Challenges to clinical nursing education in the Middle East and North Africa: a systematic review and meta-synthesis of qualitative studies

Abstract

Background

Clinical learning is a vital component of nursing education, enabling the development of technical and non-technical skills. However, clinical training faces several challenges. This study aims to synthesize the main challenges that hinder clinical nursing education in the Middle East and North Africa.

Methods

A systematic review and meta-synthesis of qualitative studies conducted following the PRISMA guidelines. PubMed, Scopus, Web of Science, and ScienceDirect databases were searched for studies published in English or French from 1999 to 2024 in the MENA region. Two researchers independently assessed the retrieved papers using the Consolidated Criteria for Reporting Qualitative Research. Findings from primary studies were analyzed thematically using NVivo software following the Braun and Clarke’s framework.

Results

Twenty-six studies were reviewed. A thematic analysis of the findings from the primary studies revealed four main themes synthesizing the main challenges faced by nursing students in clinical learning: (1) Unsupportive clinical environment, (2) Organizational and planning shortcomings, (3) Ineffective supervision and evaluation, and (4) Personal factors and students’ attributes.

Conclusions

Clinical education in the MENA region faces several challenges that could compromise the training of future nurses and, in turn, potentially affect the quality and safety of the care provided. It is recommended to strengthen academic and clinical partnerships, optimize mentoring, and upgrade clinical infrastructure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04759-w.

Background

In a changing environment and dynamic healthcare systems, nurses must be highly prepared to perform their duties [1]. To provide high-quality, safe care, nurses require education and training that aligns with global nurse education standards [2].

Nursing education combines theoretical courses with clinical training, the latter occupying a central place, accounting for 50% of the total program hours [3, 4]. Clinical training is based on Kolb’s experiential learning model [5]. Two fundamental principles govern experiential learning: contextualization in an authentic learning environment and supervision. Authentic experiences allow students to practice on real patients, understand the complexity of care, reason, and make decisions, thereby building their knowledge [6, 7]. The practical learning process requires mentoring; students learn through observation, imitation under an expert’s guidance (clinical nurse, preceptor, or supervisor) [5, 8, 9].

Experiential learning occurs in complex, uncontrollable clinical learning environments (CLEs) [1, 10]. However, several factors related to the clinical environments, curricula, organization, and clinical supervision could negatively influence students’ clinical learning [11, 12].

Relational and organizational obstacles documented by Jafarian (2020) reflect the complexity of CLE [13]. Lack of support and relational shortcomings in the clinical setting were among the key challenges faced by Egyptian and Saudi nursing students [14].

Clinical supervision is an integral part of clinical training; clinical instructors coordinate with clinical settings, provide supervision, and participate in student evaluation [15–17]. However, previous studies reported some concerns about a lack of pedagogical, technical, and non-technical skills among clinical instructors [18, 19]. Amin (2022) highlighted organizational and planning difficulties, particularly the overcrowding of departments due to the large number of students, which limits learning opportunities and reduces the quality of supervision [20].

Nursing education systems in the Middle East and North Africa (MENA) region are heterogeneous, particularly in terms of governance, regulation, and curriculum. For the purpose of this review, the MENA region was defined operationally according to the regional grouping presented in annex 1 p. 129 of the WHO State of Nursing in the World 2025 report by combining the North Africa and Middle East subgroups [21]. This region consists of 21 countries, 25% of which have not yet established mechanisms for accrediting nursing education, this percentage remains exceptionally high compared to other regions, where the percentage of countries that have not integrated accreditation standards for nursing education does not exceed 9%. Over the last decade, several countries, particularly in North Africa, have moved towards academizing nursing education by transitioning to university degrees (bachelor’s, master’s, doctorate) [4, 14, 19]. However, some countries still maintain three-year technical training programs in nursing alongside bachelor’s degree programs [16, 22]. This reflects the incomplete standardization of nursing education in the MENA region. The diversity of training programs and institutions leads to competition and overcrowding in clinical placements, undermining the quality of supervision and reducing clinical learning opportunities.

The same WHO report highlights disparities in governance and nursing faculty qualifications across countries in the MENA region [21]. This shows variability in training management across countries, which can negatively affect coordination and clinical supervision strategies. Recent studies conducted in certain countries in the region have confirmed several organizational, structural, and human constraints that hinder the quality of nursing students’ training [1, 10, 19].

Countries in the MENA region are experiencing population growth, which is increasing the demand for healthcare. This unstable region is also experiencing successive, prolonged crises, which are putting pressure on training systems. Despite efforts to improve nursing training, several gaps persist [23]. Research on nursing education in this region is scattered or untranslated, which limits the development of a comprehensive regional perspective. This review will help develop a global vision by providing a deep understanding of the main shortcomings and major challenges affecting the clinical education systems. The synthesis and interpretation of data extracted from studies examining aspects of these barriers would provide a database that policymakers can use to define relevant actions and strategies.

This study aims to synthesize challenges faced by nursing students in clinical education in the MENA region.

Materials and methods

Study design

A qualitative systematic review and meta-synthesis were conducted. The research protocol was established in accordance with the PRISMA guidelines [24] and was registered in PROSPERO (CRD420251002337). Available at: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251002337.

Eligibility criteria

The PICo strategy was used to determine the inclusion and exclusion criteria [25].

Inclusion criteria

• Population (P): Undergraduate nursing students, clinical instructors, and nurses.

• Phenomenon of interest (I): only qualitative studies focusing on challenges or obstacles faced in clinical training.

• Context (Co) clinical learning/training of nursing students in the clinical setting located in countries belonging to MENA region. “Clinical setting” refers to any real-world environment in which nursing students carry out their clinical learning activities, including hospitals, primary healthcare centers, and any other healthcare facilities used for clinical placement.

• Article type: only primary qualitative studies published in English or French between 1999 and December 2024.

Exclusion criteria

• Quantitative studies or those using a mixed methods design,

• Studies focusing on medical or midwifery students’ perspectives,

• Studies reporting challenges related to the COVID-19 context.

Information sources

The electronic databases of PubMed, Scopus, Web of Science, and ScienceDirect were searched for original papers published within the last 25 years (January1999 to December 2024). The last access to databases was on March 10, 2025.

Search strategy

Identification of keywords and combinations used in databases was carried out by two researchers. We combined the following Mesh terms and Free words: (“student nursing” OR “trainee” OR “Tutee” OR “Mentoree” OR “Instructor” OR “Educator” OR “Mentor” OR “Preceptor” OR “Nurse”) AND (“Challenge” OR “Barrier” OR “Problem” OR “Difficultie”) AND (“clinical education” OR “clinical teaching” OR “clinical learning” OR “clinical practice” AND (Qualitative)) OR “Grounded Theory” OR “Phenomenology” OR “Hermeneutics”)). The search strategy was refined using filters for publication year (from 1999 to 2024), language (French and English), and countries belonging to the operationally defined MENA region (Egypt, Morocco, Tunisia, Sudan, Libya, Somalia, Jordan, Afghanistan, Iran, Pakistan, Bahrain, Saudi Arabia, Lebanon, Djibouti, Iraq, Yemen, Kuwait, Qatar, Oman, Syria, and the United Arab Emirates) (Additional file 1).

Study selection

All research articles retrieved from the databases were imported into Mendeley Reference Manager to remove duplicates. Two independent authors reviewed studies by title and abstract, which reduced the number of included studies. Articles were further assessed for full-text compliance with the inclusion and exclusion criteria (Additional file 2). Disagreements between the authors were discussed with a third author to reach a consensus.

Quality assessment

Two authors independently assessed the quality of each included study using the Consolidated criteria for reporting qualitative research (COREQ) framework [26], which consists of 32 items grouped into three domains (Research team and reflexivity, Study design, Data analysis and reporting). In a second step, the two authors compared and discussed the evaluation’s results. Disagreements were discussed with a third author to reach a consensus.

Data extraction

The following data were extracted from the selected articles: authors, year, study aim, methodology, sample size, participants profile (referred to the category of the participant in each study such as students, nurses and clinical instructors), data collection method, analysis method, and key findings.

Data synthesis

A thematic analysis approach was employed following Braun and Clarke’s framework [27]. Findings from primary studies were reviewed line by line for a first familiarization with the data. Key results were further coded and grouped to derive sub-themes, which were then synthesized into main themes. This process was conducted collaboratively by two researchers. Disagreements were discussed with a third researcher to achieve consensus.

Reporting bias assessment

Not applicable.

Results

Study selection

A total of 1669 studies were identified from databases, of which 165 duplicates were removed. Based on the defined inclusion and exclusion criteria, we screened 1504 articles, excluded 1408 on title and abstract review, and 70 on full text review (Additional file 2). Finally, 26 studies were included for data extraction and thematic analysis. The PRISMA flowchart is shown in Fig. 1.

Fig. 1.

PRISMA flow-chart of the study selection process

Study characteristics

The review identified 26 studies published from January 1999 to December 2024 in 06 countries: Iran (n = 20) [28–35, 37–48], Jordan (n = 2) [18, 36], Oman (n = 1) [49], Morocco (n = 1) [50], Saudi Arabia (n = 1) [22], Emirates Arabs unis(n = 1) [16].

The included studies involved 705 participants, including 631 nursing students, 67 instructors, and 7 clinical nurses. As shown in Table 1, all included studies employed a qualitative research design: five used a phenomenological research method, two employed the grounded theory approach, and 19 used the conventional qualitative method. Data were collected using various methods: focus group (n = 4), individual semi-structured interviews (n = 20), both (focus group and individual interviews) (n = 1), and reflective journal writing (n = 1). Sample sizes ranged from 7 to 90 participants. Regarding sample profiles, 16 studies included only nursing students, seven studies were conducted among students and instructors, and the remaining three studies included nursing students, instructors, and clinical nurses.

Table 1.

Characteristics of the included studies

Author(s), year, and location	Research aim	Methodology	Participants and sample size	Methods of data collection	Methods of data analysis	Main findings
Ahmadi et al. [28] 2020 Iran	To examine the challenges of internship education faced by nursing students.	Qualitative design	Nursing students (n = 8)	Semi-structured interviews	Content analysis using MAXQDA-10	Insufficient preparation in pre-Internship Unsuitable clinical environment Negative professional interactions Ineffective Faculty Observers Planning shortcomings Subjective Evaluation Identity Ambiguity and Fear
Baraz et al. [43] 2015 Iran	To determine the learning challenges of nursing students in clinical environments	Qualitative design	Nursing students (n = 18)	Semi-structured interviews	Content analysis	Incompetency of instructors Distorted process of evaluation Communication barriers Lack of diversity in clinical cases Stressful psychosocial environment
Dadgaran et al. [29] 2013 Iran	To describe the role of sociocultural factors in the clinical learning of nursing students.	Qualitative design	Nursing students. (n = 21)	Semi-structured interviews	Content analysis using MAXQDA 2010	Public attitude toward nursing profession Suppressive familys’attitude lack of nurses’ cooperation A large number of students Fear
Farzi et al. [30] 2018 Iran	To explain the clinical education problems and strategies to improve it through the experiences of the nursing students and clinical educators.	Qualitative design	-Nursing students (n = 35) -clinical educators (n = 5)	Semi-structured interviews	Content analysis- (Graneheim and Lundman approach)	Fear and low self-confidence Insufficient readiness of students Incompetence of the instructors Unpleasant clinical atmosphere Discrimnation
Gaeeni et al. [31] 2021 Iran	To understand the experiences of nursing students and clinical instructors and explain the challenges of clinical education in nursing.	Qualitative design	-Nursing students (n = 25) -Clinical instructors (n = 8)	Semi-structured interviews	Content analysis using the MAXQDA-10	Ineffective teaching methods Lack of confidence Focus on routine-oriented work Lack of support Nurses superficial knowledge Ineffective educational planning
Ghorbanzadeh et al. [44] 2023 Iran	To identify the stressors of nursing students in the clinical environment	Qualitative design	Nursing students (n = 16)	Semi-structured interviews	Content analysis (inductive approach of Aloo and Kingas)	Fear Planning difficulties Uselessness of internship courses Interactions with staff and patients Instructors’ attributes.
Jahanpour et al.[32] 2016, Iran	To explore factors that can hinder nursing students’ clinical learning	Qualitative design	Nursing students (n = 12)	Reflective journal writing	Content analysis	Ineffective communication Inappropriate role Models of nurses Incompetence of the instructor Theory-practice gap
Jamshidi et al. [33] 2016 Iran	To explore Iranian nursing students’ challenges in the clinical learning environment.	Qualitative design	-Nursing students (n = 17) -Clinical instructors (n = 3)	Semi-structured interviews and focus groups.	Content analysis	Ineffective communications Discrimination Emotional reactions: stress and the Inferiority complex
Jasemi et al. [34] 2018 Iran	To identify challenges in the field of clinical nurse education.	Qualitative design	-Nursing students (n = 9) -Nursing educators (n = 2) -Qualified nurses (n = 3)	Semi-structured interviews	Content analysis using MAXQDA software	Limited training time Unsystematic methods of teaching Deficient evaluation methods Limited capability of the instructor Misbehavior of nurses Poor educational facilities
Joolaee et al. [35] 2015 Iran	To explore Iranian nursing students’ preparedness for clinical training	Qualitative design	-Nursing students (n = 17) -Nursing educators (n = 3) -Nurse (n = 1)	Semi-structured interviews	Content analysis	Rejection of the profession Fear and anxiety Reality shock Lack of preparation Low self-confidence
Mamaghani et al. [45] 2018 Iran	To explain the Iranian nursing students’ experiences of their clinical learning environment.	Qualitative design	Nursing students (n = 21)	Semi-structured interviews	Content analysis	Inconsistent educational methods No systematic evaluation process Limited educational opportunities Nurses’negative attitude Incompetency of the clinical instructors Identity ambiguity and discrimination
Najafi et al. [37] 2019 Iran	To describe the nursing students’ experiences in a clinical learning environment	Grounded theory method	-Nursing Students (n = 19) -Nursing instructors (n = 4) -Clinical nurses (n = 3)	Semi-structured interviews, field notes, and observation	Thematic analysis using Strauss and Corbin’s approach	Inefficient role of the instructors Improper assessment Stressful socioprofessional environment Lack of confidence and motivation Unfavourable scheduling Insufficient clinical practice
Nasrin et al. [38] 2012 Iran	To understand the nursing students’ motivation process in the clinical education, with a focus on the nurses’ role in this regard.	Grounded theory method	Nursing students (n = 16) -Nursing instructors (n = 4)	Semi-structured interviews	constant comparative method, using MAXQDA	Factors of demotivation among nursing students: -Inappropriate nurses’ behaviour, -Extreme work conditions, nurses’ -Powerlessness, -Lack of psychological security; -Underpayment
Pazargadi et al. [46] 2012 Iran	To determine nursing students` perspectives on their clinical evaluation	Qualitative descriptive study.	Nursing students (n = 40)	Focus group	Content analysis	Professional attributes of educators Inappropriate evaluation lack of positive atmosphere Lack of motivation among teachers
Rafati et al.[47] 2017 Iran	To understand nursing students’ experiences of stressors in their first clinical experience	Descriptive phenomenological design	Nursing students (n = 7)	Semi-structured interviews	Content analysis using “Colaizzi’s method”	The sense of inadequacy Being ignored and disrespected Lack of communication skills Negative educators’treatment Unclear and excessive expectations
Rafiee et al.[39] 2014 Iran	To explore the views of nursing students about clinical evaluation problems	Qualitative exploratory approach	-Nursing students (n = 40) --Instructors (n = 8)	Semi-structured interviews	Content analysis	Problems of clinical evaluation Difficulties related to clinical instructors Unsuitable programming of clinical education Organisational shortcomings
Rezakhani et al.[48] 2020 Iran	To determine the challenges faced by nursing students while working with nurses in the ward.	Qualitative descriptive study	Nursing students (n = 20)	Semi-structured interviews	Content analysis using MAXQDA 12	Inappropriate social norms among staff: (disrespect, distrust, wrong patterning) Insufficient work commitment Inadequate knowledge of nurses Weak educational facilities
Seyedamini et al.[40] 2021 Iran	To explore students ' perceptions of the problems hindering their clinical education.	Phenomenological qualitative research	Nursing students (n = 20)	Semi-structured interviews	Content analysis	Inadequate clinical space lack of motiva¬tion among students Inclusive self-confidence Missbehaviors of the educator Inadequate teaching methods Relationships between patients and students
Sharif & Masoumi [41] 2005 Iran	To investigate student nurses’ perceptions of their clinical practice.	Qualitative design	Nursing students (n = 90)	Focus group	Content analysis	Fear and reality shock Theory oractice gap Inappropriate role model of instructors Weak clinical supervision Identity ambiguity
Zamanzadeh et al.[42] 2021 Iran	To describe challenges related to the OSCE integration perceived by educators and nursing students	Qualitative design	-Nursing students (n = 15) -Faculty members (n = 18)	Semi-structured interviews	Thematic analysis-	Shortcomings in management Lack of resources Poor coordination in educational fields Lack of exam consistency Insufficient competence of the examiners
Bawadi et al. [18] 2019 Jordan	To explore the perceptions of Jordanian nursing students and clinical instructors related to clinical training in the clinical setting.	Phenomenological approach	-Nursing students (n = 28) -Clinical instructors (n = 12)	Focus group	Thematic analysis-	Lack of facilities and Reality shock The high number of students Discrimination Inappropriate evaluation/teaching approach Low self-confidence and motivation
Nabolsi et al. [36] 2012 Jordan	To explore the experience of nursing students in their clinical training.	Phenomenological qualitative approach	Nursing students (n = 30)	Fo us group	Interpretive approach (Gadamer, 1995)	Theory-practice gap Ineffective role of the instructors Lack of resources and clinical cases Unpleasant atmosphere in the ward Inappropriate internship programming Variation in evaluation criteria
Alazri et al.[49] 2023 Oman	To explore nursing students’ perceptions of the challenges they faced during their clinical experience	Qualitative descriptive design	Nursing students (n = 32)	Focus group	Thematic analysis	Inappropriate teaching strategies Theory-practice gap, High ratio of students to instructor Low self-confidence Inadequate evaluation methods
Essfadi et al.[50] 2024 Morocco	To explore the clinical learning experience of Moroccan undergraduate nursing students.	Phenomenological design	Nursing students (n = 34)	Semi-structured interviews	Thematic analysis	Theory-practice gap Lack of equipment The high number of students Insufficient supervision Inappropriate planning Fear and lack of confidence
Albloushi et al.[22] 2019 Saudi Arabia	To examine the sense of belonging of the Saudi female nursing students in clinical settings: meaning, consequences, and factors	Qualitative design	Nursing students (n = 16)	Semi-structured interviews	Thematic analysis	Sense of belongingness (obstacles/facilitators): -Obstacles: negative attitudes of nursing staff; Lack of preparation -Facilitators: presence of the clinical educators, feeling valued, being accepted -Consequences: Motivation, commitment
Saifan et al. [16] 2021 UAE	To explore factors contributing to the theory-practice gap in nursing education	Qualitative descriptive approach	Nursing student (n = 25)	Semi-structured interviews	Thematic analysis using NVivo software.	Theory-practice gap Lack of pedagogical skills Unaware preceptors Fear and Little self-confidence Inadequate laboratory preparation

Risk of bias in studies

Chosen articles were evaluated based on the COREQ checklist. Scores ranged from 17 to 28 out of 32. The domain of research team and reflexivity is poorly documented, with a score of 1–7 out of 8. Fifteen studies did not meet more than half of the criteria in this domain reflecting a lack of transparency regarding the role of the researchers [28–42]. The domain of study design is relatively well covered, with scores ranging from 6 to 13 out of 13 (methodological details are reported). The final domain, analysis and presentation of results, is well documented, with scores ranging from 7 to 11 out of 11, reflecting the clarity and scientific rigor of the findings (Additional file 3).

Results of syntheses

Findings from primary studies were contrasted, aggregated, and synthesized into 10 sub-themes, which were then grouped into four themes summarizing the main challenges and barriers faced in nursing clinical education: (1) Unsupportive clinical environment; (2) unsuitable structure, organizational and scheduling shortcomings; (3) Ineffective supervision and evaluation, (4) Personal factors and students’ attribute as stated in Table 2. Findings were structured and presented with a clear differentiation of perspectives (students vs. instructors). A quantitative content analysis was conducted to examine the distribution of themes and sub-themes across included studies: (Additional file 4).

Table 2.

Main themes and sub-themes emerging from thematic analysis

Themes	Sub-themes
Unsupportive clinical Environment	Inappropriate professional interactions
	Sense of belongingness-Identity ambiguity
	Discrimination
Unsuitable structure, organizational, and planning shortcomings	Lack of resources and facilities
	Theory-practice gap
	Planning shortcomings
Ineffective supervision and evaluation	Ineffective role of instructors
	Inappropriate clinical evaluation system
Personal factors and students’ attributes	Lack of Motivation to learn
	Perceived fear

Theme 1. Unsupportive clinical environment

This theme was the most frequently reported (21/26 studies) and summarized the main relational and logistical problems faced in clinical training [16, 18, 22, 28–34, 36–38, 40, 41, 43–50]. This theme included the following three sub-themes:

Inappropriate professional interactions

Across multiple studies [16, 18, 22, 28–34, 36–38, 40, 41, 43–50], the lack of support and staff indifference were the key barriers faced by nursing students in the clinical setting. Most students felt that healthcare professionals did not collaborate with them during their internships. The students’ role was limited to observation, with no practical experience.

Most of them were not helpful; they didn’t allow me to do anything. I was observing what they were doing. The nurse was so bad (student) [22]

Clinical instructors attribute this low level of cooperation and involvement on the part of clinical staff to workload and a shortage of professionals. Some have highlighted the negative impact of staff indifference on students’ commitment to training.

Some preceptors are overloaded with responsibilities, and working night shifts makes them tired and not capable of following students’ learning needs. (Instructor) [36]

Students really come to the department and don’t work willingly; they always seek for a way to escape, they make excuses (Instructor) [37]

Clinical instructors have suggested that faculties strengthen partnerships with clinical settings to involve nurses more closely in the training process.

The relationship between the faculty and clinical environment should be better. I think it is better that clinical nurses are asked to participate in clinical education (Instructor) [30]

Sense of belongingness - Identity ambiguity

The feeling of belonging to the healthcare team is a determining factor for students. Students felt that being accepted into a team reinforced their psychological security and motivation to learn.

I feel safe if they welcome me, and I will give more and come to the clinical setting every day because I am motivated to learn (Student) [22]

Some interns felt that being ignored and marginalized by nurses, who often treat them as outsiders, was a negative factor that led to stigmatization and disengagement among students.

The nurses either refused to work with us or mistreated us; they were not welcoming, and some of them said frankly that they didn’t want students, told us to get out (Student) [22]

Hospital staff always look down on us as servants or valets who have come to the ward to do the routine‑oriented tasks. (Student) [31]

Discrimination

Several studies (10/26) have reported that nursing students often suffer discrimination in clinical settings [18, 22, 30, 33, 36–38, 45, 47, 50]. Clinical staff assign tasks to medical interns, respect them, and offer them privileges, unlike nursing students, who are stigmatized and undervalued.

When we go to the ward, nurses frown on us, but when they see the interns or residents, they behave with them sincerely and answer their questions better. (Student) [30]

Once I went to the library in the hospital. The librarian said to me, “You cannot use it. I have orders that only medical students can use it. (Student) [45]

Theme 2. Unsuitable structure, organizational, and scheduling shortcomings

Data synthesized from 21 studies indicate that logistical and organizational constraints, as well as ineffective educational planning, hinder the training process [16, 18, 28, 30–32, 34–37, 39–45, 47–50]. This theme encompasses the following three sub-themes:

Lack of resources and facilities

The lack of equipment was an obstacle to learning in the internship settings. Students reported that it was sometimes impossible for them to practice and perform certain practical techniques because of a lack of necessary equipment.

Lack of facilities in wards causes us not to do lots of procedures. (Student) [34]

In addition to the lack of equipment, many students were dissatisfied with the internship conditions, as certain resources and facilities, such as locker rooms and conference rooms, were not available.

We nursing students have a physical environment problem. No classroom for a conference, no place to rest. (student) [40]

Clinical instructors shared the same concerns as students, indicating that they had difficulty supervising learners due to a lack of equipment.

There is less capacity to supervise students, equipment is not always available, and the care that is provided isn’t always of the best quality. (Student) [18]

Theory-practice gap

Synthesized evidence from 16 studies revealed that the gap between theory and practice was a major challenge in clinical training [16, 18, 28, 30–32, 34–37, 41, 43–45, 49–50]. Students experienced cognitive dissonance when they discovered that nursing practices differed from what they had learned in the classroom and sometimes did not even meet quality standards.

We have the knowledge, but when we try to apply it, we do not know what to apply. (Student) [49]

In the clinical area, they are using different ways to perform the procedures than we learned in class. (Student) [16]

Some nurses with whom we work do the clinical tasks as a matter of routine and at times regardless of meeting the standards. This reduces both the quality of care and our motivation in learning. (Student) [31]

Clinical instructors emphasized the cognitive dissonance students experience when observing nurses’ practices in clinical settings. According to some instructors, students questioned the credibility of the knowledge they had acquired in the classroom.

Students are sometimes shocked that the nursing practice they see does not always meet quality standards. Then they ask us why our teaching is unreal. (Student) [18]

Planning shortcomings

Students reported problems in programming clinical education, especially the large number of students, the short duration of internships, and the paucity of diverse clinical cases within training sites.

The large number of students at a site limits learning opportunities.‘There were a lot of us on the same placement site, more than 30 students, working with just one nurse. (Student) [50]

The time allocated for the clinical practice is too short. (Student) [49]

We haven’t seen many cases at all; we go to the department, and everything is repeated. (Student) [37]

Instructors also did not appreciate the planning of internships; they reported feeling exhausted due to the large number of students to supervise and the busy schedule.

Teaming up a large number of students and scheduling internships for the whole week will leave both instructors and students exhausted, hence reducing educational quality. (Instructor) [31]

Theme 3. Ineffective supervision and evaluation

This theme reflects the gaps in supervision and the shortcomings of the evaluation system described in the included studies. These dysfunctions have been summarized into two sub-themes:

Ineffective role of clinical instructors

The role of the supervisor has been documented in 21 studies as a key determinant of clinical training [16, 18, 28, 30–37, 39–47, 49–50]. The quality of supervision depends on the clinical instructor’s profile. Studies have reported varied experiences, with some students satisfied with their supervisors’ knowledge and skills.

Some instructors have sufficient knowledge and skills, so they have a higher self-confidence level, and they help us to understand how to do our duties. (Student) [49]

Most students did not appreciate the role of clinical instructors; they indicated that most of them lacked theoretical knowledge and teaching skills. Some instructors were unable to give practical demonstrations, and others focused more on theoretical concepts than on practical tasks.

Most of the instructors did not have a particular lesson plan. We did not know what we should learn on this ward. (Student) [45]

During my studies I could find no pattern, there was no instructor who could execute ideal care in the clinical environment. Mostly, they had low skills and capabilities (Student) [34]

For their part, instructors often explain the constraints of clinical supervision by citing the workload associated with the large number of students and the shortage of clinical instructors.

In one cohort, I had three students in ICU, three in the CCU, and another three in cardiac ICU. Moving between these students consumes my whole day. (Instructor) [18]

Inappropriate clinical evaluation system

Almost half of the studies included in this review (12/26) raised issues regarding the clinical evaluation process [18, 28, 34, 36–37, 39, 42–43, 45–46, 49–50]. Students reported problems of unfairness and subjectivity in clinical assessments. According to students, the assessors were often focusing on theoretical knowledge rather than practical skills. Exam periods were the most stressful for students during their training.

Most times, instructors made subjective assessments; there were no special criteria for evaluation. Sometimes a weak student got a good grade while a clever student got a low grade. (Student) [34]

I think that instructors often evaluate us unfairly. We are in a clinical area and not in the classroom, but they still evaluate us on our knowledge and not on our clinical performance (Student) [18]

For their part, clinical instructors shared the same view as students: they acknowledged that assessment tools were ineffective and that assessments were not conducted at the appropriate time. According to some faculty members, examiners lack competencies in clinical evaluation.

We all believe that these clinical evaluation forms are not efficient; they don’t measure the student’s progress and achievement. (Instructor) [39]

There are some problems with the examiners; they put students under stress and do not know how to deal with them. They confuse the students, ask improper questions, or do not act according to standards. (Instructor) [42]

Theme 4. Personal factors and students’ attributes

Personal factors related to students, including intrinsic motivation and fear, were among the key determinants that can influence students’ learning process. The aspects, reasons, and consequences of these factors are summarized in the following two sub-themes:

Lack of motivation to learn

Motivation is a key factor in the clinical learning process. Motivated students were more engaged thanks to their active participation in daily internship activities. Students listed several factors that influence their motivation to learn [18, 22]. Support from instructors, families, and clinical staff stimulates student motivation. However, bad behavior and negative attitudes from those around the student hinder their desire and commitment:

I think teachers play the main role. If the teacher has no motive or incentive, the students will be the same. (Student) [46]

Discrimination has left no incentive for me. I want to leave nursing. Not only me, but all nursing students are upset. I do not know why they do it. (Student) [45]

Clinical instructors emphasize that students’ lack of motivation is a major obstacle; even under favorable conditions, it is difficult to help unmotivated students.

Some students are not interested or motivated to learn and expect to be spoon-fed. However, they do need to study, and if they do not do so, then how is this the fault of the instructor? (Instructor) [18]

Perceived fear

Data from nearly half of the studies revealed that fear among students was a major obstacle to their learning [16, 28–30, 33, 35, 37, 40–41, 43–44, 47, 49–50]. According to some students, this fear stems from a lack of self-confidence, insufficient preparation, and negative feedback from instructors.

Once I wanted to examine a patient, I was so stressed. I was afraid of doing something that would cause harm to the patient. (student) [33]

I was worried all the time lest I make an error and the educator treat me badly, or the head nurse or the personnel come down on me. (student) [35]

The instructors stated that it is generally a lack of confidence among new students that causes them to feel afraid.

Students often do not have enough confidence early in their internship; they gradually become more confident as they get used to the hospital and its environment. (instructor) [33]

The nurses’ opinion on student fear is consistent with educators’; they attribute this problem to a lack of self-confidence among novice students.

When the guys from lower years come here for the first time, their self-confidence is low. (Nurse) [35]

Discussion

This review analyzed 26 studies examining the main structural, human, and organizational challenges that hinder the clinical training of nursing students in countries across the MENA region. These findings corroborate the difficulties documented in the international literature, confirming that these obstacles do not reflect an isolated situation limited to the MENA region. The review by Cant et al. (2021), which included studies from several geographic regions (North America, Northern Europe, Australia, and Western Asia), showed that clinical learning is influenced by logistical resources, the quality of supervision, and the gap between theory and practice [51]. Similarly, another study conducted in the sub-Saharan African context highlighted similar issues: a shortage of qualified instructors, inadequate supervision, limited resources, and student motivation and attendance [52]. These difficulties and dimensions overlap with several challenges identified in the present review. The lack of support and indifference from clinical staff are among the serious concerns faced by both students and their clinical instructors in the clinical setting [18, 36, 49]. The low level of involvement by clinical staff in student training activities is a well-documented challenge, Arkan (2018) highlighted that Turkish nursing students were often left alone in departments without assistance or cooperation from clinical staff [53]. This low involvement of nursing staff is often due to workload, as nurses focus more on care activities, and student learning is not a priority for them. Staff shortages and high workload are among the main causes of this unavailability and of the weak staff involvement in training activities [54].

In clinical settings, nursing students interact with different stakeholders. The socio-professional interactions can sometimes be delicate [13, 20, 22]. Students were sometimes mistreated and underestimated, particularly when their faculty members were absent. Students are not the only ones suffering from these problems; their clinical instructors report a lack of respect from clinical staff, claiming they are seen as outsiders within the departments [20, 55]. Many students criticized the discrimination between nursing interns and medical interns [30, 45]. This negative attitude widens the gap between students, accentuates feelings of inferiority among nursing students, and fuels negative attitudes toward the nursing profession [12, 13]. These conclusions are in line with those of a previous systematic review including international studies, which reported that stigmatization of nursing students is a very common and serious problem [11].

Nursing training relies on practical training, which requires sufficient equipment and resources [1, 19]. This review highlights the difficulties students encounter in this regard [28, 50]. Students cannot acquire practical skills without sufficient training. The nursing profession is practice-oriented, so if students do not practice enough, it will be difficult for them to perform technical procedures accurately and independently. These findings are consistent with those of previous studies that have raised concerns about the lack of educational resources and facilities at clinical sites [56, 57].

Kolb’s experiential learning refers to the application of theoretical knowledge acquired in the classroom to practical situations [5]. This review summarizes the various gaps related to the discrepancies between the theory taught in class and nursing practices in clinical settings. The theory-practice gap creates a dilemma and cognitive dissonance among students [18, 38]. These results are consistent with those of Günay (2018), who found that Turkish students were shocked by nursing practices that differed from what they had learned in class and sometimes did not comply with quality standards [58]. This gap is difficult to bridge during the first few days of the internship, which prevents students from easily applying their knowledge. Faced with this diversity of practices, confused and lost students often struggle to choose which practical model to apply [17].

Planning and organization are key factors in training. This review reports the problem of department overcrowding at training sites identified in several studies. Learning opportunities are very limited due to the large number of students [36, 50]. This organizational situation does not align with international clinical supervision standards, which recommend that each supervisor should accompany no more than trainees [2]. This is exacerbated by the insufficient time allocated to clinical learning; students often fail to achieve all the objectives due to short internship duration [49].

According to Kolb, experiential learning requires a mentor who guides the novice student [5]. The student observes, imitates, and learns from their expert preceptors and teachers. However, this review shows that nursing students were dissatisfied with the role of their clinical instructors. Clinical nurse teachers lacked pedagogical, technical, and non-technical skills [30, 32, 43]. These findings corroborate those of previous studies [19, 59] who emphasized that some clinical instructors did not add value to student learning. In order to strengthen the role of instructors in clinical training, the WHO has defined eight competencies required for clinical instructors to improve their role within CLE (theories and principles of adult learning; planning; nursing practice; research and evidence; communication/collaboration and partnership; ethical/legal principles and professionalism; monitoring and evaluation; leadership and advocacy) [60, 61].

Regarding the nursing education evaluation system, the review summarizes the most common problems, including ineffective evaluation tools and methods [18] and a lack of evaluation skills among evaluators [42]. The clinical evaluation problems documented in the MENA region are similar to those reported in other contexts. Nursing students in Turkey reported the ineffectiveness of assessment tools, the lack of formative assessments, and the lack of assessment skills among evaluators [11, 59]. Assessment is an integral part of training. The use of reliable tools, standardized approaches, and expertise in assessment methods ensures the transparency of assessment processes and the credibility of results, while limiting psychological repercussions for students [62].

In addition to environmental, organizational, and logistical issues, this review reveals the negative effect of certain personal factors related to the student, particularly motivation [18]. Students who lack motivation are less engaged, even when conditions are favorable. Motivation to learn is influenced by external factors, particularly the attitude of significant individuals (teachers, staff, and families) [45, 46]. This is consistent with the findings of Erden (2024), The negative attitudes of those around the student toward the nursing profession strongly influence the motivation of learners, who develop a negative attitude toward learning [63]. The second personal factor that hinders learning is the perceived fear. This inhibits initiative, especially when students fear harming patients or being reprimanded by supervisors for a mistake [43]. Student fear is closely linked to poor preparation before internship, low self-confidence, and insufficient support [35, 50]. Faculty members and field supervisors must support and encourage students in order to overcome the fear that holds them back [13]. Good prior preparation at the institute (practical simulation sessions, demonstrations, meetings) increases students’ self-confidence and reduces errors that can hinder them [64]. Simulation increases students’ self-confidence and prepares them to engage more easily in learning activities once they are in the field [65].

Limitations

Although the objective of the study was to synthesize the main challenges and barriers faced by student nurses in the MENA region, the results of the study selection show a predominance of studies describing the Iranian context, with few studies representing the rest of the countries in the region. Furthermore, the challenges identified in this study must be interpreted in light of the heterogeneity of nursing education systems in the MENA region, organizational differences (institutional capacity), and the varying availability of clinical placement settings and clinical supervision models. Thus, while the observed issues align with international trends, their intensity and manifestations may vary depending on national and institutional contexts.

The second limitation is associated with the research strategy, which relied on four databases; it is possible that interesting studies published in other databases were not identified, limiting the diversity of perspectives analyzed.

Conclusions

This review shows that clinical training for nursing students in MENA countries continues to face major challenges, particularly in terms of clinical supervision, educational resources, and the organization and standardization of teaching and assessment processes. Although these issues are also documented in other geographical contexts, their manifestation in the MENA region must be interpreted while taking into account the differences in training systems and supervision models adopted by the countries in that region. This review highlights the need to strengthen the role of clinical supervisors through continuing education, ensure the implementation of clinical supervision standards, and rethink curricula and the evaluation system. At the health policy level, it is essential to integrate nursing education as a strategic priority. More ambitious investments in human resources, infrastructure upgrades, and strengthened institutional collaboration through partnerships will help training systems in MENA countries prepare professionals who will contribute to optimizing regional healthcare provision. Further research is needed in MENA countries that are currently underrepresented in order to generate more context-specific data.

Electronic Supplementary Material

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Abbreviations

MENA

Middle East and North Africa

COREQ

Consolidated Criteria for Reporting Qualitative Research

WHO

World Health Organization

Author contributions

E.R: Conceptualization - Data curation - Data analysis. S.T: Data curation - Data analysis. M.A: Data curation - Data analysis. A.B: Conceptualization. F.L: Conceptualization, Data curation- Study supervision. All authors contributed to the Original manuscript preparation. All authors read and approved the final manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.