Clinical practice experiences of nursing students in Türkiye: a qualitative study using reflexive thematic analysis

Abstract

Aim

This study aimed to explore, in depth, the challenges nursing students encounter during clinical practice, the emotions they experience and coping strategies they use to manage these challenges.

Background

Clinical practice is a critical component of nursing education, enabling students to integrate theoretical knowledge into practice. However, factors such as limited instructor support, inadequate laboratory preparation and the demands of clinical environments may negatively affect students’ learning experiences.

Design

A qualitative study using reflexive thematic analysis.

Methods

The study was conducted at Ağrı İbrahim Çeçen University between April and July 2025. 18 nursing students with clinical practice experience participated in semi-structured, face-to-face interviews. Data were analysed using Braun and Clarke’s reflexive thematic analysis, supported by MAXQDA qualitative data analysis software. Data collection and analysis proceeded iteratively until sufficient depth and richness of data were achieved. Reflexive discussions were conducted throughout the analysis process to enhance analytical rigour.

Results

Two main themes and five subthemes were identified, including challenges and emotional experiences, causes of difficulties, coping strategies and recommendations. Students reported issues such as insufficient instructor support, large clinical groups, limited psychomotor skills and perceived ‘intern bias’. Emotional responses included feelings of inadequacy, low motivation and fear of making mistakes. Coping strategies involved peer support, self-affirmation and seeking guidance from clinical nurses. Participants recommended increasing instructor availability, expanding simulation-based training and strengthening mentoring systems.

Conclusions

The findings suggest that strengthening supportive instructional approaches, structured clinical environments and enhanced simulation opportunities may be important in nursing education. These findings may inform educators and clinical mentors in developing more supportive and effective clinical learning environments.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study used a qualitative design with reflexive thematic analysis to explore nursing students’ clinical practice experiences in depth.

• Data were collected through face-to-face interviews, which enabled rich, detailed accounts of participants’ experiences.

• The study was conducted in a single institution, which may limit the transferability of the findings.

• The findings are based on self-reported data, which may be subject to recall or response bias.

• The relatively short interview duration may have limited the depth of some accounts.

Introduction

Clinical education is the most fundamental learning component that enables nursing students to apply their theoretical knowledge in practice, develop clinical reasoning skills and support the acquisition of a professional identity.¹ However, the clinical setting often becomes a stressful and challenging learning environment for students due to heavy workloads, limited resources, complex patient profiles and inadequate instructor guidance.^{2 3}

The difficulties experienced by students in the literature are explained by multidimensional factors, including a lack of technical skills, role ambiguity, fear of making mistakes, low self-confidence and negative attitudes toward instructors.⁴ This situation may negatively affect students’ clinical performance and learning satisfaction and may weaken their professional commitment.⁵ In particular, insecurity and fear of making mistakes during clinical decision-making lead to ‘decision-making anxiety’, causing students to avoid practice.⁶

Underlying clinical stress is not only individual inadequacies but also a lack of instructor support and negative social interactions. Mathisen et al noted that students feel excluded due to their ‘intern identity’, while Tadesse et al stated that empathetic guidance may increase psychological safety.^{7 8} It has been reported that students employ strategies such as social support, self-affirmation, peer solidarity and effective communication to cope with stress.⁹ Peer support and positive relationships with nurses increase learning motivation, while mentoring programmes strengthen self-efficacy.¹⁰ In recent years, simulation-based education and virtual reality applications have improved clinical skill performance by reducing students’ fear of making mistakes.^{10 11}

However, existing studies are primarily quantitative and do not provide an in-depth explanation of students’ emotional processes and subjective experiences. Therefore, it appears important to qualitatively examine the challenges students encounter in clinical practice, the reasons behind them, their emotional responses and the coping strategies they employ. This research aims to reveal the challenges that nursing students encounter in clinical practice, their coping strategies for addressing these challenges and the solutions they develop, using a qualitative approach based on reflexive thematic analysis. The findings are expected to contribute to strengthening student support systems in nursing education and restructuring clinical learning environments. In this context, the present study specifically aims to explore not only the challenges encountered by nursing students, but also their emotional experiences, coping strategies and suggested solutions.

Research questions

1. What challenges do nursing students encounter during clinical practice?

2. What emotions do nursing students experience during clinical practice?

3. What coping strategies do nursing students develop to manage these challenges?

4. What recommendations do nursing students propose to improve clinical practice?

Materials and methods

Type of research

This study is a qualitative research project using reflexive thematic analysis to gain a deeper understanding of the difficulties nursing students encounter during clinical practice, the reasons for these difficulties and the coping methods they employ. An experiential qualitative approach was adopted to explore participants’ perspectives in depth. The thematic analysis method, developed by Braun and Clarke, was used to systematically analyse the qualitative data and structure them under relevant themes.¹²

Research location and time

The research was conducted between May and July 2025 at the Department of Nursing, Faculty of Health Sciences, Ağrı İbrahim Çeçen University. The interviews were conducted in a quiet, well-lit interview room within the faculty, free from distractions, allowing participants to express themselves comfortably. The interview environment was arranged in accordance with the principles of confidentiality and trust.

Research population and sample

The study population consisted of 2nd, 3rd and 4th-year students from the Nursing Department of the Faculty of Health Sciences at Ağrı İbrahim Çeçen University during the study period. Students who met the inclusion criteria and volunteered to participate were purposively sampled. Data collection continued until sufficient depth and richness had been achieved. A total of 18 students participated in the study.

Inclusion criteria

• Being 18 years of age or older.

• Being a 2nd, 3rd or 4th-year student in the Nursing Department at Ağrı İbrahim Çeçen University.

• Not having any illness that impairs decision-making ability.

• Voluntarily agreeing to participate in the study.

Data collection tools

Data were collected using two researcher-developed instruments: a Demographic Information Form and a Semi-Structured Interview Form, both of which are presented in online supplemental file 1.

Demographic Information Form

A form developed by researchers in line with the literature, consisting of questions about age, gender, grade level, clinical practice duration, laboratory experience, previous difficulties encountered in the clinic and clinical satisfaction level.

Semi-Structured Interview Form

The semi-structured interview form was created by reviewing similar studies in the literature.^{7 13} The eight open-ended questions in the form allowed students to describe their clinical practice experiences, the difficulties they encountered, their perceptions of instructor and nurse support and provide detailed suggestions. The content validity of the interview form was evaluated by 10 academics specialising in nursing education and qualitative research. The statements were simplified and made more coherent in line with the experts’ suggestions.

The form was piloted with two students, and since no difficulties were identified in terms of language and comprehensibility, it was used directly in the main study. Sample questions:

• ‘What were the most challenging situations you encountered during clinical practice?’

• ‘How did you cope with these challenges?’

• ‘How did the attitudes of your instructors or nurses affect your experience?’

Data collection

Data were collected through face-to-face, semi-structured, in-depth interviews conducted by a researcher experienced in qualitative research. Each interview lasted approximately 15–30 min, and a voice recorder was used with the participants’ permission. Participants’ emotional safety was ensured during the interviews, and they were allowed to pause and take a break when recounting difficult experiences.

After the interviews, all audio recordings were transcribed verbatim, anonymised and coded as P1–P18. Data collection and analysis were conducted iteratively, allowing continuous reflection on emerging patterns within the dataset. From the 15th interview onwards, no substantially new patterns were identified, and similar patterns were observed in the subsequent interviews (16th, 17th and 18th). Saturation was tracked using a saturation grid documenting the emergence of new codes and patterns across interviews. These observations indicated that data saturation had been reached, and therefore, data collection was concluded after the 18th participant. (see online supplemental file 1).

The obtained texts were imported into MAXQDA 2020 and prepared for coding. The interviews were conducted in Turkish and subsequently translated into English for reporting purposes. The initial translation was performed by the research team, and accuracy was ensured through a review process by two independent researchers proficient in both languages. Discrepancies were discussed and resolved by consensus to preserve the original meaning of participants’ statements.

The interviewer had no direct educational or evaluative relationship with the participants. To minimise potential power imbalance, participants were informed that participation was entirely voluntary, that their responses would not affect their academic evaluation and that confidentiality would be strictly maintained. Interviews were conducted in a neutral and supportive manner, and participants were encouraged to express their views freely. In addition, the researchers remained aware of their potential influence on the data collection and interpretation process and took care to maintain a reflective and unbiased approach throughout the study.

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Data analysis

Data were analysed using Braun and Clarke’s reflexive thematic analysis.¹² An inductive approach was adopted, allowing themes to be generated from the data. Codes and themes were developed through an iterative and reflexive process. The researchers engaged in ongoing discussions to refine meanings and ensure analytical depth.

1. All researchers repeatedly read the transcripts to become familiar with the dataset.

2. Initial codes were generated through a reflexive and interpretative engagement with the data.

3. Patterns of shared meaning were developed into themes through iterative team discussions.

4. Themes were reviewed, defined, and refined before reporting.

Analysis depth was increased using features such as code matrix scanning, theme mapping and memo notes in MAXQDA qualitative data analysis software.

Data collection was conducted by a researcher with experience in qualitative research and training in interview techniques. The interviewer had no prior relationship with the participants, which helped minimise potential influence on responses. Reflexivity was maintained throughout the research process; the researchers were aware of their potential preconceptions and continuously reflected on how their professional nursing backgrounds might influence data collection and interpretation. Reflexive notes were taken during and after the interviews and were considered during the analysis process. To enhance reflexive interpretation, the researchers discussed codes, meanings and developing themes throughout the analytic process. Themes were developed through an iterative and reflexive process, with ongoing discussions among researchers to enhance depth and interpretative rigour. In addition, direct quotations were used to support the findings, ensuring that interpretations remained grounded in the data and enhancing transparency and credibility. The interviews were conducted in Turkish and subsequently translated into English for reporting purposes. The initial translation was carried out by the research team. To ensure accuracy and preserve the original meaning, the translated texts were independently reviewed by two bilingual researchers and any discrepancies were discussed and resolved by consensus. Regarding reflexivity, the interviewer was a faculty member working in the same institution where the study was conducted; however, the interviewer had no direct educational or evaluative relationship with the participants. To minimise potential power imbalance, participants were informed that their participation was entirely voluntary, that their responses would not affect their academic standing and that confidentiality would be strictly maintained. Interviews were conducted in a neutral and supportive environment, and participants were encouraged to express their views freely. The researchers also remained aware of their potential influence on the research process and adopted a reflective approach throughout data collection and analysis. This study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR) guideline (see online supplemental file 2).

Ethical principles

All participants were informed of the purpose, methods and potential contributions of the research. Verbal informed consent was obtained from all participants, and the ethics committee approved this approach given the non-invasive nature of the study. All data were anonymised to protect confidentiality. The study was conducted in accordance with the principles of the Declaration of Helsinki. To minimise potential coercion, participants were informed that participation was entirely voluntary, that they could withdraw at any time without any consequences and that their responses would not affect their academic evaluation.

Data availability statement

The datasets generated and/or analysed during the current study are not publicly available due to the qualitative nature of the data and the risk of participant identification. However, de-identified excerpts of the data may be made available from the corresponding author on reasonable request. Requests will be evaluated in line with ethical approval and data protection requirements.

Results

A total of 18 nursing students participated in the study. Of these, 9 were male and 9 were female. In terms of academic year, 6 students were in the 2nd year, 6 in the 3rd year and 6 in the 4th year. Participants were aged between 19 and 28 years. The demographic characteristics of the participants are summarised in table 1. Most participants reported not having received training in coping with stress during clinical practice. The majority perceived the support provided by clinical instructors or nurses as partially adequate and also reported feeling partially adequate in terms of professional competence during clinical practice. Regarding clinical challenges, participants reported experiencing difficulties either frequently or rarely during their clinical practice. The most commonly reported difficulties included knowledge deficits, physical fatigue, communication issues and insufficient guidance.

Table 1. Demographic and selected characteristics of participants (N=18).

Participant	Gender	Year	Level of feeling professionally adequate during the clinical practice process	Frequency of challenges encountered during clinical practice
1	Male	4	Partially adequate	Frequently
2	Male	4	Adequate	Frequently
3	Male	4	Partially adequate	Frequently
4	Female	4	Partially adequate	Frequently
5	Female	4	Adequate	Rarely
6	Female	4	Partially adequate	Frequently
7	Male	3	Adequate	Rarely
8	Male	3	Adequate	Rarely
9	Male	3	Partially adequate	Rarely
10	Female	3	Adequate	Rarely
11	Female	3	Adequate	Rarely
12	Female	3	Inadequate	Frequently
13	Male	2	Partially adequate	Rarely
14	Male	2	Partially adequate	Frequently
15	Male	2	Partially adequate	Rarely
16	Female	2	Partially adequate	Rarely
17	Female	2	Partially adequate	Rarely
18	Female	2	Partially adequate	Frequently

Analysis of the interview data generated 2 themes, 5 subthemes and 35 codes related to the difficulties nursing students experienced during clinical practice and their suggested solutions. The theme ‘Challenges Encountered in Clinical Practice and Experienced Emotions’ includes the subthemes ‘Challenges Encountered’ and ‘Emotions Felt Towards Challenges’. The theme ‘Causes of Problems Experienced in Clinical Practice, Recommendations and Coping Strategies’ includes the subthemes ‘Causes of Difficulties’, ‘Recommendations’ and ‘Coping Strategies’ (table 2).

Table 2. Themes, subthemes, and codes obtained from the interviews.

Theme	Subtheme	Code	Participant	n
Challenges and emotions experienced in clinical practice	Challenges encountered	Inadequacy in clinical decision-making	1,2,3,4,5,7,8,9,10,11,12,13,14,16,17,18	16
		Time management	1,2,3,4,5,6,7,8,9,10,12,13,14,17,18	15
		Insufficient internship duration	2,3,4,5,7,8,10,12,13,14	10
		Insults from the patient or/patient’s relatives	1,2,5,8,9,10,11	7
		Feeling undervalued/disrespected	3,4,7,10,12,15	6
		Instructors’ hurtful words/attitudes	3,4,7,12,16	5
		Insufficient psychomotor skills	6,10,11,15,18	5
	Feelings perceived in response to difficulties	Sense of inadequacy	1,3,5,7,9,10,11,12,13,16,18	11
		Low motivation	2,3,4,5,6,7,8,10,12,13,16	11
		Low self-confidence	1,5,6,8,11,12,16,18	8
		Fear	1,3,4,5,6,8,11,18	8
		Stress/sadness	4,5,7,8,9,11,16	7
		Feeling of worthlessness	1,2,4,6,8,9,10	7
		Decreased professional commitment	6,7,12,16,17,18	6
Causes of problems experienced in clinical practice, recommendations and coping strategies	Reasons for difficulties	Insufficient instructor support	1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18	18
		Intern bias	1,3,4,5,7,8,10,11,13,15,16,17	12
		Lack of knowledge	1,3,4,9,11,13,14,16,17,18	10
		Concern about incorrect application	3,4,6,8,9,10,13,14,16,17,18	11
		Insufficient instructor training	2,4,6,3,9,11,12,15,18	9
		Insufficient laboratory training	3,8,9,10,12,15,16,18	8
		Inadequate nursing support	2,6,8,10,12,14,16,18	8
		A large number of students	5,6,8,11,13,14,18	7
		Lack of self-confidence	2,4,5,11,17	5
	Recommendations	Instructors should be supportive/patient	2,3,4,5,7,8,10,12,14,15,16,18	12
		Active participation of instructors in the application	2,6,7,9,11,12,14,15,16,17	10
		Increasing laboratory hours	3,8,9,10,12,15,16,18	8
		The number of instructors should be increased	2,4,6,12,15,18	6
		The number of students should be reduced.	2,5,6,11,13,18	6
		Method diversity in theoretical courses	8,11,12,13,16,17	6
		Encouragement from clinical supervisors	7,10,11,12,16	5
	Coping strategies	Getting support from friends	1,7,9,10,12,14,16,18	8
		Efforts to establish effective communication	2,4,5,7,8,9,17	7
		Increasing knowledge level	3,6,7,8,11,17	6
		Receiving support from a clinical nurse	1,6,9,14,18	5
		Self-affirmation	2,7,8,17,18	5

Subtheme 1: challenges encountered

Seven codes were identified for the subtheme of challenges encountered: ‘inadequacy in clinical decision-making’, ‘time management’, ‘insufficient internship duration’, ‘insults from patients/patient relatives’, ‘feeling inadequate/belittled’, ‘communication problems’, ‘harsh words/attitudes from instructors’ and ‘inadequate psychomotor skills’ (table 2). The biggest challenge students face in clinical practice is their inadequacy in clinical decision-making. Students stated that when they encounter a patient, they experience hesitation about what type of care to provide or whether the care they provide will be effective. Additionally, another problem commonly experienced by students is their inability to manage time effectively during clinical practice. Students reported difficulty managing time effectively due to the frequent rotation schedules and the large number of students in the practice groups. They stated that they were unable to meet patient needs during their limited internship periods adequately. Furthermore, students emphasised that they experienced difficulties due to being perceived as inadequate, being belittled by clinical instructors or nurses, the harsh words and attitudes of instructors and their insufficient psychomotor skills. Some interview examples related to the codes in subtheme 1 are as follows:

P1: After taking the patient’s medical history, I hesitate before performing even the simplest care; therefore, I usually cannot perform care without consulting nurses.

P3: Our instructors often see us as inadequate… I was unsuccessful when I first tried to measure blood pressure. At that moment, our instructor gave me a discouraging response. His words deeply affected me, and for a long time after that, even during my internship, I couldn’t bring myself to measure blood pressure with confidence.

P8: When opening a vein, I always want to do it correctly the first time. Because if I can’t, it will hurt the patient, and I may face the patient’s reaction. Also, being an intern creates a separate pressure in itself.

P18: I often spent my time filling out forms or writing care plans instead of caring for patients. So there wasn’t enough time left for real practice. Additionally, it was challenging to take an active role during treatment due to the large size of the internship groups. I usually asked the nurses for help with planning my time and divided the work with my friends, but that wasn't always enough.

Subtheme 2: feelings experienced regarding difficulties

Seven codes were identified for the subtheme of feelings towards difficulties: ‘feeling of inadequacy’, ‘low motivation’, ‘lack of self-confidence’, ‘fear’, ‘stress/sadness’, ‘feeling of worthlessness’ and ‘weakening of professional commitment’ (table 2). Students emphasised that the most intense emotions they felt due to the difficulties they experienced during clinical practice were feelings of inadequacy and low motivation. Students stated that they believed their self-confidence had been shattered because they felt inadequate, and that they experienced fear when performing any care procedure or when they thought they might harm the patient. They stated that these feelings caused them stress and sadness, that they felt worthless due to the reactions of their instructors and nurses and that their belief in and commitment to the profession weakened. Some interview examples related to the codes in subtheme 2 are as follows:

P5: Sometimes when I experience difficulties during practice, my morale inevitably drops psychologically, and my motivation decreases. We get reactions from patients like, ‘You’re just a student, don’t even try.’ This negatively affects our self-confidence.

P9: The fact that our instructors don’t spend enough time with us or aren’t there for us generally makes us feel inadequate. I need support or guidance on some issues, but when I don’t get it, I feel inadequate. This situation naturally upsets me.

P11: I hesitate to think, ‘What if I do this procedure and something goes wrong, or I do something wrong, or I harm the patient?’

P17: At first, I tried to fight it. I wanted to change things. But after a while, you become tired, fed up, and lose hope. This gradually pushes me toward apathy. I lose the desire to go to the hospital, my motivation completely drops.

Subtheme 3: causes of difficulties

Nine codes related to the subtheme of the cause of difficulties: ‘insufficient instructor support’, ‘intern bias’, ‘lack of knowledge’, ‘fear of making mistakes’, ‘instructor inadequacy’, ‘insufficient laboratory training’, ‘insufficient nurse support’, ‘large number of students’ and ‘lack of self-confidence’ (table 2). All students stated that the main reason for the difficulties they experienced in clinical practice was the lack of support from the instructors accompanying them in the clinic. In addition, students cited the prejudice of patients and nurses towards interns, lack of knowledge and fear of making mistakes as reasons for the difficulties they experienced. Among other reasons, students listed the insufficient number of instructors, inadequate laboratory training, insufficient support from nurses, the large number of students in the clinic and classroom and a lack of self-confidence. Some interview examples related to the codes in subtheme 3 are as follows:

P2: Our instructors are not there for us when we encounter problems. No matter what goes wrong at the hospital, nurses are always quick to blame us, saying, ‘You’re a student, you’ll make mistakes.’ There are also not enough instructors, so they can’t keep up with us and can’t be very helpful.

P4: Especially looking at first-year students as if they ‘don’t know anything’ really lowers motivation. Apart from that, we sometimes experience the following problem during practical training: Due to a lack of theoretical knowledge, we can’t feel confident during the practical training.

P13: The number of students needs to be reduced because when the capacity is too high, some students don’t even get to touch a patient that day. I think the real problem is that students are always pigeonholed as ‘interns’. This generally creates a prejudice.

P15: I think the reason students struggle is that nursing education lacks enough well-equipped instructors who can demonstrate theoretical knowledge through practical application while supervising students. The duration of lab classes is also too short.

P16: We had to move up to the next grade without being able to practice properly. In our time, we never got to use the simulation lab; we never had that opportunity.

Subtheme 4: recommendations

Seven codes for the recommendations subtheme: ‘instructors should be supportive/patient’, ‘active participation of instructors in practice’, ‘increase in laboratory hours’, ‘increase in the number of instructors’, ‘decrease in the number of students’, ‘methodological diversity in theoretical courses’ and ‘encouragement from clinical supervisors’ (table 2). Students made essential recommendations to overcome the difficulties they experienced in clinical practice. In particular, students recommended that instructors be more supportive during practice, be patient with them and actively accompany students during their practice sessions. Additionally, students suggested increasing laboratory practice hours to overcome the difficulties they encountered, particularly with psychomotor skills. They also proposed increasing the number of instructors, as some clinics did not have faculty members present during practice sessions, and reducing the number of students in practice groups and classes. They also emphasised the use of different teaching methods to increase the retention of theoretical knowledge and the encouragement of clinical supervisors during practical sessions. Some examples of interviews related to the codes in subtheme 4 are as follows:

P6: First of all, the number of students must be reduced. When there is an extensive group of students in a service, both learning efficiency decreases, and not everyone gets enough opportunity to practice. Also, there must be an instructor in every clinic. If the instructor stands next to the student, they can demonstrate the basic practices one-on-one.

P7: I think instructors should be a bit more lenient and understanding towards students. Nurses can also encourage students by trusting them more and giving them independent responsibilities.

P10: First of all, students should not go on internships before fully learning the practices. Laboratory classes should definitely be increased.

P12: If our teachers value us, everyone around us will look at us differently. This value should not remain just words. Communication should be conducted in the same way.

P16: In theoretical classes, small role-plays or case studies could sometimes be done. Practical hours and laboratory work hours could be increased. This way, we can more easily transfer what we learn in theory to practice.

Subtheme 5: coping strategies

Five codes were identified for the coping strategies subtheme: ‘seeking support from friends’, ‘attempting to communicate effectively’, ‘increasing knowledge level’, ‘seeking support from clinical nurses’ and ‘self-persuasion’ (table 2). Students stated that they primarily sought support from friends to cope with the difficulties they experienced in clinical practice. In addition, students reported using coping strategies such as trying to communicate effectively, working harder to increase their knowledge level, seeking support from clinical nurses and self-encouragement. Some interview examples related to the codes in subtheme 5 are as follows:

P1: If I can’t figure something out, I try to get support from my internship friends. Since the patients and their relatives know I’m a student, they often don’t allow me to provide care. In this case, I attempt to persuade them through communication. If I’m not successful, I get support from clinical nurses.

P3: When I feel inadequate in a certain area, I research it and ask questions as much as I can. There have also been times when I’ve sought support from my instructors.

P8: To cope with stress, I motivate myself. I tell myself, ‘You can do it, you've already learned this, you’ve done it before.’ Even if I can’t do it, I remind myself that it’s not the end of the world. This way, I try to control my anxiety by giving myself confidence.

P14: I’m afraid of doing something wrong. That’s why I often work alongside nurses or consult them whenever possible.

Discussion

Findings were interpreted through a reflexive thematic analysis approach.

Subtheme 1: challenges encountered

The clinical practice process is a multidimensional learning environment that shapes nursing students’ professional identity development as they translate their theoretical knowledge into practice. Findings show that students struggle due to inadequacies in clinical decision-making, time management difficulties, short internship periods, negative patient and instructor attitudes, communication problems and psychomotor skill deficiencies. This situation points to the multilayered nature of the stress students encounter at the cognitive, emotional and social levels. Inadequacy in clinical decision-making is the most frequently mentioned difficulty by students and is directly related to knowledge gaps and self-efficacy levels. Al-Zayyat and Al-Gamal noted that decision-making confidence decreased in students experiencing role ambiguity, while Korkut stated that indecisiveness weakened learning motivation.^{1 6} The findings indicate that unsupported students tend to become passive learners. Time management difficulties are also an important theme. Students stated that they were unable to provide adequate patient care due to the excessive workload and large groups. This finding has also been noted in the studies by Arkan et al and Pimmer et al.^{2 14}

Students’ inability to complete planned initiatives limits their learning opportunities. The short internship period is another factor that limits the development of psychomotor skills. Aryuwat et al found that short-term clinical placements reduced students’ self-efficacy perceptions, while Hashemi and Maghzi emphasised that self-efficacy plays a mediating role in clinical success.^{5 15} The findings show that students internalise their lack of practical experience as a ‘feeling of inadequacy’. Negative social interactions in the clinic, such as belittlement, prejudice and insults from patients and their relatives, also create feelings of worthlessness in students. Mathisen et al noted that students feel excluded due to their ‘intern identity’, while Tadesse et al stated that empathetic instructor guidance may increase psychological safety.^{7 8} Findings show that professional belonging is closely related to social acceptance. Instructors’ judgmental and harsh attitudes lead to students’ loss of self-confidence. Algunmeeyn et al reported that harsh criticism may reduce clinical participation. This suggests that instructor behaviour may play an important role in students’ learning.¹⁶ Inadequacy in psychomotor skills and fear of making mistakes were also frequently mentioned. Oanh et al found that safe simulation environments increased students’ confidence in decision-making, while Lim et al found that peer mentoring systems improved psychomotor skills and reduced fear of mistakes.^{10 11}

Overall, the findings indicate that nursing students become entrapped in a cycle of stress due to knowledge gaps, emotional pressure and a lack of social support in clinical settings. Importantly, this study extends existing knowledge by demonstrating that these factors do not operate independently but interact dynamically, reinforcing one another and influencing students’ agency and engagement in clinical learning environments. These findings are consistent with recent international literature on clinical learning environments, psychological safety and supervision in nursing education. Beyond confirming previous literature, these findings highlight how the interaction between emotional burden, instructor behaviour and clinical hierarchy shapes students’ learning trajectories and sense of professional identity. However, elements such as structured feedback, an empathetic instructor approach, peer support and simulation-based education mitigate these adverse effects. These results are consistent with those of Mohamed et al and Hansen et al, which suggest that supportive learning environments can reduce stress levels and increase professional competence.^{17 18} These findings suggest that learning in clinical settings is not only a technical process but also a socially and emotionally constructed experience shaped by power dynamics and perceived competence. In this sense, the study provides a more integrative understanding of how emotional, relational and structural factors jointly shape students’ learning experiences, rather than examining these dimensions in isolation.

Subtheme 2: feelings experienced regarding difficulties

The clinical practice process is the most common source of feelings of inadequacy among nursing students. Participants indicated that, in particular, insufficient guidance from instructors and being left alone during practice increased their feelings of ‘inadequacy’. This finding is consistent with the study by Arkan et al, which revealed a relationship between high stress and low clinical success in students with low self-efficacy.² Hashemi and Maghzi also reported that self-efficacy mediates the relationship between theoretical knowledge and clinical performance, and that students may exhibit a tendency toward ‘learned helplessness’ in the absence of adequate guidance.¹⁵ Low motivation developed in relation to students’ perceptions of fatigue, uncertainty and repeated failure. Participants stated that they ‘lost the desire to fight’ in environments where they were not supported or only criticised. This situation parallels the meta-analysis by Vo et al, which found that stress and burnout levels are associated with a loss of motivation.¹⁹ Zhang et al emphasised increased stress and decreased professional commitment among students after the pandemic.²⁰

A large proportion of students reported experiencing a lack of self-confidence, which stemmed from both feelings of inadequacy and the dismissive attitudes of instructors or clinical nurses. Mathisen et al stated that students often encounter stigmatising expressions, such as ‘you don't know’ or ‘you can’t do it’, which can lead to a loss of self-confidence.⁷ The feeling of fear, which is frequently emphasised in the findings, is particularly related to the anxiety of making mistakes and harming patients. Al-Zayyat and Al-Gamal found that fear of making mistakes reduced students’ participation in practical training; Oanh et al showed that simulation-based environments significantly reduced this fear.^{1 11} Students reported experiencing stress, sadness and feelings of worthlessness in the face of harsh attitudes from instructors and adverse reactions from patients’ relatives. Tadesse et al stated that empathetic instructor behaviour may increase students’ psychological safety; Reeve et al indicated that peer support plays a protective role in coping with stress.^{8 13} Some participants reported that their negative experiences ultimately weakened their professional commitment. ‘Reluctance’ and ‘hopelessness’ were prominent among students who experienced constant stress and feelings of worthlessness in the clinical setting. These findings support the studies by Zhang et al, which revealed that a lack of support and stress reduce the intention to continue in the profession, and by Aryuwat et al, which showed that emotional exhaustion slows down professional identity development.^{3 5}

Subtheme 3: causes of difficulties

The difficulties experienced by students during the clinical training process are found to be rooted in a combination of structural, relational and individual deficiencies. The vast majority of participants defined the most fundamental difficulty as ‘insufficient instructor support’. Arkan et al stated that the lack of guidance weakens students’ clinical decision-making skills and prompts them to adopt a passive learner’s position.² The participants’ statements that ‘our instructor was not there for us, we could not get help’ are parallel to these findings. The issue of instructor support stands out not only as a quantitative but also as a qualitative deficiency. Participants reported complaining about instructors’ ‘unapproachable’ or ‘harsh’ attitudes. Tadesse et al demonstrated that a patient and empathetic instructor approach may enhance self-efficacy, whereas critical and distant attitudes hinder psychological safety.⁸

Another important reason is the intern bias students are exposed to in the clinic. Findings reveal that students are labelled as ‘ignorant’ or ‘incapable’ by both nurses and patients/patient relatives. This situation weakens their sense of professional belonging and may reduce their motivation. Mathisen et al stated that reducing students to their ‘intern identity’ decreases their professional commitment.⁷ Dias et al showed that low levels of social acceptance make it challenging to cope with stress. Participants also frequently mentioned a lack of knowledge and fear of making mistakes.⁹ This situation has been linked to the disconnect between theory and practice. Hashemi and Maghzi noted that students with low knowledge levels remain passive due to a fear of making mistakes.¹⁵ Akyüz E, Ergöl emphasised that a lack of knowledge may lead to a loss of self-confidence.²¹

Another source of difficulty is the inadequacy of laboratory training and the large size of student groups. Participants stated that they could not use the simulation laboratory sufficiently and that active participation decreased in crowded environments. Aryuwat et al reported that large groups reduced opportunities for individual feedback, while Berhe and Gebretensaye reported that inadequately equipped clinical settings increased learning stress.^{5 22} Finally, the lack of nursing support created a role model deficit among students. Tadesse et al stated that supportive nursing attitudes may play an important role in clinical adaptation; Ahmari Tehran et al indicated that a lack of orientation may lead to role ambiguity.^{8 23} Students’ lack of self-confidence becomes both a cause and a consequence of these factors. Lim et al noted that peer mentoring systems break this cycle and significantly increase students’ self-confidence.¹⁰

Subtheme 4: recommendations

Recommendations addressing the difficulties students experience in clinical practice reveal important areas for improvement at both the educational and structural levels. Participants emphasised the need for instructors to adopt a supportive, patient and empathetic approach. Students stated that the active presence of instructors in the field during practice sessions boosted both morale and motivation to learn. Tadesse et al also showed that an empathetic attitude may increase students’ self-efficacy and psychological safety.⁸ The direct participation of instructors in clinical practice may be an important factor in enhancing students’ self-confidence and decision-making skills. Arkan et al and Aryuwat et al noted that the presence of instructors may reduce fear of making mistakes and may increase motivation to learn.^{2 5} Therefore, the students’ suggestion that ‘there should be an instructor in every clinic’ is not only a pedagogical necessity but also may be important for the development of professional identity and may support safer clinical learning processes

At a structural level, students cited crowded clinical groups, limited instructor availability and insufficient opportunities for feedback as the most significant obstacles. Ahmari Tehran et al and Berhe and Gebretensaye reported that student density may increase learning stress and may reduce the quality of guidance.^{22 23} Hashemi and Maghzi emphasised that reducing the number of students per instructor directly may improve clinical performance and self-efficacy.¹⁵ Another recommendation is to increase the use of laboratory and simulation applications. Students stated that insufficient laboratory experience before practice is at the root of their psychomotor skill deficiencies. Oanh et al noted that simulation-based education may reduce the fear of making mistakes.¹¹ Lim et al stated that laboratory work supported by peer mentoring strengthens clinical success and stress management.¹⁰

Furthermore, students recommended the widespread use of active learning methods (such as case studies, role-playing and group work) in theoretical courses. Mohamed et al reported that these methods increase professional commitment and learning motivation.¹⁷ Ultimately, students emphasised the importance of fostering a culture of trust and acceptance in the clinic. The statement, ‘If our teachers value us, everyone will look at us differently,’ highlights the emotional aspect of acceptance. Tadesse et al demonstrated that students working in a trusting environment experience less fear of making mistakes.⁸ In contrast, Dias et al found that a supportive approach may reduce stress and may increase professional satisfaction.⁹

Subtheme 5: coping strategies

The clinical practice period tests nursing students’ stress-coping and emotional resilience skills, as well as their technical skills. Peer support, the strategy most frequently used by students, serves as an essential buffer for both emotional relief and problem-solving. Reeve et al noted that peer support may reduce stress levels, may increase feelings of trust and is crucial for sustaining learning motivation.¹³ Tadesse et al reported that open and empathetic communication may increase self-confidence, while Aryuwat et al reported that these skills break the ‘intern bias’ and increase acceptance.^{5 8}

The behaviour of increasing knowledge reflects students’ intrinsic motivation and responsibility for learning. Hashemi and Maghzi stated that individual learning efforts strengthen self-efficacy and reduce clinical anxiety.¹⁵ Akyüz and Ergöl indicated that a lack of knowledge is the leading cause of loss of self-confidence.²¹ Some students mentioned receiving support from clinical nurses as an effective strategy for managing their mental health. Tadesse et al reported that nursing support accelerates professional identity development and may reduce fear of making mistakes.⁸ The Practice Education Facilitator model proposed by Mathisen et al also supports this, suggesting a strong mentoring relationship in terms of both knowledge and emotional support.⁷

Another coping strategy expressed by students is the use of self-suggestion and cognitive restructuring strategies. Participants attempted to maintain emotional balance in stressful situations through positive self-talk, prayer and the belief that ‘making mistakes is a natural part of learning’. Al-Zayyat and Al-Gamal state that such strategies are among the most common methods of stress management, while Dias et al note that faith-based approaches reduce anxiety, especially in environments with low perceived control.^{1 9} When all findings are evaluated together, it is evident that students benefit from both internal (self-affirmation, knowledge enhancement, emotional balance) and external (friends, nurse, instructor support) resources in coping with difficulties. This aligns with Vo et al’s ‘integrative coping model’, which suggests that effective stress management is achieved through the balanced use of individual awareness and environmental support networks.¹⁹ It should also be considered that some of these findings may be shaped by the specific institutional and cultural context of the study setting, particularly hierarchical relationships and student–instructor ratios. Nevertheless, similar patterns reported in the literature suggest that certain aspects may be transferable to other nursing education contexts.

Limitations of the study

This research should be evaluated within certain methodological and contextual limitations. As the study was conducted with nursing students from a single university, the findings cannot be generalised to other institutions or cultural contexts. The relatively homogeneous participant group may also limit the diversity and representativeness of the findings. In addition, the data are based on participants’ self-reported experiences, which may be influenced by social desirability and recall bias. Furthermore, as the analysis relies on the researchers’ interpretation, this may have influenced the interpretation of the findings.

As the study captured participants’ experiences at a single point in time through one-off interviews, changes over time could not be examined. Longitudinal studies may provide a more comprehensive understanding of how clinical experiences evolve. Moreover, the study reflects only students’ perspectives and does not include those of instructors, nurses or patients, which may limit a more holistic understanding of the clinical learning environment. Environmental and contextual factors such as clinical resources, laboratory access, student–instructor ratios and rotation duration were also not controlled and may have influenced students’ experiences and coping strategies.

Despite these limitations, the study offers valuable insights into the challenges nursing students encounter in clinical practice, as well as their emotional responses and coping strategies. The findings may contribute to improving clinical education by informing approaches related to supervision, psychological support, mentoring and simulation-based learning. Additionally, the relatively short duration of interviews (15–30 min) may be considered a limitation, as longer interviews might have provided more in-depth and nuanced data.

Clinical relevance

This research provides valuable insights into the development of clinical education processes by examining the challenges nursing students encounter during clinical practice, their emotional responses and their coping strategies. The findings suggest that students may experience decreases in self-confidence, motivation and decision-making skills when they do not receive adequate support and guidance. This situation may have implications for patient safety and quality of care. The findings suggest that strengthening empathetic communication, effective guidance and structured mentoring systems may be important in clinical education environments. Supportive, patient and accessible instructor attitudes may contribute to the development of students’ self-efficacy and professional identity.

Furthermore, increasing simulation-based learning opportunities and laboratory applications, reducing student numbers and strengthening one-on-one feedback opportunities may support the development of clinical skills. The findings may also have implications for the restructuring of clinical practice in nursing education, suggesting that supportive, safe and learning-oriented clinical environments may play an important role in enhancing students’ stress management skills, clinical competence and the quality of patient care. In this respect, the study may contribute to strengthening quality, safety and professional development in nursing education and may support improvements in patient care.

Conclusions and recommendations

This qualitative study revealed that nursing students experience multifaceted challenges at cognitive, emotional and structural levels during clinical education. The findings highlight that factors such as limited instructor support, large class sizes, insufficient practice opportunities and negative interpersonal interactions are associated with reduced self-confidence, motivation and professional commitment. The results suggest that clinical learning is shaped not only by the acquisition of technical skills but also by the quality of social interactions and the learning environment. Participants’ accounts indicate that supportive instructor behaviours, structured guidance and opportunities for practice may facilitate students’ learning experiences and engagement. Based on students’ perspectives, several implications can be considered. These include increasing instructor presence during clinical practice, reducing student group sizes, strengthening feedback mechanisms and expanding laboratory and simulation-based training opportunities. In addition, fostering respectful, supportive communication in clinical settings may contribute to a more psychologically safe learning environment. At the institutional level, initiatives focused on students’ stress management, self-efficacy and psychosocial support may enhance their clinical learning experiences. Overall, this study contributes to the literature by providing an in-depth understanding of how nursing students experience clinical practice and how these experiences shape their learning processes, engagement and professional development.

Data availability statement

Data are available upon reasonable request.