Early resident perceptions of clinical readiness in Italy: associations with demographic and educational factors

Background

The transition from undergraduate medical education to residency is a critical phase that demands rapid adaptation to clinical responsibilities, institutional cultures, and complex healthcare systems. Despite curricular reforms, many graduates report feeling underprepared, particularly in procedural and systems-based domains. The aim of the study was to evaluate self-perceived clinical readiness among first-year residents and identify educational and demographic factors they believe influenced their transition into postgraduate training.

Methods

A retrospective survey was conducted at Humanitas University and affiliated hospitals between 2024 and 2025. Sixty first-year residents across 27 specialties completed a structured survey eight months into residency training, assessing their readiness at the start of residency and at the time of survey completion. Quantitative data were analyzed using descriptive statistics and multivariate regression to identify potential influencers of readiness.

Results

Residents reported a significant increase in perceived readiness over the first eight months (mean score: 2.2 to 3.3, p < 0.001). Confidence was highest in non-technical domains (e.g., teamwork, feedback) and lowest in procedural skills. International exchanges were positively associated with initial perceived readiness (β = 0.47, p = 0.046), while prior internships in the same specialty and graduation from state universities were negatively associated (β = − 0.63 and − 0.50, respectively; p < 0.05). Simulation-based training was rated less useful than clinical internships and exchanges.

Conclusion

Readiness for clinical practice appears to be a dynamic perception that evolves during the early months of residency and is influenced by how trainees interpret their prior educational experiences. These self-reported associations highlight potential areas for further investigation, underscoring the need for studies using longitudinal and performance-based measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08733-7.

Highlights

• Self-perceived readiness significantly improves within the first 8 months of residency.

• International exchanges positively impacted initial readiness.

• Procedural competence remains a key area of perceived weakness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08733-7.

Introduction

The transition from medical school to residency is a pivotal phase requiring new doctors to rapidly apply theoretical knowledge, adapt to institutional cultures, and assume patient care responsibilities [1]. At this critical juncture, newly qualified doctors are required to translate theoretical knowledge into independent clinical decision-making, adapt rapidly to new institutional cultures, and assume direct responsibility for patient care [2]. The concept of workplace readiness at this stage encompasses a broad spectrum of competencies, including clinical reasoning, technical proficiency, communication, teamwork, and systems-based understanding of healthcare delivery [3, 4]. These requirements are further intensified by the ongoing transformation of healthcare environments, driven by technological innovation, the expansion of interprofessional practice, and the increasing engagement of patients as active partners in care [5–7].

Despite efforts to prepare graduates, studies show persistent gaps in hands-on experience and misalignment between curricula and residency expectations, with notable variation across specialties and countries [1, 8–10]. Curricula often struggle to keep pace with the evolving expectations of contemporary healthcare, and many graduates report uncertainty or heightened stress as they assume clinical roles [11–14].

Conceptual frameworks in medical education have increasingly sought to clarify what constitutes workplace readiness and how it can be effectively nurtured. Recent models emphasize that readiness extends beyond individual competence to include adaptability, situational awareness, and integration within complex clinical systems [15, 16]. Crucially, readiness is not a static trait but a context-dependent construct shaped by the dynamic interaction between learners and their training environments [9]. Understanding how new residents experience and evaluate their preparedness is therefore essential for designing effective transition programs.

This study was designed to quantify changes in self-perceived readiness across technical, non-technical, and systems-based domains among first-year residents. It aimed to explore how trainees experience and interpret workplace preparedness during the initial phase of postgraduate medical education. Furthermore, the study sought to to explore associations between perceived readiness and demographic or contextual factors. The findings are intended to inform curriculum development, supervision frameworks, and institutional strategies that promote a more equitable and responsive transition into clinical practice.

Methods

Study design and setting

This retrospective panel survey was conducted at Humanitas University and its affiliated 10 teaching hospitals between 2024 and 2025. Humanitas University is a private medical institution located in Pieve Emanuele (Lombardy) and integrated with the Humanitas Research Hospital (IRCCS), a nationally accredited teaching and research center. The university hosts ca. 3,000 students, including more than 700 postgraduate trainees and 30 Schools of Medical Specialization. Its affiliated Humanitas hospital network trains over 400 medical residents annually across multiple sites in Milan, Bergamo, Castellanza, Turin, and Catania, ensuring exposure to a wide range of clinical settings.

Participants

The study focused on first-year postgraduate medical residents enrolled across 27 accredited clinical specialties. All residents who began their specialty training during the study period were eligible for inclusion, provided they were formally enrolled in an accredited program at Humanitas University. The cohort commenced training in November 2024, which allowed for an initial period of acclimatization before data collection began. The need for consent to participate was waived by the Comitato Etico Territoriale Lombardia | N° XII/281 DEL 15/05/2023 as the study involved anonymized data and posed minimal risk to participants.

Data collection

A structured online survey was administered between the eighth and ninth months of residency to assess self-perceived clinical readiness at two distinct time points: (1) retrospectively, reflecting on preparedness at the start of residency, and (2) at the time of survey completion, capturing current levels of comfort and readiness. The survey covered technical, non-technical, and systems-based competencies. Demographic data included age, gender, university of graduation, geographic region, and institution type (state vs. non-state).

The instrument featured a mix of yes/no, categorical, and 5-point Likert-scale questions addressing prior clinical experience and the perceived usefulness of university training activities such as clinical internships, international exchanges, and simulation-based education. Competencies were evaluated through agreement with statements related to clinical practice, teamwork, innovation, and practical skills. In this context, “international exchange experience” refers to periods of clinical or academic training completed outside the students’ home institution-typically in a foreign country-allowing exposure to different healthcare systems, clinical practices, and cultural contexts. “Internship,” in contrast, denotes the supervised clinical rotations completed within the Italian undergraduate medical curriculum, during which students participate in patient care activities in hospital wards or outpatient services under the guidance of faculty and clinical tutors.

The survey was developed through a structured, iterative process that included initial item drafting, expert review (n = 6) to assess relevance and clarity, pilot testing, and subsequent refinement based on respondent feedback [17]. These steps were undertaken to strengthen the instrument’s content adequacy and readability; however, no formal psychometric validation (e.g., factor analysis or reliability testing) was performed. The final version included both quantitative items and open-ended prompts to capture nuanced perceptions. An English-language version of the survey has been uploaded as a supplementary file.

The survey was administered online using Microsoft Forms©. The invitation was distributed by the Data Manager of the Data Insights and Strategic Development Office at Humanitas University, who is not involved in residency or student training, nor in any aspect of academic evaluation. The survey link was emailed to all eligible first-year residents, followed by two reminder emails sent one week apart. Participation was voluntary, anonymous, and uncompensated. No identifiable information was collected, and responses could not be traced back to individual participants.

Statistical analysis

Quantitative data were analyzed using descriptive statistics and linear regression models to identify predictors of self-perceived readiness. Both univariate and multivariable analyses were performed using ordinary least squares (OLS) regression. Variables associated with the outcome at p < 0.20 in univariate analyses were entered into the multivariable model, which was refined using backward stepwise elimination until all retained predictors met a significance threshold of p < 0.05.

Geographic origin and gender were examined in univariate analyses but were not included in the multivariable model. Geographic origin was highly correlated with university type (state vs. non-state), resulting in collinearity; university type was therefore retained as the more proximal and interpretable predictor. The reference category comprised residents graduating from non-state universities who reported neither specialty-specific internship experience nor participation in international exchanges. All analyses were conducted using Python (version 3.11.5). Statistical significance was set at α = 0.05.

Results

Participant characteristics

Of the eligible first-year residents, sixty first-year completed the survey. As shown in Tables 1 and 62% (n = 37) respondents were female and under the age of 30. Four respondents (23%) had graduated from Humanitas University, with the remianing 56 participants (77%) coming from other institutions, primarily state universities located in Northern Italy. In terms of specialty distribution, 27 participants (45%) were enrolled in medical disciplines, 22 participants (36.7%) in surgical specialties, and 11 participants (18.3%) in service-oriented fields.

Table 1.

Demographic characteristics of First-Year medical residents (N = 60)

Characteristic	Category	Percentage	Absolute Number (n = 60)
Gender	Female	62%	37
	Male	38%	23
Age Group	< 30 years	95%	57
	30–35 years	5%	3
	36–40 years	–	0
	> 40 years	–	0
Region of Graduation	North	60%	36
	Center	22%	13
	South & Islands	18%	11
Type of University	Non-state	60%	36
	State	40%	24
Degree from Humanitas University	Yes	23%	14
	No	77%	46
AREA OF SSM*	Medicine	45%	27
	Surgery	36.7%	22
	Other services	18.3%	11

*Medical Disciplines include: Allergology, Dermatology, Hematology, Endocrinology, Cardiology, Gastroenterology, Pulmonology, Infectious Diseases, Emergency Medicine, Internal Medicine, Neurology, Oncology, Rheumatology

Surgical Disciplines include: General Surgery, Gynecology, Neurosurgery, Ophthalmology, Orthopedics, Otolaryngology, Urology

Other services: Pathological Anatomy, Anesthesiology, Hygiene, Nuclear Medicine, Radiology, Radiotherapy

Effect of prior experience during undergraduate education

Participants retrospectively rated their undergraduate clinical internships as moderately useful for their current residency training, with international exchange programs generally perceived as even more beneficial, though less commonly experienced (26 out of 60 students; 43%). As shown in Table 2, Simulation activities received lower usefulness ratings overall (3/5). Most respondents (59/60; 98%) had completed an internship in the same discipline as their specialty school, with the majority of clinical exposure occurring during the final years of undergraduate education. A significant proportion (33%) of students reported substantial hands-on experience through extended clinical internships.

Table 2.

Impact of undergraduate Preparation activities on Self-Perceived confidence

Category	Perceived usefullness (Mean Score/5)*	% of Respondents Participating in such activities
Clinical Internship	3.3	98%
International Exchange	3.5	43%
Simulation-Based Activities	3.0	67%

*Likert Scale: 1 = not useful, 5 = extremely useful

Self-Perceived readiness

Residents retrospectively rated their preparedness at the start of residency as 2.2 out of 5 (SD 0.9). As shown in Table 3, after approximately eight months of training, when the survey was administered, this rating had increased to 3.3 out of 5 (SD 0.7). A Wilcoxon signed-rank test confirmed that this improvement was statistically significant (p < 0.001).

Table 3.

Self-Perceived readiness in core competencies eight months into residency

Competency	Mean ± SD
Patient history taking	4.4 ± 0.9
Performing clinical procedures	2.5 ± 1.2
Identifying patient problems	3.4 ± 0.9
Teamwork/coordinating with team	4.0 ± 0.8
Accepting feedback	4.3 ± 0.7
Managing complex situations	3.7 ± 0.9
Understanding hospital workflows	3.3 ± 1.0
Asking for help	4.2 ± 0.9
Using electronic medical records	4.0 ± 1.0

Mean scores and standard deviations are reported for technical, non-technical, and systems-based competencies. Ratings are based on a 5-point Likert scale, where 1 = not prepared and 5 = completely prepared

In terms of technical competencies, after 8 months into residency, residents expressed high confidence in taking patient histories (4.4/5) and identifying clinical problems (3.4/5), but lower confidence in performing clinical procedures (2.6/5). Non-technical skills were rated more favorably, with strong confidence in teamwork (4.0/5), accepting feedback (4.3/5), and managing complex situations (3.7/5). Residents also reported good ability to ask for help (4.2/5) and use electronic medical records (4.0/5), but only moderate understanding of hospital workflows (3.3/5). There was a strong demand for increased training during the first year of residency (mean 4.2/5).

Interestingly, while geographic differences were observed in self-perceived readiness on the first day of residency when recalling their first days, scores converged after 8 months into residency. This suggests quite a rapid adaptation and leveling of competencies once residents are immersed in clinical practice, highlighting the equalizing effect of experiential learning during the early stages of postgraduate education.

Predictors of Self-Perceived initial readiness

Univariate analysis

In univariate models (see Table 4), graduation from a state university was associated with lower self-perceived readiness (β = − 0.48; 95% CI − 0.97 to 0.01; p = 0.06), and having previous clinical experience similarly showed a negative association (β = − 0.48; 95% CI − 0.96 to 0.00; p = 0.05), while international exchanges suggested a possible positive effect (β = +0.42; 95% CI − 0.06 to 0.91; p = 0.09). Lower readiness was also reported by graduates from Southern Italy/Islands compared with other regions (β = − 0.67; 95% CI − 1.28 to − 0.06; p = 0.03).

Table 4.

Univariate analysis of factors associated with initial Self-Perceived clinical readiness

Female sex	Coefficient (95% CI)	P-value
	0.15 (−0.35, 0.66)	0.54
State university	−0.48 (−0.97, 0.01)	0.06
Previous clinical experience	−0.48 (−0.96, 0.00)	0.05
Previous internships	0.19 (−1.74, 2.11)	0.85
International exchanges	0.42 (−0.06, 0.91)	0.09
Simulation activities	−0.03 (−0.55, 0.50)	0.92
Previous internships in the same specialty	−0.62 (−1.26, 0.02)	0.06
North	0.31 (−0.19, 0.80)	0.22
Centre	0.16 (−0.44, 0.76)	0.60
South/Islands	−0.67 (−1.28, −0.06)	0.03

This table presents the results of univariate OLS regression analyses examining associations between each demographic/educational variable and self-perceived clinical readiness on the first day of residency as recalled 8 months later

Multivariant analysis

In the final multivariable model (Table 5), three variables were independently associated with initial self-perceived readiness: graduation from a state university (β = − 0.50; 95% CI − 0.97 to − 0.03; p = 0.036), previous internship in the same specialty (β = − 0.63; 95% CI − 1.24 to − 0.02; p = 0.044), and participation in an international exchange (β = +0.47; 95% CI 0.01 to 0.93; p = 0.046). Previous clinical experience was not retained in the final model. The baseline corresponds to residents who graduated from non-state universities and reported neither specialty-specific internships nor international exchanges (β = 2.81; 95% CI 2.17 to 3.46; p < 0.001).

Table 5.

Multivariate analysis of factors associated with initial Self-Perceived clinical readiness

Variable	Coefficient (95% CI)	p-value
Baseline*	2.81 (2.17, 3.46)	< 0.001
State University	−0.50 (−0.97, −0.03)	0.036
Previous internships in the same specialty	−0.63 (−1.24, −0.02)	0.044
International Exchange	0.47 (0.01, 0.93)	0.046

Multivariate regression results identify significant predictors of self-perceived clinical readiness on the first day of residency as recalled 8 months into residency. The baseline is the average score of residents having graduated in non-state universities who did not participate in specialty-specific internships or international exchange programs

Discussion

This study examined how first-year residents perceive their readiness for clinical practice and how prior educational experiences may shape their transition into postgraduate training. Although self-perceived readiness at the start of residency was reported as relatively low, these differences narrowed quickly across multiple competency domains. This pattern suggests a rapid adaptation and leveling effect once residents became immersed in real clinical environments, underscoring the equalizing role of experiential learning during the early months of residency. More broadly, the findings reinforce that perceived readiness is not a fixed endpoint achieved at graduation but a dynamic, context-dependent construct that evolves substantially over time.

This pattern aligns with theories of situated learning and professional development, which describe competence as emerging through engagement in authentic clinical settings rather than through classroom-based instruction alone [18, 19]. Similar trajectories have been reported internationally, where supportive workplace cultures, clear role definition, and structured feedback have been shown to facilitate early professional growth [20].

A particularly interesting finding was the universally low readiness recalled for the first days of residency, with mean scores just above 2 on a 5-point scale. Regardless of previous training, institutional background, or specialty, new residents entered practice feeling underprepared. This pervasive sense of low readiness mirrors global evidence on “transition shock,” where newly qualified doctors experience anxiety and uncertainty when confronted with real responsibility [21, 22]. Despite curricular reforms and the spread of competency-based education [23], many graduates still perceive a gap between undergraduate preparation and the complex demands of clinical work. Such results suggest that readiness should be understood not as an endpoint of undergraduate education but as the beginning of a supervised developmental trajectory [24].

Although perceived readiness improved substantially during the first months, specific domains remained weaker. Perceived confidence in procedural and systems-based competencies were rated inferior to interpersonal and teamwork domains, aligned with international findings that practical and organizational skills are among the least developed at graduation [25]. Interestingly, simulation-based learning was rated as less useful than clinical internships or international experiences. While simulation effectively builds technical proficiency, learners may not perceive it as fully representative of the contextual complexity of clinical care [19]. Enhancing its realism, through interprofessional participation, scenario integration with real patient care, and structured debriefing, could improve both perceived and actual transferability.

The perceived influence of prior educational experiences further illuminates how readiness develops. International exchanges were associated with higher initial readiness, suggesting that exposure to diverse health systems enhances adaptability, cultural competence, and self-efficacy, attributes essential for functioning in complex healthcare environments [26, 27]. Conversely, prior internships in the same specialty correlated with lower initial perceived readiness, possibly because such experiences heighten awareness of complexity or generate expectations misaligned with postgraduate realities. These results imply that not all experiential learning contributes equally to preparedness: broad, integrative, and reflective experiences may have greater educational value than narrow technical repetition [28].

Taken together, these findings reinforce that perceived readiness for clinical practice is not a fixed trait but a developing construct, shaped by individual background, curricular design, and institutional culture.

While our data are associative rather than causal and warrant confirmation in prospective longitudinal studies, the patterns observed suggest that strengthening longitudinal clinical exposure, systems thinking, and structured reflection in undergraduate programs may support the transition to residency.

Strengths and limitations

This study offers new empirical insights into Italian medical education and contributes to the broader European dialogue on clinical practice readiness. By examining how diverse educational experiences, such as prior internships, university background, and international exposure, relate to perceived preparedness, the study provides a richer understanding of the factors shaping early postgraduate transitions. The nationwide sample of residents from varied training backgrounds also enhances the relevance and transferability of the findings.

The study has several limitations. First, although the survey captured perceptions at two distinct points in time, its design was retrospective rather than longitudinal, as data were collected at a single administration and relied on residents’ recall of their initial readiness. Second, the exclusive reliance on self-assessment limits the interpretability of the findings, as perceived readiness may diverge from objective measures of competence or supervisor evaluations. Third, the retrospective nature introduces recall bias, which may have influenced participants’ reconstruction of their initial confidence levels. Finally, the study did not account for possible variation in specialty-specific workload, supervision, or patient exposure, factors that may significantly shape residents’ developmental trajectories. Future research should employ mixed-methods, multi-institutional designs incorporating direct performance assessments, structured supervisor feedback, and prospective longitudinal tracking to strengthen and extend these findings.

Conclusion

Readiness for clinical practice is an evolving, context-dependent perception rather than a fixed endpoint achieved at graduation. Although the associations identified in this study are self-reported and exploratory, they indicate that many residents experience a meaningful burden during the transition into postgraduate training and may benefit from structured transition-to-residency curricula and targeted support programs. To more fully understand how readiness develops and which formative experiences genuinely contribute to it, future research should incorporate longitudinal study designs, objective performance-based assessments, and multi-institutional samples. Such approaches will be essential for generating robust evidence capable of informing the design of more effective educational strategies and support structures that better prepare graduates for the demands of clinical practice.

Authors’ contributions

CE, SO, VV, and RS contributed substantially to the conception or design of the manuscript, as well as to the acquisition, analysis, and interpretation of the data. CE, SO, and VV reviewed all the changes and contributed significantly during the revision with a thorough analysis of the manuscript’s scientific content and scientific value. RS has been leading the statistical analysis of the data sets, and MP guided the extraction and evaluation of the data. CE has been leading in the drafting of the manuscript, while all authors contributed their respective expertise, such as methodology (SO, VV) and data analysis (RS). All the authors read and approved the final version of the manuscript.

Funding

No financial contribution has been received, and the authors report no sponsorship involvement in the research that could have influenced the outcome of this work.

Data availability

We used anonymised data which are currently stored in our local data warehouse. The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study, consisting of a survey involving human participants, was submitted to the Comitato Etico Territoriale Lombardia 5 (Via Alessandro Manzoni 56, 20089 Rozzano, Italy), established pursuant to Regione Lombardia Resolution No. XII/281 of 15 May 2023. The Ethics Committee determined that formal ethics approval was waived, as the survey collected non-interventional, fully anonymized data and posed minimal risk to participants. In accordance with Italian national regulations, ethics approval is not required for non-interventional survey studies based exclusively on anonymized data. Consequently, informed consent to participate was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.