and discovery of problems by organizing and utilizing information”; “delegation of patient care actions, symptom relief, maintenance and promotion of daily life functions for problem solving or avoidance, and individualization”; “facilitation of interactive behaviors for problem solving”; “psychological support to patients for overcoming challenges”; and “self-evaluation of problem solving.” Each concept evaluates the quality of behavior. For instance, “exploration and discovery of problems by organizing and utilizing information” assesses the quality of actions involved in collecting, organizing, and integrating patient information from various sources to identify and discover existing or potential problems. “Delegation of patient care actions, symptom relief, maintenance and promotion of daily life functions for problem solving or avoidance, and individualization” evaluates the quality of assistance provided to patients while considering symptom relief, the maintenance and promotion of daily life functions, and treatment progression tailored to individual patient needs. “Facilitation of interactive behaviors for problem solving” evaluates the quality of patient interactions to facilitate problem solving. “Psychological support to patients for overcoming challenges” assesses the quality of the psychological support provided to help patients overcome their problems. “Self-evaluation of problem solving” evaluates the quality of the self-assessment of problem-solving situations and identifies areas for improvement. The measurement was conducted on a 5-point scale ranging from “always” (5) to “rarely” (1), with higher scores indicating higher nursing problem-solving behaviors. The reliability and validity of the scale have been verified. Permission to use the scale was obtained through the publisher's website from the authors.

The overall Cronbach's alpha coefficient of the scale was 0.951. The alpha coefficients for the subscales ranged from 0.783 to 0.951, indicating that the OPSN has sufficient reliability in terms of internal consistency for the overall scale and its subscales. Additionally, the results of the factor analysis showed that the OPSN, comprising 25 items, was appropriately grouped into a five-factor solution corresponding to the five explanatory concepts of nursing behaviors, thus demonstrating its construct validity (Funashima, 2015).

Data Collection

Surveys and QR codes were created using the paid version of Google Forms. After obtaining ethical approval, the purpose of the study was explained. Written and verbal consent was obtained from the hospital's head nurse. Thereafter, survey papers containing the QR codes and research explanations were sent to each hospital's nursing department. These papers were distributed to the nurses by the head nurses of each ward, along with explanations of the research and survey request forms. After receiving these documents, the nurses willing to participate in the study were instructed to respond to the survey using the QR codes provided in the survey papers. Responses to each scale were requested three times at different intervals (June, September, and December) for the same survey content. The surveys were conducted anonymously. The first response was via a QR code on the paper, whereas the second and third responses were sent to the participants’ registered email addresses. Longitudinal links were established using optional e-mail addresses. The registered emails were deleted after the completion of the study.

Statistical Analysis

Participants’ basic attributes were calculated in terms of numbers and percentages. The mean and standard deviation were calculated for age. The effects of each theoretical practicum and the effects of integrating nursing and practical training were categorized as low and high. Based on their experience, the groups expressed that the training was “not received at all,” “received very little,” and “neither” for the low group and “received moderately” and “received considerably” for the high group. As normality was confirmed, a two-factor analysis of variance (ANOVA) was performed for nursing problem-solving behavior, with the low and high groups of the effects of each theoretical practicum and of the integration of nursing and practical training effects for each response period. Additionally, a one-factor ANOVA was conducted for specific changes in clinical training content and nursing problem-solving behaviors for each response period. The significance level was set at 5%. We used SPSS Windows Version 26 for the statistical analysis.

Ethical Considerations

This study was approved by the Ethics Review Board of University. Written research requests were sent to the institutions where the study was to be conducted. After obtaining approval, the participants received written explanations of the study. Only those participants who provided written informed consent were included in this study.

Results

Basic Attributes

Table 1 lists the basic attributes. The first survey (in June) included 225 respondents (18 males and 223 females). The second survey (in September) included 140 respondents (10 males and 130 females). The third survey (in December) included 85 respondents (five males and 80 females). The responses were obtained for all three periods (June, September, and December), and after missing values were included, 73 respondents (two males and 71 females; response rate: 32.4%) were included in the analysis. Their average age was 23.23 years (±3.68).

Table 1.

Basic Attributes of Participants.

			N ＝ 73
		n	％
Gender	Male	2	2.7
Gender	Female	71	97.3
Education	Vocational school	19	26
	Junior college	1	1.4
	University	47	64.4
	Postgraduate school	6	8.2
Qualification	Nurse	71	97.3
Qualification	Midwife	2	2.7
Work shift	Day shift only	13	17.8
	3 Shift rotation	15	20.5
	2 Shift rotation	45	61.6
Department	General ward	49	67.1
	Obstetrics and gynecology ward	1	1.4
	Pediatric ward	5	6.8
	Intensive care unit	11	15.1
	Operating room	6	8.2
	Psychiatric ward	1	1.4
Acceptance of COVID-19 patients at your hospital	Accepting severe patients	13	17.8
	Accepting moderate patients	5	6.8
	Accepting mild patients	27	37
	Not accepting patients	28	38.4

Degree of Influence of Each Clinical Training

Table 2 shows the degree of influence of each clinical training. First, the integration of nursing and practical training was categorized as “not received at all” by eight individuals (11%), “received very little” by 16 individuals (21.9%), “neither” by four individuals (5.5%), “received moderately” by 25 individuals (34.2%), and “received considerably” by 20 individuals (27.4%). Specifically, 22 individuals (30.1%) had all clinical training, 34 (46.6%) utilized some theoretical practicum for clinical training, four (5.5%) used online resources for clinical training, 9 (12.3%) had all theoretical practicums within the campus, and 4 (5.5%) had all online clinical training.

Table 2.

Degree of Impact of Each Clinical Practicum.

			N ＝ 73
Aspect of clinical practicum		n	％
Integrated nursing practicum	Not received at all	8	11
	Received little	16	21.9
	Neither	4	5.5
	Received moderately	25	34.2
	Received significantly	20	27.4
Specific Impact	Entirely clinical practicum	22	30.1
	Partial utilization of on-campus practicum for clinical practicum	34	46.6
	Partial utilization of online for clinical practicum	4	5.5
	Entirely on-campus practicum	9	12.3
	Entirely online practicum	4	5.5

Each clinical practicum (adult, maternity, pediatric, geriatric, psychiatric)	Not received at all	2	2.7
	Received little	14	19.2
	Neither	0	.00
	Received moderately	38	52.1
	Received significantly	19	26
Specific Impact	Entirely clinical practicum	4	5.5
	Partial utilization of on-campus practicum for clinical practicum	55	75.3
	Partial utilization of online for clinical practicum	9	12.3
	Entirely on-campus practicum	4	5.5
	Entirely online practicum	1	1.4

Second, for each theoretical practicum, two individuals (2.7%) had not received any practicums, 14 (19.2%) had received very few practicums, 38 (52.1%) had received moderate practicums, and 19 (26.0%) had received considerable practicums. In particular, four individuals (5.5%) had completed clinical training, 55 (75.3%) utilized some theoretical practicum for clinical training, nine (12.3%) used some online resources for clinical training, four (5.5%) had completed all theoretical practicums within the campus, and one (1.4%) had completed online clinical training.

Relationship Between Subjective Perception of the Influence of Each Clinical Training by Response Period and Nursing Problem-Solving Behavior

Table 3 shows the relationship between subjective perception of the influence of each clinical training. The influence of each clinical training was categorized into two groups: low and high. The influence of the clinical training on the low group was defined as “not received at all,” “received very little,” or “neither”; the influence on the high group was either “received moderately” or “received considerably.” Nursing problem-solving behavior was analyzed using a two-factor ANOVA for each response period on the basis of the high- and low-influence groups of each clinical training program. Consequently, significant interactions were identified for “exploration and discovery of problems by organizing and utilizing information” in the third period, “delegation of patient care actions, symptom relief, maintenance and promotion of daily life functions for problem solving or avoidance, and individualization” in the first and third periods, “facilitation of interactive behaviors for problem solving” in the third period, “psychological support to patients for overcoming problems” in the first period, and “self-evaluation of problem solving” in the first and third periods. The simple main effects were calculated. In the low influence group of integrating nursing and practical training for the “exploration and discovery of problems by organizing and utilizing information” in the first and third periods, the scores of the low influence group of each theoretical practicum were significantly higher than the high influence group. Furthermore, in the low influence group of the integration of nursing and practical training for “delegation of patient care actions, symptom relief, maintenance and promotion of daily life functions for problem solving or avoidance, and individualization” in the first and third periods, the scores of the low influence group of each theoretical practicum were significantly higher than the high influence group. In the low influence group of integrating nursing and practical training for “facilitation of interactive behaviors for problem solving” in the third period, the scores of the low influence group of each theoretical practicum were significantly higher than the high influence group. In the low influence group of integrating nursing and practical training for “psychological support to patients for overcoming challenges” in the first period, the scores of the low influence group of each theoretical practicum were significantly higher than the high influence group. In the low influence group of integration of nursing and practical training for “self-evaluation of problem solving” in the first and third periods, the scores of the low influence group of each theoretical practicum were significantly higher than the high influence group. In summary, individuals who perceived less influence of each practicum had higher scores on nursing problem-solving behaviors than those who perceived more influence.

Table 3.

Relationship Between Subjective Perceived Impact of Each Clinical Practice and Nursing Problem-Solving Behavior by Response Periods.

	Specific clinical practicums	Low				High
	Integrated clinical practicum	Low		High		Low		High		Main effect (Integrated clinical practicum)			Main effect (specific clinical practicums)			Interaction
	Time	M	SD	M	SD	M	SD	M	SD	F	ｐ	η²	F	ｐ	η²	F	ｐ	η²
Search and discover problems by organizing and utilizing patient information	Time 1 (June 2022）	17.45	3.70	14.25	2.87	14.57	4.13	13.39	4.44	1.81	0.18	0.03	2.48	0.12	0.04	0.53	0.47	0.01
	Time 2 (September 2022）	16.25	1.71	14.73	3.66	14.00	4.84	14.09	2.55	1.66	0.20	0.03	0.52	0.47	0.01	0.41	0.52	0.01
	Time 3 (December 2022）	16.18	3.92	14.91	3.69	13.29	4.68	13.25	3.30	0.22	0.64	0.00	0.25	0.62	0.00	3.00	0.05	0.06
Patient life/treatment behavior agency for problem solving/avoidance, symptom relief, maintenance/promotion of living functions and their individualization	Time 1 (June 2022）	18.64	4.32	15.25	5.06	14.85	5.11	12.86	4.37	4.12	0.05	0.07	0.21	0.65	0.00	3.12	0.05	0.06
	Time 2 (September 2022）	17.27	5.33	15.25	0.50	15.00	4.88	14.03	3.64	1.57	0.22	0.03	1.15	0.29	0.02	0.14	0.71	0.00
	Time 3 (December 2022）	18.27	3.69	15.27	2.65	12.50	4.77	12.57	4.77	0.95	0.33	0.02	1.05	0.31	0.02	7.97	0.01	0.12
Facilitation of interaction for patient problem solving	Time 1 (June 2022）	18.64	3.59	16.24	5.12	16.25	4.23	13.93	4.39	2.76	0.10	0.05	0.00	0.98	0.00	2.74	0.10	0.05
	Time 2 (September 2022）	18.82	2.48	15.14	3.11	14.88	4.29	14.50	3.29	2.07	0.16	0.03	0.60	0.44	0.01	0.32	0.57	0.01
	Time 3 (December 2022）	18.82	2.48	16.61	3.11	14.50	5.23	14.07	3.62	1.06	0.31	0.02	0.48	0.49	0.01	7.11	0.01	0.11
Psychological support for patients to overcome problems	Time 1 (June 2022）	20.55	4.25	16.94	4.57	17.25	5.02	14.64	4.48	4.17	0.05	0.07	0.11	0.74	0.00	3.38	0.05	0.06
	Time 2 (September 2022）	18.55	5.68	18.25	3.95	16.57	4.55	16.03	4.38	1.84	0.18	0.03	0.07	0.79	0.00	0.01	0.94	0.00
	Time 3 (December 2022）	18.91	3.24	16.42	4.24	15.00	5.79	15.64	4.45	0.36	0.55	0.01	1.04	0.31	0.02	2.35	0.13	0.04
Self-assessment of problem solving	Time 1 (June 2022）	17.91	4.74	14.55	4.27	13.25	4.64	13.14	4.23	1.39	0.24	0.02	1.23	0.27	0.02	4.25	0.04	0.07
	Time 2 (September 2022）	17.36	5.55	16.50	1.91	17.71	5.11	14.30	4.02	0.38	0.54	0.01	2.04	0.16	0.03	0.72	0.40	0.01
	Time 3 (December 2022）	17.18	4.47	15.30	4.66	13.75	3.77	12.93	4.30	0.81	0.37	0.01	0.12	0.73	0.00	3.75	0.05	0.06

Relationship Between Specific Changes in Integration of Nursing and Practical Training by Response Period and Nursing Problem-Solving Behavior

The relationship between specific changes in integrating nursing and practical training by response period and problem-solving behaviors was examined (Table 4). A significant difference was found in the third period for the “exploration and discovery of problems by organizing and utilizing information.” Post hoc tests revealed that “all clinical training” had significantly higher scores than “all campus-based training.”

Table 4.

Relationship Between Specific Nursing Integration and Practical Training Changes by Response Periods and Nursing Problem-Solving Behavior.

		All clinical training		Some utilizing on-campus training for clinical experience		Some utilizing online training for clinical experience		All on-campus training		All online training
		M	SD	M	SD	M	SD	M	SD	M	SD	F	p
Search and discover problems by organizing and utilizing patient information	Time 1 (June 2022）	14.75	5.12	14.45	3.82	16.50	5.80	12.78	4.87	14.50	4.61	0.55	.70
	Time 2 (September 2022）	15.75	1.71	14.09	2.75	15.00	1.83	13.89	4.70	14.00	3.83	0.32	.86
	Time 3 (December 2022）	15.25	4.99	15.50	4.26	18.75	2.22	13.11	3.86	13.23	3.73	2.46	.05
Patient life/treatment behavior agency for problem solving/avoidance, symptom relief, maintenance/promotion of living functions and their individualization	Time 1 (June 2022）	15.05	5.29	15.36	4.68	17.50	5.97	14.00	5.72	14.50	3.87	0.37	.83
	Time 2 (September 2022）	14.68	4.87	14.74	3.86	15.75	4.57	14.78	4.84	14.75	1.26	0.06	.99
	Time 3 (December 2022）	14.09	5.18	15.62	5.04	19.50	3.32	14.33	4.03	13.50	4.12	1.31	.28
Facilitation of interaction for patient problem solving	Time 1 (June 2022）	15.86	4.95	16.74	4.31	16.50	3.00	15.22	4.52	14.75	4.57	0.36	.83
	Time 2 (September 2022）	14.86	4.22	15.36	4.10	15.00	4.55	16.56	2.13	15.50	2.52	0.31	.87
	Time 3 (December 2022）	19.25	2.99	16.76	3.96	15.86	4.98	15.67	3.97	15.00	4.69	0.76	.56
Psychological support for patients to overcome problems	Time 1 (June 2022）	16.68	4.96	18.35	4.35	17.25	5.44	15.00	5.74	14.50	4.04	1.36	.26
	Time 2 (September 2022）	16.29	4.77	16.35	4.82	16.50	6.25	18.11	3.14	17.00	2.65	0.29	.88
	Time 3 (December 2022）	20.33	4.04	16.59	4.65	21.75	2.06	16.22	4.35	16.23	5.32	1.64	.18
Self-assessment of problem solving	Time 1 (June 2022）	14.38	4.93	14.74	4.05	15.75	6.99	14.89	5.11	14.75	4.11	0.08	.99
	Time 2 (September 2022）	16.33	5.11	15.10	4.38	15.75	6.50	16.56	3.54	15.25	2.99	0.32	.86
	Time 3 (December 2022）	15.50	3.70	15.18	4.78	19.75	2.87	15.11	4.86	13.50	4.49	1.68	.16

Relationship Between Specific Changes in Each Theoretical Practicum and Nursing Problem-Solving Behavior by Response Period

Given the minimal impact observed with an “all online practicum,” which accounted for only one participant, it was merged with the “all campus-based practicum” to form the category of “all online or campus-based practicum.” The relationship between specific changes in each theoretical practicum by response period and problem-solving behavior was examined (Table 5). The results revealed significant differences in the first and second instances of “exploration and discovery of problems by organizing and utilizing information.” Multiple comparisons revealed that in June 2022, the “all clinical practicum” group scored significantly higher compared with the “partial utilization of online practicum” and “all campus-based practicum” groups. Similarly, in September 2022, the “all clinical practicum” group scored significantly higher than the “all campus-based or online practicum” group. Subsequently, significant differences were observed between the first, second, and third instances of “delegation of patient care actions, symptom relief, maintenance and promotion of daily life functions for problem solving or avoidance, and individualization.” Multiple comparisons found that the “all clinical practicum” group scored significantly higher than the “all campus-based or online practicum” group. Significant differences were also noted in the first instance (June 2022) of “psychological support to patients for overcoming challenges.” Multiple comparisons revealed that the “all clinical practicum” group scored significantly higher than the “all campus-based or online practicum” group.

Table 5.

Relationship Between Specific Changes in Each Specialty Training and Nursing Problem Response Behaviors by Response Period.

		All clinical training		Some utilizing on-campus training for clinical experience		Some utilizing online training for clinical experience		All on-campus training and All online training
		M	SD	M	SD	M	SD	M	SD	F	p
Search and discover problems by organizing and utilizing patient information	Time 1 (June 2022）	17.00	5.48	14.81	4.23	14.25	3.77	10.56	2.92	3.37	.02
	Time 2 (September 2022）	16.50	1.29	14.62	3.06	11.33	3.77	13.25	2.22	4.16	.01
	Time 3 (December 2022）	16.25	3.50	15.18	4.23	13.50	3.11	11.67	3.77	2.28	.09
Patient life/treatment behavior agency for problem solving/avoidance, symptom relief, maintenance/promotion of living functions and their individualization	Time 1 (June 2022）	17.00	5.29	16.00	4.87	10.11	2.80	12.75	2.63	4.95	.00
	Time 2 (September 2022）	15.50	2.89	15.29	4.24	15.00	4.55	11.33	2.96	2.49	.05
	Time 3 (December 2022）	15.75	3.86	15.80	4.92	12.50	2.52	11.44	4.88	2.38	.05
Facilitation of interaction for patient problem solving	Time 1 (June 2022）	19.00	6.38	16.39	4.52	14.25	2.99	13.78	1.48	2.30	.09
	Time 2 (September 2022）	16.75	5.91	15.78	3.84	15.00	1.41	12.78	2.73	1.97	.13
	Time 3 (December 2022）	17.75	1.71	16.87	4.36	13.22	3.35	14.75	4.27	2.15	.10
Psychological support for patients to overcome problems	Time 1 (June 2022）	18.75	6.29	17.75	4.89	14.22	2.22	13.00	2.45	2.97	.04
	Time 2 (September 2022）	17.25	5.25	17.04	4.67	15.75	2.50	14.67	4.18	0.99	.40
	Time 3 (December 2022）	17.50	2.52	17.44	5.08	16.33	2.52	13.67	3.57	1.72	.17
Self-assessment of problem solving	Time 1 (June 2022）	17.25	4.86	15.13	4.56	13.50	2.38	11.56	3.88	2.19	.10
	Time 2 (September 2022）	16.25	4.86	16.21	4.57	14.25	1.71	12.88	4.26	1.46	.23
	Time 3 (December 2022）	14.75	4.27	15.56	4.68	14.25	4.35	12.00	4.36	1.75	.16

Discussion

In this study, the researchers longitudinally examined how the cancellation or modification of clinical training due to COVID-19 affected the problem-solving behavior of newly graduated nurses in the academic year 2022. The researchers analyzed the degree of the impact of each clinical training program. Overall, 62% of the participants reported being affected, with nursing integration and practical training being the most impacted. Additionally, 78% of the participants reported being affected by specific training. Specifically, the most common change was “utilizing partial on-campus training instead of clinical training,” a result consistent with that of Sugawara et al. (2020). Changes such as “all clinical training” had a higher impact on nursing problem-solving behaviors than other modification types.

Newly graduated nurses in 2022 were affected by shortened or modified training due to COVID-19 in nursing integration and practical training, including each specific training session, which likely influenced their nursing problem-solving behaviors.

Subsequently, the researchers investigated the relationship between the subjective perception of the degree of impact of each clinical training session and nursing problem-solving behavior for each survey period. In the first survey (June 2022), significant differences were observed in nursing problem-solving behaviors among those who perceived specific training, nursing integration, and practical training as having a low impact. Specifically, those who experienced “all clinical training” had higher scores in nursing problem-solving behaviors within each particular training.

In the second survey (September 2022), no significant differences were found in the subjective perception of the degree of the impact of clinical training on nursing problem-solving behavior. However, in each specific training, those who experienced “all clinical training” had higher scores in certain aspects of nursing problem-solving behaviors.

In the third survey (December 2022), significant differences were observed in nursing problem-solving behaviors among those who perceived specific training, nursing integration, and practical training as having a low impact. Specifically, in nursing integration and practical training, those who experienced “all clinical training” had higher scores in certain aspects of nursing problem-solving behaviors.

In summary, newly graduated nurses who perceived that each specific training, nursing integration, and practical training were affected by COVID-19 tended to exhibit fewer nursing problem-solving behaviors. A study comparing nursing students who experienced one week of clinical training with those who experienced simulation-based training revealed that students who experienced at least one week of clinical training were better able to learn problem solving, individualization, and psychological support than those who did not. This suggests that these nursing problem-solving behaviors stemmed from clinical training during nursing education and affected the nursing problem-solving behaviors of newly graduated nurses.

Newly graduated nurses entered the workforce in April, worked night shifts with support from their mentors around June, and developed the necessary nursing skills to work night shifts independently from September to October (Miyasaka & Kaneko, 2022). Therefore, they were likely to be influenced more by clinical training in nursing education institutions around June. Additionally, at the six-month mark, a correlation was identified between “introspection support” from peers and the self-evaluation scores of nursing practice competence, suggesting that reflecting on tasks with peers promotes the acquisition of nursing practice competence among newly graduated nurses (Yamaguchi et al., 2017). However, owing to inadequate communication among the staff during the COVID-19 pandemic, reflecting on tasks with peers may have been insufficient, thereby affecting the problem-solving behaviors of newly graduated nurses who perceived the impact of COVID-19.

The challenge is that even in the December survey, significant differences were identified in certain nursing problem-solving behaviors, suggesting that these behaviors are challenging to improve with clinical experience alone. “Exploration and discovery of problems by organizing and utilizing information” involves collecting patient information from various sources and organizing and integrating it to identify potential problems (Funashima, 2015). Clinical training often lacks sufficient online patient information, making it challenging to develop information-gathering skills (Yamaguchi et al., 2021). Therefore, newly graduated nurses affected by clinical training during the COVID-19 pandemic had significantly decreased competence in information gathering in nursing practice. However, nursing practice competence improved as nurses began to collect and integrate patient information after graduation. Mentors must understand the lack of “exploration and discovery of problems by organizing and utilizing information” among newly graduated nurses and deliberately provide clinical experiences to support its development.

“Delegation of patient care actions, symptom relief, maintenance and promotion of daily life functions for problem solving or avoidance, and individualization” involves providing assistance tailored to individual patient needs while considering symptom relief and the maintenance and promotion of living functions and treatment progress (Funashima, 2015). “Facilitation of interactive behaviors for problem solving” refers to the quality of interaction with patients to facilitate problem resolution (Funashima, 2015). Thus, although information aggregation competence, psychological support, and the identification of nursing problem improvement points improve with clinical experience, mutual interaction with patients and individualized assistance provision competencies are difficult to improve. This may be due to the characteristics of clinical training, with “multiple patient care” prevalent nationwide in nursing integration and practical training and the focus on individualized care planning, implementation, and evaluation in each specific training. Therefore, COVID-19 affected each particular training in terms of the “delegation of patient care actions, symptom relief, maintenance and promotion of daily life functions for problem solving or avoidance, and individualization” and “facilitation of interactive behaviors for problem solving.”

Furthermore, because of the impact of COVID-19, educational programs for newly graduated nurses have been revised, with measures taken to address the lack of clinical training experience, such as observing senior nurses’ practices and enhancing mental health support (Suenaga, 2022) Therefore, significant changes included modeling and mental health support, whereas other aspects were likely based on the usual postgraduate education. The Japanese Nursing Association (2016) established a clinical ladder to build a nursing evaluation system and improve career development. Level 1 was “practicing nursing according to basic procedures and seeking advice as needed.” Additionally, “caregiving skills” aimed to assist and support care recipients using basic nursing techniques on the basis of nursing procedures and guidelines rather than individualized nursing, indicating that generalized nursing practice education is being conducted. Therefore, competence in “delegating patient care actions, symptom relief, maintenance and promotion of daily life functions for problem solving or avoidance, and individualization” and “facilitating interactive behaviors for problem solving” may be difficult to improve. This impact may be addressed at Level 2 or 3 of the ladder. However, if these nursing practice competencies continue to be affected during this period, they may affect the nursing care provided to patients and their families. Even at Level 1, additional emphasis was placed on individualized nursing development, suggesting the need for a new educational program for newly graduated nurses affected by changes in clinical training due to COVID-19.

The findings of this study highlight the profound and lasting effects of COVID-19-induced changes in clinical practice on the problem-solving behaviors of newly graduated nurses. Healthcare systems can better equip newly graduated nurses to meet the demands of future crises and routine practice, ultimately contributing to improved patient care and nurse satisfaction.

In the future, during pandemics, such as those of emerging infectious diseases, clinical fieldwork may be impossible at times. Thus, clinical training methods that utilize the advantages of online platforms must be devised while emphasizing individualized nursing practices.

Limitations

A limitation of this study was its small sample size. Moreover, the data were collected only from one prefecture, thereby limiting the generalizability of the results. Thus, continuous surveys must be conducted to increase the sample size. Ultimately, efforts should be made to enhance educational support for newly graduated nurses affected by COVID-19 and reconsider the approach to nursing education, particularly in future public health emergency declarations.

Conclusion

This study longitudinally examined how the cancellation or modification of clinical practice due to COVID-19 impacted the problem-solving behaviors of newly graduated nurses who began their careers in 2022. The findings demonstrated that disruptions to clinical practice caused by COVID-19 significantly influenced nurses’ problem-solving behaviors. Specifically, newly graduated nurses who were able to participate fully in clinical practice exhibited higher practical competence. Furthermore, while aspects such as “psychological support for patients to overcome problems” improved with clinical experience, other competencies—such as the ability to consolidate information, identify areas for improvement in nursing problems, facilitate smooth interactions with patients, and individualize care—tended to show limited improvement despite increased clinical experience.

Footnotes

Acknowledgments

We wish to express our gratitude to the directors of the participating nursing departments and all the nurses involved for offering their support and cooperation in this research despite the demands of the coronavirus pandemic.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Considerations

This study was approved by the Ethics Review Board of Hyogo University (Grant no: 21011).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by JSPS Grant-in-Aid for Scientific Research (KAKENHI) (24K13590).

ORCID iD

Takashi Ohue

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