From novice to professional self: a qualitative study of nursing students’ internship experiences in Iran

Abstract

Background

Clinical education is central to nursing curricula, yet a persistent theory–practice gap challenges student readiness. In Iran, internship programs were recently introduced to bridge this gap, particularly in newly established nursing schools. However, students’ lived experiences during this critical transition remain underexplored.

Aim

This study explores the lived experiences of final-year nursing students during their internship at Khoy University of Medical Sciences, Iran.

Methods

A qualitative descriptive design and conventional content analysis was undertaken to use explore students’ experiences on this topic. In-depth, semi-structured interviews were conducted with 14 final-year nursing students, selected through purposive sampling with maximum variation to capture diverse perspectives. Interviews were audio-recorded, transcribed verbatim, and analyzed iteratively using MAXQDA (v.12). Trustworthiness was rigorously maintained through Lincoln and Guba’s criteria (credibility, dependability, confirmability, and transferability).

Findings

Four interrelated themes emerged: (1) dissonance between academic instruction and clinical reality, (2) tension between the educational mandate and the service imperative, (3) professional growth forged through authentic clinical experience, and (4) reconstruction and consolidation of professional identity. These themes reflect a transformative developmental process; however, the data were analyzed using conventional content analysis without applying a predefined theoretical framework.

Conclusions

The internship functions as a transformative developmental phase that facilitates students’ transition toward professional autonomy. Realizing its potential requires structured academic, clinical collaboration, trained preceptors, and learning-centered assessment, particularly in resource-constrained settings.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04838-y.

Introduction

Clinical education is a fundamental component of nursing curricula, serving as the essential bridge through which students acquire the competencies required for safe and effective patient care [1, 2]. The primary goal of nursing education, training graduates capable of assuming full professional responsibilities, is largely achieved through clinical internships [3]. Consequently, nursing education programs strive to integrate theoretical knowledge with practical skills to prepare students for the complexities of modern professional practice [4].

Recent international studies reveal evolving trends in nursing internship programs designed to enhance clinical competence, professional autonomy, and practice readiness [5]. For instance, countries such as the United States, Canada, and Australia have implemented structured preceptorship models and competency-based assessments to narrow the persistent theory-practice gap [6]. Similarly, various Asian nations are currently revising their internship structures to improve mentorship quality and standardize assessment tools. These international developments offer valuable insights into contemporary nursing education, provided they are interpreted through the lens of local educational and socio-cultural realities.

However, the direct translation of these international models to the Iranian context is not straightforward. Significant variations in health system organization, faculty-to-student ratios, and clinical supervision patterns directly impact the implementation of nursing internship programs. Therefore, localized research is essential to understand the specific strengths and challenges of internship education within Iranian institutions.

In recent years, simulation-based learning has emerged as a valuable strategy, allowing students to practice clinical decision-making in a safe environment [7]. While simulations effectively bolster student confidence, they cannot fully replicate the unpredictability, emotional complexities, and interdisciplinary dynamics of real-patient care [8]. Thus, direct exposure to authentic clinical environments remains indispensable for cultivating professional identity and adaptability.

Nevertheless, evidence suggests that newly graduated nurses often struggle when assuming professional responsibilities, highlighting a persistent theory-practice gap [9, 10]. This divide stems from interconnected factors, including a misalignment between academic curricula and clinical needs, a shortage of qualified clinical preceptors, and students’ insufficient awareness of their own strengths and weaknesses [1, 4, 11]. From the students’ perspective, these barriers significantly compromise the quality of learning and clinical competence [12].

In contemporary healthcare systems, training clinically competent nurses requires targeted strategies to align education with actual practice [13]. A robust integration between academic and clinical settings is essential for delivering professional, evidence-based care [14, 15]. Yet, traditional clinical rotations have often failed to foster readiness for independent practice, frequently leaving students feeling unprepared and overwhelmed [16–18].

The internship model employed in this study is grounded in Patricia Benner’s “Novice to Expert” theory (1984), which serves as the conceptual framework for clinical instruction. According to Benner, nursing competence is acquired incrementally through experience-based learning and situated clinical practice. In this framework, the internship provides a supportive environment where students participate as active members of the healthcare team, gradually assuming greater responsibility under guided supervision. This model emphasizes the importance of reflection and mentorship in translating theoretical understanding into competent clinical judgment [19].

As an alternative approach, the internship model allows students to take direct responsibility for patient care. In this model, the clinical preceptor primarily oversees performance, while students function as active members of the healthcare team [20, 21]. Research indicates that this model can significantly enhance students’ clinical competence, self-confidence, and professional commitment [22, 23].

In Iran, despite the issuance of national internship guidelines in 2012, implementation across universities has been inconsistent, leading to disparities in educational quality and supervision patterns. Khoy University of Medical Sciences, having recently implemented this internship program, provides a critical case study for examining this model. Due to the lack of long-established protocols, this institution offers a unique lens through which to observe how constraints and contextual conditions shape clinical learning and the evolution of students’ professional roles during genuine immersion.

Despite the increasing adoption of the internship model, little is known about how the student experience influences their transition from “novice” to a “cohesive professional self.” Existing research has largely focused on competency acquisition, offering limited insight into the deeper developmental processes through which professional identity and values are forged within authentic clinical settings. Therefore, this study utilizes a qualitative content analysis approach [24–26] to examine the lived experiences of final-year nursing students at Khoy University of Medical Sciences, shedding light on how authentic clinical immersion shapes their developmental pathways and the formation of their professional identity.

Methods

Study design

This study employed a qualitative descriptive design to explore nursing students’ first-hand experiences of the newly introduced internship program. This approach was appropriate for capturing participants’ perceptions in a real educational context. As the program was implemented for the first time in our faculty, the study focused on students’ experiences during the initial implementation phase.

Participants and sampling

Fourteen final-year nursing students from the Faculty of Nursing at Khoy University of Medical Sciences participated in this study. The study was conducted in affiliated teaching hospitals where the nursing internship (clinical practicum) is implemented. In this university, the internship program lasts for two semesters and involves full-time clinical placements in hospital wards. The primary responsibility for patient care lies with the hospital staff, while clinical instructors supervise students. The student’s duty schedule is prepared by the department head in three shifts, and students receive a stipend during their internship. The duration of placement in various wards is determined based on the number of credit hours.

Participants were selected using maximum variation sampling to ensure a diverse range of perspectives. This involved strategically choosing students across key demographic dimensions, including age, gender, marital status, geographic origin (local vs. non-local), and place of residence (student dormitory vs. private home). To be included in the study, participants had to meet specific criteria: (1) be a final-year undergraduate nursing student, (2) have completed at least one internship rotation in a clinical ward, and (3) be willing to share personal experiences. Students who did not meet these inclusion criteria, or who were unwilling to continue participation or had incomplete internship experiences at the time of data collection (exclusion criteria), were not included in the study.

Data saturation was initially achieved at the 12th interview; however, two additional interviews were conducted to ensure analytical robustness, resulting in a final sample of 14 participants.

Data collection

Data were collected between August 20 and October 7, 2025, through in-depth, semi-structured, individual interviews conducted by the first author, an experienced qualitative researcher. Participants were recruited voluntarily using maximum variation sampling. Eligible students were identified and invited to participate, and all were informed about the study purpose, confidentiality, and their right to withdraw at any time before providing written informed consent. Prior to data collection, ethical approval was obtained from the Ethics Committee and Research Council of Khoy University of Medical Sciences, and written informed consent was secured from all participants.

Data were collected using a semi-structured interview guide developed specifically for this study (see Supplementary File 1). The content validity of the guide was confirmed by a panel of 10 nursing faculty members, and the final protocol was approved by the Ethics Committee. Interviews were conducted in quiet, private rooms within the affiliated teaching hospitals (e.g., an office in the hospital’s Education Department) or in the consultation room of the Faculty of Nursing. These spaces were selected to ensure comfort, privacy, and minimal interruptions. The internships themselves were carried out in various inpatient units of the affiliated teaching hospitals, as detailed in the Participants and Sampling section. Each interview began with the open-ended prompt:

Please describe the moment you were told that this year’s clinical training would be conducted as an internship, and tell me about your experiences from the very first days of starting this rotation.

Follow-up probes (e.g., “What challenges did you face?”, “Can you give an example?”, “How did this affect your sense of professional identity?”) were used flexibly to deepen reflection and enrich data. Interviews lasted 30–80 min, were audio-recorded with consent, and supplemented with handwritten field notes (later typed) to capture nonverbal cues and contextual insights.

Data analysis

Data were analyzed using conventional content analysis, guided by the approach described by Graneheim and Lundman [24, 25]. All interviews were transcribed verbatim and imported into MAXQDA software (version 12) for data management and analysis. Data analysis was conducted concurrently with data collection.

The first author and the corresponding author, who were primarily responsible for the analysis, independently read and reread the transcripts to achieve immersion in the data. Meaning units relevant to the research aim were then identified and condensed. Initial inductive codes were generated. Subsequently, the two analysts compared their code lists and discussed similarities and differences in scheduled analytic meetings, a process that formed a core part of our peer debriefing and credibility-building efforts. Any discrepancies in coding or categorization were resolved through discussion and, when necessary, by returning to the original transcripts to ensure that the final interpretation accurately reflected participants’ perspectives.

Throughout this process, codes that appeared overlapping or conceptually similar were refined, merged, or redefined through constant comparison. Codes were then organized into subcategories and categories based on semantic and conceptual similarities. Through iterative discussions within the research team, overarching themes representing the latent content of the data were developed and finalized. The analytical process was consistently documented to ensure traceability and confirmability. This analytical process led to the emergence of 384 primary codes, 24 subcategories, 12 categories, and 4 interpretive themes.

The research team comprising faculty members with expertise in nursing education and qualitative methods reviewed coding decisions and thematic development at regular intervals.

Trustworthiness

Trustworthiness was ensured using Lincoln and Guba’s (1986) criteria [26]:

Credibility was enhanced through prolonged engagement with participants and regular peer debriefing meetings among the research team. Member checking was conducted by sharing relevant transcripts and preliminary categories with several participants, the head of nursing, and the hospital’s nursing services manager to confirm the accuracy of interpretations.

Dependability was supported by maintaining a consistent analytical process and documenting analytic decisions. An independent qualitative researcher reviewed the audit trail and confirmed methodological coherence.

Confirmability was achieved by transparent documentation of all research stages—from interview guide development to final theme generation—and ongoing discussions to minimize researchers’ potential bias.

Transferability was strengthened through external validation with four non-participant nursing students, who confirmed that the findings reflected their broader experiences of the phenomenon.

Researcher reflexivity and positionality were also considered throughout the study. The first author, who conducted the interviews and had prior teaching experience with some participants, maintained a reflective journal documenting assumptions, reactions, and decisions during data collection and analysis. This practice helped to acknowledge the researcher’s positionality within the academic setting and to mitigate potential influence on participants’ responses and data interpretation.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and adhered to established ethical principles for qualitative research. Participants were fully informed of the study’s purpose, their voluntary participation, and the right to withdraw at any time. Confidentiality was ensured by removing identifiers and using pseudonyms. All data were stored securely and used solely for research purposes. The study was approved by the Ethics Committee of Khoy University of Medical Sciences.

Results

Fourteen final-year nursing students participated in the study (8 males, 6 females), aged 22 to 30 years. The majority were single and resided in student dormitories or off-campus housing, with a mix of local and non-local origins (Table 1). Data saturation was achieved by the 12th in-depth, semi-structured interview, and two additional interviews were conducted to ensure analytical stability and depth.

Table 1.

Demographic characteristics of participants

Participant	Gender	Age range	Marital status	Local or Non-local resident
P1	Female	20–22	Single	Local
P2	Female	23–25	Single	Non-local
P3	Male	23–25	Single	Non-local
P4	Male	20–22	Single	Local
P5	Male	23–25	Single	Local
P6	Male	20–22	Single	Local
P7	Male	26–30	Married	Local
P8	Male	23–25	Single	Non-local
P9	Female	20–22	Single	Local
P10	Male	23–25	Single	Non-local
P11	Female	23–25	Married	Local
P12	Male	23–25	Single	Non-local
P13	Female	20–22	Single	Non-local
P14	Female	23–25	Single	Non-local

The data generated rich accounts of students’ internship experiences, from which four main themes emerged. These themes, supported by twelve categories and twenty-four subcategories, portray the multifaceted and transformative aspects of students’ clinical learning journey. Each theme is presented below with illustrative participant quotations that highlight their lived experiences (Table 2).

Table 2.

Themes and categories emerging from students’ experiences of the nursing internship

Themes	Categories
1. Dissonance between academic instruction and clinical reality	• Inadequate pre-clinical preparation • Weak collaboration between university and hospital •Absence of transparent evaluation and effective supervision
2. Tension between the educational mandate and the service imperative	• Students substituted for clinical staff • Authoritarian climate and organizational fatigue • Moral dissonance and normalization of substandard care
3. Professional growth forged through authentic clinical experience	• Accelerated skill acquisition through real-time clinical engagement • Emotional and ethical maturation through human connection • Emergence of intellectual autonomy and evidence-based agency
4. Reconstruction and consolidation of professional identity	• Internalization of the nursing self • Reorientation of academic and career aspirations • Development of critical consciousness and ethical resilience

Theme 1: Dissonance between academic instruction and clinical reality

Students consistently described a profound and unsettling gap between the knowledge and skills acquired in university and the complex, often unpredictable demands of real-world clinical practice. This dissonance emerged as a foundational challenge that shaped their early internship experiences and threatened their sense of preparedness. This theme is organized into three categories, each revealing distinct dimensions of this misalignment.

Category 1: Inadequate pre-clinical preparation

Participants reported that their academic training had been heavily oriented toward theoretical knowledge and examination success, with minimal exposure to hands-on patient care. This left them feeling unprepared for the autonomy and responsibility expected during the internship. Underlying this category were sub-thematic concerns such as exam-driven curricula, limited procedural practice, and delayed immersion in clinical settings. As one student reflected:

We had learned everything from textbooks, but when it came to actually doing it, we realized how vast the difference is between watching and performing. On my first day with a real patient, I felt completely incompetent. Our education was geared toward passing exams, not assuming real responsibility. (P. 4)

Category 2: Weak collaboration between university and hospital

A recurring source of frustration was the lack of coordination and shared accountability between academic and clinical institutions. Students often found themselves in ambiguous roles, receiving conflicting messages and minimal integrated support. This category encompassed experiences of institutional fragmentation, role confusion, and absence of a unified educational vision. One participant described the situation vividly:

The faculty told us to go to the hospital, and the hospital said, ‘You’re a student—your issues belong to the university.’ No one wanted to take responsibility for us. It made us feel utterly unsupported. (Participant 6)

Category 3: Absence of transparent evaluation and effective supervision

Many students criticized the internship assessment system as arbitrary, subjective, and disconnected from meaningful learning outcomes. Evaluation often prioritized task completion and physical presence over clinical reasoning, ethical judgment, or reflective growth—highlighting sub-themes such as performance being based on workload compliance and lack of formative feedback. As Participant 8 noted:

A student who only recorded vital signs received a higher grade than I did, even though I had fully managed patient records and medication administration. Evaluations were tied to physical labor, not learning.

Collectively, this theme illustrates how structural and pedagogical misalignments between academic training and clinical practice undermined students’ confidence, delayed their transition toward professional autonomy, and posed significant barriers to identity formation during a critical developmental phase.

Theme 2: Tension between the educational mandate and the service imperative

Students consistently articulated a fundamental contradiction at the heart of their internship: while formally framed as a pedagogical experience designed to cultivate clinical competence and professional identity, it often functioned in practice as a mechanism for fulfilling understaffed clinical units’ operational needs. This duality generated persistent role conflict, moral distress, and emotional exhaustion. The theme unfolds across three interrelated categories, each exposing a different facet of this institutional tension.

Category 1: Students as substitute clinical labor

Participants frequently described being assigned routine, non-educational tasks—such as transporting patients, fetching supplies, or completing administrative paperwork—under the guise of “learning.” These duties, though essential to ward functioning, offered little opportunity for supervised skill development or reflective practice. Over time, the boundary between learner and auxiliary staff blurred, compromising both rest and academic engagement. As one student lamented:

In the ward, I felt less like a student and more like a worker. Nurses constantly said, ‘Do this, take that patient for tests.’ By the time I got back to the dorm at night, I was too exhausted to even open a book—let alone sleep. Education got lost in the volume of work. (P. 2)

Category 2: Authoritarian climate and organizational fatigue

The clinical environment was frequently characterized as rigid, high-pressure, and devoid of psychological safety. Students reported long shifts without breaks, punitive responses to minor infractions, and an implicit expectation of unquestioning compliance. This atmosphere stifled inquiry and discouraged help-seeking, reinforcing a culture of endurance over learning. One participant recalled:

If we were ten minutes late, they threatened to report us to the university to cancel our internship. Sometimes we worked all night without rest. In the morning, I felt like I was in boot camp, not a clinical training setting. (P. 6)

Category 3: Moral dissonance and the normalization of substandard care

Perhaps most consequential was the ethical erosion students experienced when confronted with practices that contradicted professional standards—such as delayed medication administration, lax infection control, or incomplete documentation. Initial attempts to raise concerns were often dismissed or ridiculed, leading to a gradual silencing of their professional conscience. Over time, many students internalized these deviations as “normal,” a process they described as deeply troubling yet inescapable. As Participant 7 reflected:

I saw morning medications given at noon, or antibiotics mixed up. At first I objected, but they told me I was overreacting. Gradually, I got used to it—and that was the most dangerous part.

Collectively, this theme reveals how the internship’s dual identity—as both educational rite of passage and source of low-cost labor—generated profound role ambiguity, ethical fatigue, and disillusionment. Rather than nurturing professional integrity, the clinical setting often demanded its compromise, thereby undermining a core aim of nursing education: the formation of ethically grounded practitioners.

Theme 3: Professional growth forged through authentic clinical experience

Despite the structural and emotional challenges of the internship, students consistently identified moments of profound professional transformation that emerged directly from engagement with real patients, unpredictable clinical situations, and increasing levels of responsibility. Rather than emerging from formal instruction, this growth was catalyzed by the demands of authentic practice—where theory met uncertainty, and action required judgment. The theme comprises three interrelated categories, each illuminating a distinct dimension of this experiential learning.

Category 1: Accelerated skill acquisition through real-time clinical engagement

Participants described how immersion in high-stakes, real-world contexts dramatically accelerated their technical and cognitive development. Unlike simulated or observational learning, authentic patient care demanded immediate application of knowledge, rapid problem-solving, and accountability for outcomes. Underlying this category were sub-thematic elements such as learning through crisis response, feedback from patients rather than instructors, and the internalization of procedural confidence through repetition in meaningful contexts. As one student recounted:

During one shift, a patient’s condition deteriorated rapidly, and I had to respond immediately. I’ve never been under that much stress, but in that moment, I decided to act. After the patient stabilized, I felt for the first time that I could genuinely save someone’s life. That experience was unforgettable. (P. 10)

Category 2: Emotional and ethical maturation through human connection

Beyond technical competence, students emphasized how sustained interaction with patients cultivated empathy, presence, and relational integrity—qualities they came to regard not as “soft skills,” but as core therapeutic interventions. This emotional labor, often untaught in classrooms, became a primary vehicle for ethical awareness and professional humanism. Sub-themes within this category included the therapeutic power of nonverbal communication, the moral significance of witnessing suffering, and the transformation of anxiety into compassionate engagement. As one participant reflected:

In the pediatric ward, I realized a smile could be therapeutic. When I spoke gently to a child, their anxiety lessened, and their mother calmed down too. In that moment, I understood that nursing means being human before anything else. (P. 12)

Category 3: Emergence of intellectual autonomy and evidence-based agency

Over time, students transitioned from passive rule-followers to critical thinkers who actively evaluated clinical routines against scientific and ethical standards. This shift marked the development of professional voice and moral courage—especially when confronting practices that contradicted evidence or patient safety. Key sub-themes included questioning ritualized care, choosing integrity over convenience, and embracing reflective practice as a form of resistance. One participant articulated this evolution clearly:

Several times, a nurse told me I didn’t need to follow protocols step by step, but I knew that skipping scientific principles could cause harm. I chose to take more time to do it correctly. Right there, I understood the difference between mechanical task completion and conscious, ethical nursing. (P. 9)

Collectively, this theme illustrates how the internship—however imperfect—served as a crucible for professional becoming. Authentic responsibility, even when overwhelming, became the primary driver of clinical judgment, emotional resilience, and self-trust—laying the groundwork for a practice rooted in competence, conscience, and care.

Theme 4: Reconstruction and consolidation of professional identity

By the culmination of the internship, many students described a profound reconfiguration of their self-concept—not merely as learners, but as emerging members of the nursing profession. This transformation was not linear or effortless; rather, it emerged through sustained confrontation with adversity, critical reflection, and acts of personal and professional recommitment. The internship functioned less as a training period and more as a rite of passage, through which students redefined their values, clarified their purpose, and internalized a sense of belonging. This theme unfolds across three interwoven categories.

Category 1: Internalization of the nursing self

Participants moved from initial feelings of alienation, self-doubt, and impostor syndrome toward a grounded sense of professional legitimacy. This shift was marked by increasing comfort within clinical settings, confidence in interprofessional interactions, and an emotional identification with the nursing role. Sub-thematic dimensions included the gradual dissolution of hierarchical anxiety, the embodiment of professional posture, and the transition from “pretending to be a nurse” to “feeling like a nurse.” As one student expressed:

On my first day in the ward, I was so anxious I couldn’t even speak to the nurses. But as time passed, I began to feel at home in the environment. Now, when I work alongside doctors or nurses, I don’t feel inferior—I feel this is exactly where I belong. (P. 4)

Category 2: Reorientation of academic and career aspirations

The internship served as a clarifying lens for future trajectories. Witnessing expert practice, ethical dilemmas, and systemic shortcomings prompted students to reassess their motivations and ambitions. Rather than deterring them, challenges became catalysts for deeper engagement with the profession. Embedded sub-themes included renewed commitment to lifelong learning, recognition of advanced practice as a necessity (not a luxury), and the reframing of difficulty as integral to professional maturation. One participant noted:

Seeing expert nurses showed me how knowledge can transform practice. I decided to continue my education because I realized growth is impossible without challenge. (P. 12)

Category 3: Development of critical consciousness and ethical resilience

Perhaps most significantly, students began to perceive the healthcare system not as a static backdrop, but as a dynamic and often flawed context that demanded both critique and constructive response. Instead of retreating into cynicism, many adopted what they described as “ethical resilience”: a commitment to uphold professional standards while simultaneously advocating for better conditions for patients, peers, and the profession itself. These interconnected perspectives were reflected through three aligned sub-themes: rejecting passive victimhood, embracing mentorship as a form of resistance, and reimagining their role from a learner to a change agent. Collectively, these elements illustrate the shift toward critical consciousness. As Participant 6 reflected:

Some nurses treated us poorly, but I decided to share my experience with future students so they’d be better prepared. Now I’ve realized that instead of complaining, I should support other students too. (P. 6)

Together, these categories reveal the existential core of professional formation: the internship, despite its structural shortcomings, became a transformative space where students did not merely acquire skills but authored their identities, reaffirmed their values, and claimed their place within the moral and practical fabric of nursing.

Discussion

Rather than functioning merely as an instructional phase, the internship emerged as a transformative process through which students moved from dependence and uncertainty toward greater autonomy, self-awareness, and the gradual formation of a professional self. The four themes identified in this study—disconnection, tension, growth, and reconstruction—should therefore not be understood as isolated categories, but as interrelated dimensions of identity transformation. Together, they show how professional identity is not formed in a linear or unproblematic way; rather, it develops through contradictions between educational ideals and clinical realities, through emotional and ethical tensions, and through students’ active efforts to reinterpret themselves within practice. In this sense, the findings extend beyond describing internship experiences and offer a more nuanced understanding of how the professional self is challenged, negotiated, and reconstructed during clinical immersion. The following discussion interprets these findings in relation to national and international scholarship on clinical nursing education.

Dissonance between academic instruction and clinical reality

A central finding of this study was the profound dissonance students encountered between university-based learning and the demands of real-world clinical practice. This gap stems not only from the theoretical and exam-oriented nature of academic curricula but also from systemic discoordination between educational institutions and clinical settings. As reflected in participants’ accounts, curricula often prioritize knowledge retention over the cultivation of clinical responsibility, leaving students insufficiently prepared for the relational, ethical, and practical complexities of patient care. This misalignment is further exacerbated by structural issues, including paradoxical curriculum design, limited resources, and weak integration between universities and healthcare organizations [27]. Importantly, students did not experience this dissonance merely as an educational shortcoming; it also unsettled their emerging understanding of what it means to think, act, and feel like a nurse in clinical practice.

These findings align closely with Rasouli et al.’s study at Qom University, which identified overlapping concerns such as exclusion from clinical planning, ambiguous evaluation criteria, overcrowded placements, stress induced by clinical instructors, limited patient exposure, and marginalization in care decision-making [28]. Likewise, Mahyar et al. reported poor supervision and inconsistent evaluation as systemic weaknesses in clinical education [29], which in our study were reflected in subjective assessments and the absence of regular, formative feedback. From an identity-formation perspective, such inconsistencies do more than disrupt learning. They create uncertainty about professional expectations, weaken students’ sense of legitimacy within the clinical environment, and make it difficult for them to internalize a coherent professional role. In parallel, these conditions may erode students’ trust in the educational system, particularly when supervision and evaluation are experienced as inconsistent or unfair [30].

To address these challenges, the literature emphasizes closer alignment between academic instruction and clinical practice through curriculum revision, stronger collaboration between universities and healthcare settings, and more consistent supervision and mentorship during clinical placements [31, 32]. In this sense, bridging the gap between academic instruction and clinical reality is not merely a curricular task; it is also a developmental condition for the formation of a coherent professional self in nursing students.

Tension between educational objectives and service-oriented demands

The study revealed that clinical environments often positioned students not as learners with legitimate educational needs, but as auxiliary labor within service-driven settings. This perception mirrors findings from a multinational study across nine Middle Eastern countries, which identified clinical workload and patient care responsibilities as primary sources of stress among nursing students—indicative of insufficient emotional and structural support during training [33]. To contextualize this globally, similar patterns have been documented in European and North American settings, where nursing students are routinely assigned non-educational tasks, experience role ambiguity, and report being treated as workforce substitutes during staffing shortages [9, 34]. Ineffective communication, unclear role boundaries, divergent expectations, and unprofessional conduct have been recognized as key drivers of clinical conflict, which not only hinder learning and increase stress [35], but also blur the boundaries of students’ professional role and disrupt the formation of a secure and valued professional self.

Lee et al. reported that over 79% of nursing students experience clinical incivility and feel vulnerable due to a lack of institutional support in confronting such behaviors [34]. Furthermore, Babenko and Lee demonstrated that exposure to incivility, particularly from practicing nurses leads to emotional exhaustion, diminished self-esteem, and weakened perceptions of professional competence [36]. Clinical bullying intensifies anxiety, undermines confidence, and compromises students’ sense of capability [37], transforming the student–staff relationship into a hierarchical and unsupportive dynamic that may even contribute to program attrition [38]. Such experiences can also erode students’ developing sense of professional worth and weaken the confidence needed to internalize a stable professional self.

To mitigate these tensions, it is essential to raise clinical staff awareness of students’ educational objectives and actively engage them as partners in the learning process [39]. In this context, the clinical instructor serves as a critical bridge between academic and clinical systems. A supportive instructor can cultivate an environment of psychological safety, encourage critical reflection, and foster professional growth [40], a role consistently identified as pivotal in shaping students’ clinical learning outcomes [41].

Professional growth forged through authentic clinical immersion

Despite these challenges, the clinical environment also emerged as a powerful context for students’ professional growth and identity reconstruction. When students were entrusted with authentic responsibilities and provided with adequate support, they developed greater clinical confidence, ethical awareness, and a renewed sense of purpose. This finding aligns with Dimitriadou et al.’s assertion that direct patient care and genuine caregiving experiences significantly narrow the theory–practice gap [42]. In the Iranian context, implementation of the internship model over two academic semesters significantly enhanced clinical competence compared with traditional final-year rotations [22]. Another local study reported notable improvements in students’ caregiving abilities, particularly in cognitive dimensions and patience, following the internship experience [12]. These experiences not only improved students’ clinical capabilities but also strengthened their sense of legitimacy, agency, and belonging within the profession, thereby contributing to the reconstruction of a more confident professional self.

Thus, the development of complex competencies, such as authentic patient communication, requires sustained immersion in real clinical settings, coupled with mentorship from experienced and supportive supervisors. High-quality clinical education depends on a triad of prepared learners, clinically aware and engaged supervisors, and academically qualified faculty. Only through the integration of these elements can the gap between simulated learning and authentic practice be effectively bridged [43]. In this regard, the internship model partially fulfilled this integrative function by creating conditions in which students could participate more meaningfully in authentic care while gradually consolidating their professional identity.

Reconstruction and consolidation of professional identity

After navigating these multifaceted challenges, students developed a renewed, more grounded understanding of their professional selves. As Ho et al. note, professional identity formation is neither linear nor uniform; rather, it emerges from a dynamic interplay between individual agency and environmental conditions [44]. Participants described a shift from passive compliance to critical and ethical reasoning, a clear indication of intellectual independence and the emergence of conscious nursing practice. This interpretation aligns with contemporary conceptualizations of professional identity in nursing, which frame it as an ongoing, socially constructed phenomenon shaped through interaction and active professional engagement [45].

Accordingly, nursing students gradually move from a primary focus on technical proficiency toward a more holistic, values-driven approach as they integrate theoretical knowledge with lived experience [46]. Given the multidimensional nature of these challenges, effective responses must be implemented across individual, organizational, and policy levels [30]. Without systemic reform, the transformative potential of clinical education will remain unrealized, and the risks of burnout, attrition, and moral distress will persist. Conversely, creating clinical environments in which students are recognized and valued as legitimate future members and architects of the profession can pave the way for a new generation of thoughtful, ethical, and humanistic nurses.

Limitations

As a qualitative study, the findings are not intended for statistical generalization but rather for transferability to comparable contexts. The results may be influenced by the specific setting of Khoy University of Medical Sciences, particularly as this study coincided with the inaugural year of the internship program’s implementation. Additional limitations include potential recall bias, the influence of participants’ emotional and psychological states during interviews, and the possible impact of the lead researcher’s background and assumptions—despite ongoing reflexive practices, including journaling and peer debriefing, to mitigate these influences.

Conclusion

The nursing internship is not merely a training period but a transformative rite of passage that guides students from dependency and uncertainty toward intellectual autonomy and a consolidated professional identity. Despite significant challenges—including dissonance between academic instruction and clinical reality, role tension between learner and laborer, and organizational pressures—the clinical environment, when supported by intentional structures, can foster ethical awareness, clinical confidence, and humanistic growth. Realizing this potential requires sustained academic–clinical collaboration, curricula aligned with real-world demands, and clinical instructors who cultivate psychological safety and reflective practice. Critically, a transparent, learning-centered evaluation system and the explicit recognition of students’ educational rights are non-negotiable for meaningful transformation. Without such safeguards, the internship risks perpetuating burnout and disillusionment; with them, it becomes a powerful catalyst for professional becoming. Ultimately, when implemented with humanity, structure, and support, the internship can nurture a new generation of nurses who are not only clinically competent but also ethically grounded and deeply committed to the values of their profession. Future research could focus on the effectiveness of structural interventions such as clinical instructor training or reform of evaluation systems in mitigating these challenges.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Z.H., L.M., and R.S. contributed to the study conception and design. Material preparation, data collection and analysis were performed by Z.H. and L.M. The first draft of the manuscript was written by Z.H. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

This research was financially supported as an approved research project by the Vice-Chancellor for Research at Khoy University of Medical Sciences. The funder had no role in the design of the study, collection, analysis, and interpretation of data, or in writing the manuscript.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the qualitative nature of the data and ethical restrictions regarding participant privacy, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Khoy University of Medical Sciences (Ethics Code: IR.KHOY.REC.1404.020, Date: 22 July 2025 No: 404000008). All methods were carried out in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.