The website link has been provided via social platforms (e.g., WeChat and QQ) from 14 January to 19 January 2023. Participants for the study were selected through a snowball sampling process. The professor sent the link (Online surveys are available on the Wen Juan Xing platform) to the head of each class who was willing to distribute it to the students in the class. All participants gave informed consent and understood the purpose of the study. Finally, 438 students completed the survey, and the response rate was 68.87%.

Participants were recruited from a medical university who are spread across 28 different hospitals in Anhui for internships.

Criteria for inclusion were (1) undergraduate nursing students, (2) voluntary participation in research, and (3) completion of a 9-month internship.

Four hundred and thirty-eight participants completed the survey.

The following demographic characteristics were assessed: age, gender (male or female), living area (rural, town, city), monthly household income per capita (¥ <2,000, ¥ 2001–6,000, ¥ 6,001–10,000, ¥ >10,001).

The following questions were asked with a yes/no answer: Q1. Have you been infected with COVID-19 in the last 6 months? Q2. Have you been isolated in the last 6 months? Q3. Has a friend or relative of yours died as a result of COVID-19 infection? Q4. Are you worried about a second or third wave of viral spikes from COVID-19? Q5. Did you often have direct contact with or care for COVID-19 patients in the hospital during your internship? Q6. Did you experience any negative incidents in the hospital during your internship (e.g., verbal or physical violence)? Q7. Did you have any professional exposure during your internship? Q8. Have you been assigned to work with an experienced care team during your internship?

Fear of COVID-19 Scale (FCV-19S) was used to assess the COVID-19 fears’ levels of participants (21). This seven-item tool was rated on a five-point Likert scale. One is “strongly disagree” and five are “strongly agree.” The total score (ranges from 7 to 35) is calculated by combining the scores of all items. Coronavirus-19 fear increases with a higher score. A cut-off score of 21 and above has been proposed to differentiate the severity of fears associated with COVID-19 (22).

Connor-Davidson Resilience Scale (CD-RISC 10) was used to measure psychological resilience (23). The CD-RISC has 10 self-assessment items, with answers ranging from “0- not true at all” to “4 true nearly all the time.” The maximum total score is 40, calculated from the sum of each question. A threshold score of 30 and above indicated greater resilience to stress. The Chinese version showed good structure validity (24).

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) was used to examine PTSD symptoms of internship nursing students in Anhui, China after the full liberalization of China’s COVID-19 prevention and control policy (25). The total scores of this 5-item scale ranged from 0 to 5, with two answers for each item (0 = No, 1 = Yes). Above the cut-off value, 3 has been identified as a reference screening for PTSD.

The study found that intern nursing students, as caregivers of COVID-19 patients, hold a positive correlation with PTSD. After the COVID-19 epidemic, medical students may experience higher levels of stress than non-medical students (31). When it comes to primary and secondary infectious disease prevention, nurses are the leading proactive partners (32). A significant risk of infection exists for nursing interns who care for patients in hospitals who have the COVID-19 virus, whether suspected or confirmed. To carry out their jobs, frontline nurses frequently work under pressure and sometimes may even risk their lives (33, 34). The students lacked experience in providing care for those infected with COVID-19, and even experienced nurses required psychological support throughout the pandemic. They have to make difficult choices about patient care in unpredictable and exhausting conditions. For example, inconsistent access to protective equipment, shifting guidelines, high-nurse–patient ratios, and increased workload and hours (35–37). The public was afraid of contracting COVID-19, including friends and family. Some people avoided, harassed, and even blamed medical professionals including nurses and nursing students for spreading COVID-19 (38–40). The possibility of contracting COVID-19 and infecting their families worried the nursing students who worked in the hospital as well (41). Moreover, nurses who provide direct care to COVID-19 patients frequently see patients suffering and death, which may cause them to become emotionally distressed and tired (42). As a result, it may cause a great deal of psychological stress, anxiety, and depression. Formulating long-term strategies and delivery of interventions to address psychosocial problems in intern nursing students are necessary. In Huang’s research, more psychological support, adequate medical protective equipment, training in coping strategies, and developing interventions to block the spread of infectious diseases, could improve the quality of patient care (43).

The study found that experience of occupational exposure in hospitals is another variable, which was positively correlated with PTSD in intern nursing students. Wilson et al. found that first responders experience occupational exposures that are regularly linked to PTSD (44). It was partly in accordance with this research. The occupational exposure to nursing is wide and includes things such as needlestick injuries (45), radiation exposure (46), body fluid exposure (47), and violent workplace environments (48). Of those who had experienced occupational exposure, 67.35% were nursing staff (49). It may related to the fact that nurses need to perform many operations such as oral care, sputum suction, and monitoring vital signs. Liu’ research found similar results that nurses may face a higher risk of occupational exposure to COVID-19 patients (50). It was caused by their increased time spent on wards, direct patient care, and responsibility for gathering sputum for viral testing. Several studies indicated that female are more prone to occupational exposure than their male counterparts (51, 52). The effects of PTSD brought on by occupational exposure can be extremely burdens to individuals, their families, their places of employment, and society at large (53). Compared to individuals without this diagnosis, those with PTSD diagnoses are more likely to report physical illnesses, suicide attempts, poor quality of life, additional mental disorders, and disability (54, 55). Understanding the present state of occupational exposure in intern nursing students will be beneficial in enhancing prevention awareness, preventing occupational exposure, and promoting their physical and mental well-being. To deliver effective education, the teachers need to learn about the characteristics of the nursing student cohort served by the lesson and design the lesson accordingly (56). Distance learning is being added to nursing programs more and more to improve learning opportunities and meet the increased diversity among learners (56). According to Magdalinou’s research, student and teacher interaction is crucial, and an online course with a proper design could facilitate it (57). Moreover, the use of interactive teaching methods would promote learning, and prompt technical support would decrease technological problems and encourage distance learning (57).

It is worth noting that student collaboration with an experienced team is another factor influencing PTSD in intern nursing students. Experienced frontline nurses are more likely to care for infected patients. This result indicates that nursing students working with experienced teams may have higher rates of infection. Studies in southern Iran have shown that nursing students caring for COVID-19 patients face high levels of death anxiety (18). Many studies conducted during the pandemic, focused on the Psychological and mental impact on first-line healthcare workers and showed that the frontline healthcare workers had anxiety, depression, stress, and PTSD (58, 59). After years, they were still fighting with contagion caused by Sars-CoV-2. The study conducted by Claponea RM shows that female gender, not having children, and single marital status, have a high level of burnout Syndrome (60). Burnout can have negative consequences (61). The experienced team was already fatigued and exhausted (62–65). These include reduced quality of care, absenteeism, turnover, and reduced commitment (27). Providing emotional support interventions for intern nursing students is required (66). To reduce anxiety and stress, the faculty should create a structured learning environment, follow the course schedule, communicate changes or updates promptly, modify assignments to fit the learning environment, take self-care, extend grace, and make use of campus, local, and national resources (67).

This study also found that the fear of a second or third wave pandemic was significantly associated with the severity of PTSD symptoms. Because of its deadly features, COVID-19 presented a new worldwide threat (e.g., rapid transmission, uncertainty about the transmission method, incubation period, unpredictable mortality rate, and manifestation), which rapidly evoked anxiety and fear in the Chinese population and worldwide (68). Many countries promote the transition of universities from on-site teaching and learning activities to online or virtual modalities (69). Logically, this COVID-19 epidemic and these preventive measures may have a substantial negative effect on mental health, causing widespread stress, anxiety, depression, and fear (70). The impact of PTSD on intern nursing students is profound, Students have difficulty defining their professional identities, fitting in with the team, and fearing COVID-19. Their psychological conditions were quickly made worse by long-term isolation and uncertainty (71). Even though the majority of students (67.07%) did not actively participate in the treatment of COVID-19 patients, there was still a degree of concern about contracting the virus (72). Compared with adults, students are a more vulnerable population. A recent meta-analysis, which included 33 different researchers from 18 different countries and conducted among university students, confirmed that the fear of COVID-19 was related to PTSD (73). Nursing students are worried about their future professions and study due to the uncertainty about their future careers. They also suffer constant pressure due to factors like separation from family and fear of infection, which raises the possibility of triggering PTSD (74). Consequently, nursing students and educational administrators must recognize the importance of the screening, prevention, and psychological intervention of PTSD. Schools and hospitals should concentrate on teaching nursing students all available coping methods to increase their capacity to control their emotions and effective coping tools to enhance the lives of nursing students, and their families (75).