Lived experiences of student nurses during practical examinations in Ghana: a phenomenological study

Abstract

Background

Practical examinations are critical components of nursing education, designed to assess students’ competence in clinical skills. However, these evaluations often elicit a range of psychological, emotional, and educational experiences among student nurses.

Aim

This qualitative study explores the lived experiences of student nurses during practical examinations in Ghanaian nursing institutions.

Methods

This study employed a phenomenological approach to explore the experiences of 18 student nurses during practical examinations in selected nursing schools in Ghana. Using purposive sampling, participants were recruited and interviewed through semi-structured interviews conducted between December 2024 and April 2025. The data were analyzed using Braun and Clarke’s method. The study followed Lincoln and Guba’s criteria, including credibility, dependability, confirmability, and transferability for trustworthiness.

Results

Five (5) key themes and ten subthemes were identified, including emotional responses to practical examinations, perceived preparedness and skill confidence, examiner influence and supervision style, environmental and logistical challenges, and recommendations for improvement.

Conclusion

These findings provide evidence for curriculum and policy reforms in nursing education across resource-constrained settings. It also highlights the need for more student-centered examination approaches to enhance learning and confidence. We recommend that nursing regulatory bodies and academic authorities collaborate to revise clinical assessment guidelines to prioritize student support, fairness, and skill development.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03899-9.

Introduction

In the training of professional nurses, practical examinations play a pivotal role in assessing clinical competence, critical thinking, communication, and psychomotor skills essential for safe and effective patient care [1, 2]. These examinations are often structured to replicate real-world scenarios, thereby offering a platform to evaluate how well student nurses can translate theoretical knowledge into clinical practice [3]. In many nursing education systems—including those in Ghana—practical examinations such as Direct Observation of Procedural Skills (DOPS), Mini Clinical Evaluation Exercises (Mini-CEX), and traditional bedside assessments are employed to determine students’ readiness for clinical practice and professional licensure [4].

The rationale for using DOPS, Mini-CEX, and return demonstrations lies in their effectiveness in objectively assessing clinical competence, procedural skills, and professional behavior in real-time scenarios [5]. These methods bridge the gap between theoretical knowledge and clinical practice by simulating real-life situations that demand critical thinking, decision-making, and hands-on proficiency. DOPS enables assessors to observe and evaluate a student’s execution of specific procedures under direct supervision, ensuring both technical accuracy and adherence to professional standards [6]. Mini-CEX, on the other hand, allows evaluators to assess students during brief, focused clinical encounters, providing immediate feedback on performance in areas such as communication, diagnostic reasoning, and patient interaction. Similarly, return demonstrations allow students to engage actively with clinical skills and receive formative feedback, reinforcing their learning and building confidence in essential competencies [7].

However, while these practical assessments are essential in shaping clinical proficiency, they also evoke a complex mix of emotional, cognitive, and behavioral responses among student nurses [8]. Numerous studies across diverse educational contexts have consistently reported that students often experience intense anxiety, fear of failure, and performance pressure during practical examinations, which may negatively impact their performance and self-efficacy [9]. Anxiety during assessments has been linked to poor information recall, reduced decision-making ability, and compromised psychomotor coordination—factors that are critical during clinical procedures [10].

Moreover, the behavior and attitudes of examiners, the adequacy of examination materials, the clarity of instructions, and the overall assessment environment significantly influence how student nurses experience these evaluations [11, 12]. For instance, negative examiner behaviors such as non-verbal disapproval, impatience, or harsh feedback have been shown to exacerbate stress and diminish students’ confidence [13]. Conversely, supportive examiners who provide constructive feedback and create a calm atmosphere can enhance performance and foster positive learning experiences [14].

In sub-Saharan Africa, particularly Ghana, practical nursing examinations are governed by standards set by regulatory bodies such as the Nursing and Midwifery Council (NMC). The Ghanaian nursing curriculum consists of a three-year diploma or a four-year bachelor’s degree, during which students undertake both classroom-based instruction and clinical placements. Admission is highly competitive and regulated by national examination results, with students progressing through structured clinical rotations before qualifying to sit for licensure examinations. Despite a well-defined curriculum, the educational experience varies across institutions due to differences in infrastructure, faculty numbers, and clinical exposure.

While anecdotal evidence and isolated surveys point to challenges such as inadequate preparation, limited resources, and examiner intimidation, few studies have systematically explored these phenomena through the lens of students themselves [15]. This gap is particularly concerning in the Ghanaian context, where high student-to-faculty ratios, logistical constraints, and inconsistencies in assessment procedures may intensify student stress and undermine the fairness of evaluation.

Given these concerns, this study adopts a qualitative, phenomenological approach to deeply explore student nurses lived experiences during practical examinations. A qualitative design is most appropriate for capturing the nuanced, subjective, and often emotionally charged experiences that quantitative measures may overlook. Moreover, the sensitive nature of examining students’ encounters with clinical evaluations—especially those involving perceived examiner bias or intimidation—requires a research design that allows for empathetic exploration of personal narratives.

To mitigate potential response bias due to students’ fear of academic consequences, several ethical safeguards were employed. Participation was strictly voluntary, with informed consent obtained prior to data collection. Assurances of confidentiality and anonymity were emphasized, and data were collected by an independent researcher unaffiliated with the students’ schools or grading processes. These measures helped to build trust, reduce fear of reprisal, and encourage honest reflection among participants. To date, few qualitative studies in Ghana have captured nursing students’ first-hand perspectives on practical exams.

Therefore, this study seeks to explore the experiences of student nurses during practical examinations in Ghana, focusing on their emotional responses, perceived preparedness, interaction with examiners, and suggestions for improving the assessment process. By centering student voices, the study aims to provide evidence-based insights that can contribute to the development of more supportive, fair, and pedagogically sound practical examination practices in nursing education.

Materials and methods

Study setting

The study was conducted in three accredited institutions offering nursing in the Bono Region of Ghana. These institutions serve as key training grounds for student nurses preparing for professional licensure and deployment into Ghana’s healthcare system. Each institution is recognized by the Nursing and Midwifery Council of Ghana, the Ghana Tertiary Education Commission and offers structured clinical placements in affiliated hospitals across the region and beyond. Participants in the study were selected from third to final-year students who had completed at least two rounds of practical examinations, ensuring adequate exposure to the clinical assessment process.

Study design and population

A phenomenological qualitative research design was adopted to gain deep insight into the personal experiences, perceptions, and emotional responses of student nurses during practical examinations. This approach was used to explore students lived experiences and the contextual factors that shape their perceptions of fairness, preparedness, and examiner influence.

Data were collected between December 2024 and April 2025, following ethical approval from the Committee for Human Research Publications and Ethics of the University of Energy and Natural Resources (CHRE/AP/300/024). Written permission was also obtained from the administrative heads of nursing of the three institutions. All participants provided written informed consent prior to data collection. They were assured of confidentiality, anonymity, and their right to withdraw at any stage without consequences. Participation was entirely voluntary and no incentives were provided.

Theoretical framework

The present study used Kolb’s Experiential Learning Cycle—a four-stage model of learning encompassing concrete experience, reflective observation, abstract conceptualization, and active experimentation [16]—to inform the development of the interview guide, organize themes identified during analysis, and contextualize nursing students’ experiences during practical examinations.

Sampling and recruitment

Purposive sampling of criterion-homogenous type was used to recruit 18 student nurses who met the inclusion criteria: being in their third year and fourth year and having participated in at least two practical examinations. This sampling strategy was selected to ensure information-rich participants with relevant experience in practical examination. Recruitment continued until data saturation was reached after the 16th interview, meaning no new codes, themes, or insights emerged.

Inclusion criteria

Participants were eligible for inclusion if they were third-year student nurses, and had participated in at least two practical examinations.

Exclusion criteria

Students were excluded if they were not in their third or fourth year of study, had taken fewer than two practical examinations, or declined to provide consent.

Data collection

During interviews, the researcher was mindful that their professional identity could prompt socially desirable responses or the minimization of negative experiences. To mitigate this, confidentiality, anonymity, and non-affiliation with participants’ examiners were emphasized to foster a safe conversational environment. Interviews were conducted one-on-one in quiet, private settings within the participating institutions, free from faculty presence or interruption, to reduce fear of academic repercussions. Emotional support resources were made available, and participants were encouraged to skip any questions they found uncomfortable. Field notes documented non-verbal cues such as hesitation or guardedness, which informed adaptive probing strategies to ensure authentic representation of participants’ voices.

Data were gathered through in-depth, semi-structured interviews guided by four broad domains: emotional responses, perceived preparedness, examiner interaction, and perceptions of fairness and bias. The interview guide was reviewed by three qualitative research experts for face validity and piloted with three student nurses (excluded from the final dataset) to ensure clarity, sensitivity, and appropriateness of language. Each interview, conducted in English, lasted approximately 30–45 min and was audio-recorded with informed consent using a Philips DVT4110 Voice Tracer recorder, supplemented by detailed field notes. Recruitment continued until the 18th interview, when data saturation-monitored through redundancy tracking-was reached, ensuring thematic completeness and participant variation.

A comprehensive audit trail was maintained throughout the study. This included raw data in the form of verbatim interview transcripts and field notes; data reduction outputs such as initial codes, coding trees, and thematic maps generated in NVivo 14; and data reconstruction materials, including memos explaining decisions to merge, split, or redefine themes during analysis. The audit trail also comprised reflexive journal entries, records of methodological decisions, and revisions to the interview guide informed by early findings. Furthermore, documentation from peer debriefing sessions with two qualitative researchers, along with records of how their feedback was integrated, was retained. Member-checking summaries were returned to participants for verification, with necessary revisions made to ensure their intended meanings were accurately reflected.

Data analysis

All interviews were transcribed verbatim by the lead researcher, who recognized that their dual identity as a nurse educator and qualitative researcher could influence data interpretation. This positionality offered advantages, such as a deep understanding of professional language and context, but also posed risks of overemphasizing familiar narratives or overlooking differing perspectives. The researcher also kept a reflexive journal during analysis, noting personal impressions, potential biases, and emotional responses after each transcription and coding session. These notes were reviewed regularly to identify and minimize the impact of prior assumptions, ensuring openness to unexpected meanings in participants’ accounts.

Data analysis followed Braun and Clarke’s (17) six-step thematic analysis framework: (1) familiarization with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the final report. An inductive approach was adopted to allow themes to emerge naturally from participants’ narratives without imposing preconceived categories. NVivo 14 software was used to manage data systematically, employing node trees and coding density visualizations to support analytical rigour. Open coding was conducted line-by-line, with codes grouped into broader categories that reflected recurrent patterns. These categories were refined into subthemes and overarching themes through iterative comparison and consensus among the research team.

Again, the researcher maintained an audit trail of the entire analytical process. This included coding outputs, thematic maps, and memos explaining decisions to merge, split, or redefine themes during analysis. Peer debriefing with two experienced qualitative researchers provided external review, and their feedback was incorporated into theme refinement. Summaries of transcripts were also shared with some of the participants to confirm accuracy, ensuring the final thematic framework was both rigorous and grounded in participants lived experiences.

Trustworthiness of the study

Again, methodological transparency and confirmability were ensured through the maintenance of a comprehensive audit trail. This included verbatim interview transcripts, field notes, coding outputs, thematic maps, and analytic memos detailing decisions to merge, split, or redefine themes. Reflexive journal entries, records of methodological choices, and adjustments to the interview guide based on early insights were also documented. Peer debriefing with two qualitative researchers provided additional rigor, with feedback systematically incorporated. Member-checking summaries were returned to participants for verification, and necessary revisions were made to ensure accurate representation of their intended meanings.

To ensure the credibility and reliability of the findings, the study followed Lincoln and Guba’s criteria [17]. The significant statements and formulated meanings were reviewed and refined collaboratively by the research team. The lead researcher ensured transcript accuracy through repeated listening, while two experienced qualitative researchers provided peer debriefing throughout the analysis. Member checking with selected participants further enhanced trustworthiness, allowing verification that the emergent descriptions authentically reflected their lived realities.

Results

A total of 18 student nurses participated in this study, with demographic characteristics capturing gender, age, academic level, and mode of entry. The gender distribution was relatively balanced, with 10 females and 8 males. Most participants were within the 21–30 age group (8), followed by those aged 15–20 (6), and 31–40 (4), indicating that the majority were young adults. No participant was above 40 years of age.

In terms of academic level, 9 participants were in Level 300 and 10 in Level 400, suggesting they had adequate clinical exposure and had completed at least two practical examinations. Regarding mode of entry, 10 participants were enrolled through the generic route, while 8 were top-up students. This diversity in educational background contributed to a wide range of experiences, which enriched the findings and added depth to the understanding of student nurses’ experiences during practical examinations (Table 1).

Table 1.

Demographic profile of student nurses

Characteristics of Student Nurse participants (N = 18)	Category	Frequency(N)
Gender	Male	8
	Female	10
Age	15–20	6
	21–30	8
	31–40	4
	Above 40	0
Level or year of students	L300	8
	L400	10
Mode of entry	Generic	10
	Top up to degree	8

Results

The study identified five main themes and ten subthemes (Fig. 1). related to student nurses’ experiences during practical examinations. The themes in the study are closely connected and together shape how student nurses experience practical exams. Emotional reactions like stress or confidence are influenced by how prepared and skilled students feel, which depends on the training and practice they received. The way examiners behave—whether they are kind or strict—can also reduce or increase students’ stress. Challenges such as poor equipment, limited space, and bad scheduling add more pressure and can affect performance, even if a student is well-prepared. These issues highlight the need for improvements that focus on better training, supportive examiners, and improved facilities to create a fair and supportive exam environment. The qualitative findings were deeply analyzed to unveil student experience during the practical examination. As a result, the findings and discussion were presented together, supported by relevant participant quotes and related research.

Fig. 1.

Themes and Subthemes of student nurses experience

Emotional responses to practical examinations

Student nurses experienced anxiety and fear of failure

Student nurses commonly reported feelings of intense anxiety and fear as they approached their practical examinations. Despite having practiced extensively, many described experiencing a mental block during the actual assessment. This anxiety often stemmed from the high stakes of the exam, fear of embarrassment, and worry about forgetting key procedures. These emotional burdens significantly impacted their ability to perform, as illustrated by one participant:

They say every exam induces some kind of fear, but the practical examination always leaves me paralyzed. I was so nervous that I forgot the steps even though I had practiced them so many times. (P04–L300).

Another participant emphasized the lingering fear that persisted even before the day of the examination:

I couldn’t sleep the night before. I was scared I would forget what to do in front of the examiner. The fear of making a mistake in front of the examiner was overwhelming. (P10–L400)

Across the narratives, students consistently associated practical exams with high stress levels and overwhelming fear, often resulting in cognitive disruption and emotional exhaustion prior to and during the practical examination.

Pressure to perform impaired cognitive and motor skills

Participants described the practical examination as a high-pressure situation where the demand to perform perfectly compromised their confidence and concentration. Several felt that the pressure distorted their sense of self-efficacy, even making them question their preparedness. One student remarked:

Pressure! Pressure oo pressure! It undermines my output. I felt like the entire future depended on that one procedure. In fact, I was missing heartbeats as if I had not stepped foot in the skills laboratory before. (P07–L400)

Another shared how pressure disrupted their ability to recall and apply previously mastered skills:

The experience is odd. I was shaken like a leaf as I was being given my task. Even though I knew the procedure, the pressure made it hard for me to think clearly and perform better. (P01–L300)

The overwhelming pressure of performance during practical disrupted students’ mental focus and skill execution, suggesting that stress management and emotional preparation are crucial elements often overlooked in the examination setup.

Perceived preparedness and skill confidence

Inadequate practice opportunities affected performance

Many participants reported that limited practical exposure during training hindered their ability to prepare adequately for the examination. Overcrowding in skills laboratories and insufficient hands-on opportunities were cited as major barriers to building competence. One participant shared:

We only practiced some procedures once or twice before the exam… it wasn’t enough. As a class, our number is so great that we don’t often get hands-on experience. This often makes us inadequately prepared for the examination.(P08–L400)

Others emphasized the disconnect between theory and practice:

Watching it being done is different from doing it yourself. In fact, some of the things we were asked to do, we had never actually done on real patients, and this makes it challenging. (P03–L300)

Limited hands-on exposure and resource constraints during training contributed significantly to students’ feelings of unpreparedness, highlighting the need for improved access to practice opportunities before assessment.

Clinical exposure-built skill confidence

Conversely, participants with substantial clinical rotation experience reported feeling more confident and better prepared. Regular ward exposure allowed them to perform procedures more naturally and with less anxiety during the examination. As one student expressed:

Practice, they say, makes perfect. Because I had done it several times on the ward, I felt more confident during the exam when I had a similar procedure. (P02–L400)

Another reinforced the value of consistent clinical practice:

Not skipping the ward is quite beneficial. My experience during rotation helped me a lot during the clinical examination; it felt like second nature. (P06–L300)

Students who had frequent, real-life clinical practice during their rotations developed stronger competence and composure, reinforcing the importance of meaningful clinical exposure in bridging theory and practice.

Examiner influence and supervision style

Examiner attitudes shaped student confidence

The behavior and demeanor of examiners significantly influenced students’ experiences during the assessment. Supportive examiners were seen as encouraging, while intimidating ones heightened anxiety and disrupted performance. A participant shared:

Sometimes the nature of the examiner counts a lot. One time, I had an examiner who was very calm and smiling… it made me less tense and brought out the best in my performance. (P09–L400)

In contrast, others described negative encounters that exacerbated their stress:

The demeanor of some of the instructors is disturbing and injects a sense of fear in us. I once had an examiner who frowned the whole time on every step I took and kept interrupting me… I was so shaken. (P11–L400)

This depicts that examiner demeanor played a crucial role in shaping students’ emotional states and performance; empathetic supervision eased tension, while authoritarian attitudes induced fear and performance breakdowns.

Perceived bias and lack of fairness

A recurring concern among participants was the perception of examiner bias and inconsistency in task allocation. Some students felt that favoritism and subjective grading compromised the fairness of the examination process. This was echoed in the following quote:

For me, there is no fairness in the examination process and with some of the supervisors. It felt like some students were favored. Some examiners asked easier questions than others, and also some students are assigned easy tasks. (P14–L300)

Another added:

You could tell by their tone who they liked and who they didn’t. We cannot rule out partiality, as some students are assigned easy tasks by examiners.(P04–L400)

Reports of unequal task assignment and favoritism reflected a broader concern about subjectivity and lack of transparency, undermining trust in the credibility of the evaluation process.

Environmental and logistical challenges

Inadequate equipment and infrastructure hampered performance

Participants highlighted infrastructural and logistical challenges that created additional barriers during practical exams. This included malfunctioning equipment, limited physical space, and overcrowding. One student described:

The equipment was woefully inadequate, and those available weren’t working well. I had to improvise, and it affected my flow. (P05–L300)

Another expressed frustration over the physical setup of the skills lab:

We have a narrow skills laboratory; we had to queue for long before our turn. Worse are those of us who are short—we have to stretch ourselves to see, and this makes me mentally exhausted. (P12–L400)

Deficiencies in resources and poor infrastructure negatively affected performance and added physical and mental strain to an already stressful evaluation process.

Examination settings were disruptive

The physical and ambient conditions of the examination environment—such as noise, heat, and congestion—were frequently cited as impediments to optimal performance. Students found it difficult to focus amidst these distractions:

There was so much noise and movement around the room; the room and the ward are so narrow for four groups of examiners… it was hard to concentrate. This affected my performance. (P15–L300)

Similarly, poor ventilation and faulty air-conditioning systems added to the discomfort:

The examination hall was too hot and crowded. Most of the air conditioners and fans are dysfunctional—it added to the stress and affected our output. (P17–L400)

The unsupportive physical conditions during examinations exacerbated stress and hindered performance, suggesting the need for better environmental planning during practical assessments.

Recommendations for improvement

Students suggested mock exams to improve readiness

In order to improve preparedness and reduce examination-related anxiety, participants recommended the introduction of mock practical examinations and better simulation experiences. These would allow students to rehearse under conditions similar to the real assessment. One participant suggested:

We need mock practical to prepare us mentally and emotionally. When we are exposed to pre-clinical trial examinations, it builds our tempo to perform better. (P16–L300)

Another proposed enhanced simulation environments:

If we had simulations that mimic the exam environment, we’d be less anxious. Our laboratory should be resourced with modernized equipment and consumables that mimic the ward environment. (P02–L400)

Mock assessments and improved simulation resources were seen as critical tools for enhancing preparedness and reducing anxiety by familiarizing students with the exam format and environment.

Calls for examiner training and standardization

Participants also recommended continuous training for examiners to promote fairness, reduce bias, and ensure consistency across the board. This included standardizing the assessment process and limiting subjectivity. As one participant expressed:

I think the examiners need continuous in-service training. They need to be trained to assess fairly and supportively. (P10–L300)

Another highlighted the importance of structured guidelines:

There should be guidelines to make the exam more uniform for everyone. There should be a system that minimizes human intervention and gives fair judgment.(P18–L300)

Participants advocated for structured examiner training and the adoption of standardized assessment guidelines to ensure fairness, objectivity, and equity during evaluations.

Discussion

This study reveals the complex emotional, institutional, and systemic dynamics that shape student nurses’ experiences during practical examinations in Ghana. The five major themes—emotional responses, preparedness and skill confidence, examiner influence, environmental challenges, and recommendations for improvement—illustrate the multi-layered challenges students face in high-stakes clinical assessments. These findings are best understood through the lens of Kolb’s Experiential Learning Theory, which posits that learning is a cyclic process comprising four stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation. In the context of clinical education, students engage in learning by doing (concrete experience), reflecting on their performance (reflective observation), understanding the underlying principles (abstract conceptualization), and applying these in new contexts (active experimentation). The findings demonstrate both enablers and obstacles within this learning cycle.

Emotional responses to practical examinations

A predominant theme in this study was the intense anxiety and fear that students experienced before and during practical assessments. These emotional responses, characterized by mental blocks, fear of failure, and physiological symptoms such as sleeplessness, disrupted the learning and performance process. Within Kolb’s framework, these emotional reactions interfere with the reflective observation and active experimentation phases, limiting students’ ability to apply prior learning or learn from the exam itself. This aligns with [18], who found that performance anxiety in clinical examinations impairs decision-making and psychomotor function.

Moreover, these emotional responses are not isolated but deeply embedded in the perceived stakes of the examination, reflecting what [19] term “assessment trauma.” Emotional safety is foundational for effective learning, and the lack thereof can short-circuit the experiential learning cycle. In Kolbian terms, if the learner cannot meaningfully engage in reflection and experimentation due to overwhelming stress, the learning process is stunted.

Perceived preparedness and skill confidence

Students’ narratives revealed that insufficient practice opportunities, limited equipment, and large student numbers hindered their sense of readiness. This represents a breakdown at the concrete experience stage of Kolb’s model. Without repeated, meaningful exposure to real-life or simulated clinical tasks, students struggle to internalize and confidently perform procedures during examinations. This echoes the observations of [20] and others, who note that frequency and quality of clinical practice are directly proportional to students perceived competence.

Conversely, those who engaged consistently in ward rotations reported enhanced confidence and composure, illustrating how active experimentation reinforces both skill mastery and emotional stability. These findings strongly support the importance of experiential exposure in nursing education. Practice not only develops muscle memory and clinical reasoning but also supports the emotional regulation needed in high-stakes environments [21].

Examiner influence and supervision style

The study highlights the profound influence of examiner behavior—both positive and negative—on student performance. Supportive, calm examiners were perceived as facilitators of performance, while intimidating or biased examiners induced fear and cognitive disruption. These experiences align with [22], who emphasized examiner demeanor as a crucial determinant of student confidence and clarity during clinical assessments.

From an experiential learning perspective, the examiner functions as both an evaluator and a learning facilitator. When the examiner becomes a source of intimidation or perceived bias, it fractures the reflective observation and abstract conceptualization stages, replacing critical thinking with survival responses such as compliance, rote memorization, or emotional withdrawal. Furthermore, the presence of favoritism, inconsistent grading, and unethical conduct violates the ethical underpinning of professional education and stifles student development. As noted by [23], perceptions of unfairness reduce trust in institutional systems and diminish motivation—factors that ultimately hinder long-term learning and professional growth.

Environmental and logistical challenges

The data reveal that poor infrastructure, dysfunctional equipment, and overcrowded examination settings posed significant obstacles to students’ performance. These physical conditions compromised both procedural execution and emotional regulation, highlighting the important but often overlooked role of the environment in facilitating experiential learning. According to [24], environmental stressors such as noise and congestion impair students’ ability to focus, echoing participants’ complaints about external distractions.

Kolb’s theory implicitly acknowledges the learning environment as integral to the learning process. When the clinical or simulated space is chaotic or under-resourced, students are unable to fully immerse themselves in the concrete experience or carry out active experimentation with confidence. The necessity of a safe, structured, and well-resourced setting is thus not a luxury but a prerequisite for effective learning and fair evaluation.

Recommendations for improvement

The participants’ recommendations—particularly the call for mock practical examinations, improved simulation environments, and standardized assessment protocols—reinforce the need for intentional experiential learning design. Mock exams serve as low-stakes opportunities for active experimentation, allowing students to become familiar with the exam structure, reduce anxiety, and refine procedural fluency. Patterson [25] argue that simulation-based assessments not only enhance skill acquisition but also foster reflective practice.

The recommendations, which include mock OSCEs, simulation-based practice, continuous examiner training, and improved infrastructure, align closely with Kolb’s experiential learning cycle. Simulation and peer-assisted practice provide opportunities for concrete experience, while formative assessments and feedback promote reflective observation. Curriculum reforms that integrate skill-building modules foster abstract conceptualization, and subsequent clinical practice enables active experimentation. By embedding assessment within this experiential framework, nursing education can enhance competence, confidence, and compassion among students, ultimately strengthening patient care outcomes and building a more resilient healthcare system.

Conclusion

This study underscores the urgent need to adopt more student-centered and psychologically supportive examination practices within nursing education. To enhance learning outcomes and build confidence among student nurses, institutions should integrate regular formative assessments, ideally conducted every six to eight weeks. These assessments would provide continuous feedback and help reduce the anxiety associated with high-stakes evaluations. The use of peer-assisted learning models and simulation-based practical examinations is also vital, as they allow students to rehearse clinical skills in low-pressure environments that replicate real-life scenarios, reinforcing competence and reducing fear of failure.

Beyond assessment reform, the findings highlight the importance of comprehensive curriculum redesign that explicitly integrates psychosocial support strategies, structured opportunities for skill rehearsal, and simulation-based learning modules. Aligning curricula to ensure teaching, learning, and assessment practices reinforce one another would create a more cohesive and supportive educational environment. At the same time, examiner training modules should be institutionalized as part of faculty development programs. These must emphasize ethical and student-centered evaluation, psychological safety, and constructive feedback to ensure examiners are both technically and pedagogically prepared.

Achieving sustainable improvements also requires deliberate resource mobilization strategies at both institutional and national levels. Investments in simulation laboratories, examiner development programs, and student support services are essential to make reforms viable and equitable across schools with different resource capacities. By implementing these reforms in curriculum, examiner training, and infrastructure, nursing education can significantly enhance students’ preparedness for clinical practice. This will not only strengthen the retention of essential clinical skills but also build a more confident, competent, and compassionate nursing workforce, ultimately leading to improved patient care outcomes and a more resilient healthcare system.

Limitation of the study

This study is limited by its focus on student nurses in Ghana, which may restrict the applicability of its findings to other contexts with differing healthcare education systems. As the study used only student perspectives, future research should integrate examiner and institutional viewpoints for a more comprehensive understanding. The reliance on subjective experiences introduces potential biases, and systemic issues like resource constraints and high student-to-faculty ratios may have shaped responses in unmeasured ways. Furthermore, the exclusion of examiner and institutional perspectives, along with the qualitative design’s lack of quantifiable data, underscores the need for complementary research using broader methods.

Recommendation

It is recommended that nursing schools should integrate regular mock OSCEs and simulation-based practice sessions into their curricula, as these low-stakes rehearsals can build student confidence, refine clinical skills, and reduce the anxiety commonly associated with high-stakes evaluations. In addition, examiner preparation should be institutionalized through mandatory and continuous training programs that emphasize fairness, transparency, supportive feedback, and psychological safety, thereby ensuring that assessments remain both rigorous and student-centered. Equally important is the need for improved examination infrastructure, with investments directed toward proper ventilation, reliable equipment, and adequate space to create a conducive environment for both students and examiners. Finally, regulatory bodies and academic institutions must collaborate to implement policy reforms that balance the rigor of clinical assessments with the psychological well-being of students, promoting competency-based evaluations while safeguarding confidence and mental health.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

BEA: Conceptualization, original draft, investigation, data collection, analysis. VSB: Data collection, validation, review of the manuscript AH: Conceptualization, analysis, validation, writing critical review and editing. CAA: Data collection, validation, review of the manuscript. GK: Validation, review and editing of the manuscript. DHW: Data collection, validation, manuscript review and editing.

Funding

The research had no funding. All cost was borne by the authors.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The research was conducted in accordance with the Declaration of Helsinki. Data collection was done after obtaining approval from the Committee for Human Research Publication and Ethics (CHRE/AP/300/024) of the University of Energy and Natural Resources and a written permit from the heads of the selected institution. An informed consent was obtained from all participants. Pseudonymization of transcripts was done to reassure readers of ethical rigor.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.