Explaining the challenges faced by nursing students in clinical learning environments during the post-COVID era: a qualitative content analysis

Abstract

Objectives

The COVID-19 pandemic precipitated unprecedented disruptions across global healthcare systems, with nursing education being particularly affected. In addition to the challenges encountered during the height of the crisis, the aftermath of the pandemic has continued to impose significant difficulties on nursing students, especially within clinical learning environments. Despite the breadth of emerging literature, a notable gap persists in studies explicitly examining the post-pandemic experiences of nursing students in these settings. Moreover, the present study is a qualitative study with the content analysis in Iran from October 2024 to February 2025. Twenty- two nursing students participated in this study. Data were collected from individual, and semi-structured interviews. Data analysis was conducted using the qualitative content analysis method proposed by Graneheim and Lundman (2004).

Results

The analysis yielded three overarching themes, each encompassing specific subthemes: (1) lack of clinical competence (insufficient clinical knowledge, deficiency in clinical skills, and poor clinical judgment.) (2), psychological challenges (the quagmire of hopelessness, emotional exhaustion, and lack of self-efficacy) and (3) disruption in professional interactions (lack of mutual respect and absence of a team-oriented spirit).

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-025-07396-9.

Introduction

Among the most significant and unprecedented disruptions to nursing education in recent history has been the global outbreak of COVID-19 and its aftermath. The pandemic introduced a host of complex challenges, risks, and uncertainties for nursing students, particularly those engaged in clinical education [1]. As the crisis unfolded, educational institutions worldwide—universities, nursing faculties, and clinical schools—were compelled to suspend in-person operations [2], affecting more than 1.57 million students across 191 countries and leading to profound structural changes in nursing education systems [3]. One of the most consequential developments during this period was the suspension of nursing students’ presence in clinical settings, fundamentally altering the trajectory of their professional preparation [4]. A rapid and compulsory shift from face-to-face to virtual instruction emerged as a central experience shared by students and educators alike, introducing substantial pedagogical challenges [5]. The abrupt transition to online education, combined with inconsistent conditions in clinical placements and restrictions on physical mobility, contributed to a notable decline in students’ academic engagement and performance during the pandemic [6]. Prolonged detachment from clinical environments not only complicated students’ reintegration into these settings but also undermined perceptions of their clinical competence—both from the perspective of faculty and patients, as well as from the students themselves—thereby fueling widespread concern among educators and learners alike [7–9].

Compounding these issues, the pandemic led to a significant reduction in the number and variety of hospitalized patients, limiting students’ exposure to diverse clinical cases and narrowing the scope of their hands-on training. Concurrently, the overall reduction in clinical hours curtailed opportunities for skill acquisition, directly impacting students’ practical competence and confidence [8–9].

A critical review of the existing literature reveals a conspicuous gap in studies addressing the specific challenges nursing students face in clinical learning environments during the post-COVID era. This lack of scholarly attention is troubling, given that inadequate understanding of these challenges—and the failure to implement appropriate remedial strategies—can result in long-term negative consequences, including diminished professional growth, erosion of interest in the nursing field, and a weakened sense of responsibility and commitment among students.

Consequently, a critical first step in addressing this problem is to gain in-depth, qualitative insight into students’ lived experiences. By exploring the specific challenges encountered by nursing students as they re-engage with clinical environments in the wake of the pandemic, educators and policymakers can develop targeted, evidence-based strategies to support learners more effectively. In light of the indispensable role that clinical learning plays in nursing education—and the notable absence of qualitative investigations into students’ perspectives in the post-pandemic context—this study was undertaken to identify and examine the core challenges nursing students experience in clinical settings during the post-COVID era.

Main text

Study design

The present study is a qualitative study with the content analysis in Iran from October 2024 to February 2025. Qualitative content analysis is a rigorous and systematic approach employed to draw valid and reliable inferences from textual data, facilitating the generation of new knowledge, the discovery of factual insights, and the formulation of practical guidance [10–11].

Participants and data collection

A purposive sampling strategy was employed to recruit 22 nursing students who had experienced clinical training both during and after the COVID-19 pandemic. Data collection was conducted through individual semi-structured interviews, a method well-suited for eliciting rich, in-depth accounts of personal experience. Interviews commenced with an open-ended, exploratory prompt: “After the COVID-19 pandemic, when you were informed that you had to return to clinical placement, how did you feel?” This initial question was designed to foster open dialogue and encourage participants to articulate their experiences in their own words. As interviews progressed, additional questions were formulated to align with the study’s objectives, drawing upon emerging themes in participants’ responses.

Throughout the interview process, the researcher adhered to established qualitative interviewing principles: clearly communicating the purpose of the interview, cultivating rapport and trust with participants, maintaining neutrality, and avoiding leading questions or evaluative feedback. Core questions guiding the discussions included: Can you describe experiences of re-entering the clinical environment in the post-COVID period? “How did you adapt to the clinical setting after the post-COVID pandemic?” and “What challenges did you encounter in the clinical environment during the post-COVID pandemic?” To enrich the data and probe deeper into participants’ perspectives, supplementary prompts such as “Can you explain further?”, “Could you give an example?”, and “How did you feel at that moment?” were employed. Supplementary File: Interview Guide and Questions.

The interview guide was developed according to the views of the research team and the available literature. Interviews were conducted in a private conference room within the hospital, with scheduling and location determined according to each participant’s preferences. Each session lasted approximately 45 to 65 min. All interviews were transcribed verbatim immediately following completion and were read repeatedly to promote deep familiarity with the content and ensure the integrity of the data. The interviews continued until reaching saturation. Saturation happens when no new categories could be extracted with the categories being saturated in terms of characteristics and dimensions [12]. In this study, data saturation was reached after 20 interviews, and two further interviews were done to ensure no new data was available. Yet, to ensure that the data was saturated, the researchers conducted two additional interviews.

Data analysis

Data analysis was conducted using the qualitative content analysis method proposed by Graneheim and Lundman (2004), a well-established approach for systematically interpreting textual data in nursing and health sciences research [13]. In the present study, the five-step content analysis method developed by Graneheim and Lundman (2004) was rigorously implemented, following a systematic and iterative process as outlined below: 1. Verbatim transcription of each interview was completed immediately upon its conclusion. 2. Each transcript was read repeatedly and thoroughly to facilitate a comprehensive and holistic understanding of its content. 3. Meaning units—defined as segments of text that conveyed distinct insights relevant to the research question—were identified, and corresponding initial codes were generated. 4. Similar codes were clustered into broader, conceptually cohesive categories based on observed patterns of convergence and divergence. 5. An overarching theme was then selected to encapsulate the essence of the derived categories and to reflect the latent content embedded within the data [13], Data analysis occurred concurrently with collection using MAXQDA 10.0 (R250412) for systematic management.

Rigor

To ensure methodological rigor and the trustworthiness of the findings, this study adhered to the evaluative criteria proposed by Lincoln and Guba [14]. Credibility was established through prolonged engagement with the data, iterative immersion in participants’ narratives, and triangulation via member checking and expert peer debriefing. Peer debriefing involved six academic experts, each possessing substantial expertise in qualitative nursing research, who critically evaluated the coding framework, interpretative decisions, and emerging thematic structure. Dependability was enhanced through transparent documentation of the analytical process, thereby allowing for an audit trail of methodological decisions. Audio recordings and verbatim transcripts were retained to ensure procedural traceability. To support confirmability, participants were asked to review and approve the thematic classifications assigned to their narratives, ensuring that the interpretations authentically reflected their lived experiences. The research team also took deliberate steps to curtail the influence of preconceived notions; specifically, they limited their engagement with extant literature during the data collection and analytical phases in order to preserve the inductive integrity of the findings. Throughout the research process, Bracketing—a methodological practice integral to phenomenological inquiry—was rigorously applied to suspend researcher biases, assumptions, and prior knowledge. This approach was instrumental in enabling the emergence of unfiltered accounts of participants’ experiences concerning the challenges faced in clinical learning environments during the post-COVID-19 period. By consciously refraining from evaluative judgments, the research team allowed the data to speak for itself, thereby fostering authentic representation. Finally, transferability was reinforced through the provision of rich, thick descriptions, encompassing detailed accounts of participant characteristics, data collection protocols, and analytical procedures. Direct quotations from participant narratives were included to enhance contextual depth and facilitate informed inference by readers [14].

Results

The qualitative content analysis yielded three overarching themes, each comprising two subthemes. These principal themes included: (1) Lack of Clinical Capability (2), Psychological Challenges, and (3) Disruption in Professional Interactions.

Lack of clinical capability

The most salient theme emerging from the data was the lack of clinical capability, which encompasses the students’ diminished ability to integrate theoretical knowledge with practical application in real-world clinical settings. This theme was further delineated into three interrelated subthemes: insufficient clinical knowledge, deficiency in clinical skills, and poor clinical judgment.

Insufficient clinical knowledge

“During the pandemic, all our courses—especially the specialized nursing subjects—were held online. So, it’s unrealistic to expect students to be well-prepared for the clinical environment after COVID. We didn’t actually learn anything from the theoretical lessons. It seriously set us back.” (Participant 7).

Deficiency in clinical skills

“All of our nursing fundamentals and techniques courses were conducted online, and we didn’t engage in any actual clinical work. As a result, after the pandemic, we entered the clinical setting lacking the practical skills needed to provide care. This was a major shortcoming. In my opinion, the gap between theory and practice prevented us from properly learning hands-on skills. You can’t develop clinical competence just by watching a few pictures or videos.” (Participant 10).

Deficiency in clinical judgment

“When something goes wrong with my patient, honestly, I don’t know what I’m supposed to check. I have no idea where to even begin. Sure, our professors taught us the theory, but to be honest, I didn’t learn anything meaningful. That’s why I don’t really know how to assess my patient or what signs and symptoms I should be looking out for.” (Participant 13).

Psychological challenges

Psychological resilience emerged as a prominent theme throughout participants’ narratives, manifesting in three interrelated subthemes: the quagmire of hopelessness, emotional exhaustion, and lack of self-efficacy.

The quagmire of hopelessness

“Most of my classmates have become deeply discouraged and lack any motivation. Honestly, I don’t know what happened to me—since the pandemic, I haven’t felt the same. I’ve lost my energy and excitement. That enthusiasm I used to have is gone, and I no longer have any hope for the future. It’s as if I’m sinking into a quagmire of hopelessness.” (Participant 11).

Emotional exhaustion

“Before the pandemic, I was energetic, lively, and eager to learn. But as time went on and COVID dragged out, I felt completely drained—mentally and emotionally. Even now that the pandemic is over, I still feel the same. It’s like I’m hollow inside. Even the simplest tasks feel overwhelming. I’ve even visited a psychiatrist several times, and they confirmed that my symptoms are linked to the psychological consequences of the COVID crisis. This emotional fatigue has negatively affected my life to the extent that during clinical rotations, I get exhausted very quickly and lack the stamina to provide care. And I know many other students are experiencing the same thing. I believe nursing students need to receive psychiatric counseling.” (Participant 15).

Lack of self-efficacy

“When I returned to the hospital for clinical rotations after the pandemic, I felt like I lacked the competence and confidence I needed. I was hesitant and uncertain while providing care. I think it’s because I don’t truly believe in my own abilities anymore. I’m not sure why I’ve become like this.” (Participant 19).

Disruption in inter-professional interactions

Another salient theme that emerged from participants’ narratives was the disruption of inter-professional interactions—a phenomenon exacerbated by the pandemic’s destabilizing effects on clinical education. This theme was comprised of two interrelated subthemes: lack of mutual respect and absence of a team-oriented spirit.

Lack of mutual respect

“After a long suspension of hospital internships due to the COVID-19 pandemic, when we finally returned to the clinical setting, the nursing staff did not communicate with us respectfully or professionally. I’m not sure why—perhaps the psychological toll of enduring the pandemic has negatively influenced their behavior. The nurses get angry easily and show little regard for us as nursing students. I’ve often witnessed conflicts and arguments between clinical instructors, nursing staff, and students in the wards. Such behavior existed before the pandemic, but not to this extent.” (Participant 7).

Absence of a team-oriented spirit

“I don’t know what has happened, but since the COVID-19 pandemic, the spirit of teamwork among nurses, physicians, and nursing students has greatly diminished. While this issue existed to some extent before the pandemic, it has become much more prominent afterward. (Participant 10)

Discussion

Consistent with the findings of the present study, prior research has documented significant deficits in nursing students’ theoretical understanding, psychomotor competence, and clinical reasoning resulting from the interruption of traditional clinical training [15–17]. For instance, Bryan et al. (2022) found that nursing students expressed grave concerns about their lack of clinical competence following the substitution of in-person practicums with online learning formats during the pandemic [17]. The absence of hands-on training, along with reduced face-to-face engagement with instructors, impeded students’ opportunities to acquire, rehearse, and refine essential clinical skills. This pedagogical void contributed to a pronounced disconnect between theoretical knowledge and clinical practice—a phenomenon widely reported across multiple studies [4].

Similarly, Sands (2019) reported that many nursing students exhibited insufficient clinical skills, which in turn eroded their confidence in delivering competent nursing care [18]. Not surprisingly, students tend to prefer in-person instruction, which they perceive as clearer, more interactive, and more conducive to effective learning outcomes [19–20].

Moreover, the reduction in clinical exposure appears to foster uncertainty and hesitation in decision-making within the clinical setting [21]. Song and Kim found that nursing students with fewer or more compressed clinical experiences exhibited elevated levels of anxiety and stress when required to make clinical decisions [22]. In contrast, other studies have suggested that once the pandemic restrictions were lifted, many students regained their confidence and leveraged new opportunities to rebuild clinical competence [21]. The discrepancy between these findings and those of the current study may be attributed to participants’ limited access to post-pandemic support systems or their reliance on maladaptive coping mechanisms.

One of the most salient psychological challenges articulated by participants was what may be described as a quagmire of despair—a conceptual metaphor encapsulating the emotional toll exacted by the pandemic’s educational disruptions. Participants frequently reported feelings of emotional exhaustion, diminished self-efficacy, and a paralyzing sense of futility. This psychological decline is well-documented in extant literature [23–24]. Islam et al. (2020), for example, observed that abrupt changes in instructional delivery significantly heightened students’ anxiety and psychological distress [23]. Similarly, Shaw (2020) concluded that the pandemic undermined students’ mental health by intensifying experiences of helplessness and hopelessness [24]. Other documented consequences include persistent fatigue, chronic stress, and generalized anxiety among nursing students during this period [25].

The suspension of clinical internships was especially detrimental, exacerbating students’ fears regarding their professional readiness and competence. Compounding this anxiety was the uncertainty surrounding how and when these educational disruptions would be addressed—a situation that intensified students’ emotional burdens [26]. These concealed pressures often translated into a sense of failure, waning motivation, and psychological disengagement [27]. When confronted with stress in clinical environments, students frequently resorted to maladaptive coping strategies rather than constructive problem-solving techniques [28]. Although the clinical learning environment is inherently stressful, even under normal circumstances [8], the pandemic amplified its emotional demands, often to the point of prompting students to question their career choice or contemplate withdrawal from the profession altogether [29]. Notably, students demonstrating higher levels of resilience were less likely to experience psychological deterioration during the pandemic [30], implying that participants in the current study may have lacked the necessary psychological resources to withstand and recover from adversity.

Psychological challenges such as loneliness—documented both prior to [31], during, and after the pandemic—further hindered students’ academic and professional development [21]. Loneliness was found to impair students’ ability to collaborate effectively within healthcare teams, thereby undermining both their learning and the quality of care delivery [20]. This phenomenon was mirrored in the present study, in which participants reported a pronounced breakdown in inter-professional interactions. Poor communication and weak collaborative engagement with care team members were among the most frequently cited concerns—findings that align with those of earlier investigations. For instance, Taasen and colleagues observed that pandemic-related restrictions severely compromised students’ communicative competence [21], while Jung et al. noted that reduced clinical hours and social distancing protocols curtailed students’ ability to form meaningful interpersonal relationships with both patients and colleagues [32].

Interpersonal competence is not only fundamental to the delivery of high-quality patient care but also vital to the formation of students’ professional identity and their ability to function as integrated members of the healthcare team [33–34]. However, the abrupt pivot to remote instruction drastically limited opportunities for social interaction throughout the educational continuum [35). Consistent with the findings of the present study, numerous investigations have documented the deleterious impact of the COVID-19 pandemic on students’ interactions with faculty, clinical instructors, and nursing staff [36–37]. Indeed, even prior to the pandemic, undergraduate nursing students’ communication skills were widely regarded as suboptimal [38], suggesting that the crisis merely magnified pre-existing vulnerabilities in this area.

Limitation

In this study, was conducted in southern Iran and it is recommended to be conducted in other regions of Iran and other countries.

Strengths

This study is the first study with a qualitative study approach aimed to explore and systematically articulate the multifaceted challenges faced by nursing students in clinical environments during the post-COVID era in Iran, and therefore it is considered to be of interest and can help translate nursing knowledge.

Conclusion

The findings offer a nuanced understanding of the complex array of challenges confronting nursing students in clinical learning contexts following the COVID-19 pandemic. These insights hold valuable implications for nursing education policymakers and administrators, who may leverage this evidence to develop strategic, evidence-based interventions aimed at mitigating these challenges and enhancing student preparedness for future healthcare crises.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

MB, and ZJ conceptualized and organized the study. MB, and HH were responsible for data collection and execution. MB, and, ZJ designed and/or executed the statistical analyses. All authors contributed to the manuscript’s preparation and critical review, and they have all approved the final version.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

All participants provided written informed consent prior to their inclusion in the study. The research was conducted in accordance with the principles outlined in the revised Declaration of Helsinki, which delineates ethical guidelines for medical research involving human subjects. Participants were assured of the anonymity and confidentiality of their information. Additionally, the study received approval from the Institutional Research Ethics Committee of Bushehr province University of Medical Sciences, Bushehr, Iran (Ethical Code: IR.BPUMS.REC.1403.197 ).

Competing interests

The authors declare no competing interests.

Consent to publication

Not applicable.