Healing professional rifts: a qualitative investigation of nursing students’ occupation stigmatisation during clinical rotations

Abstract

Background

Compared to students in other disciplines, nursing students often face significantly more negative perceptions about their profession. This occupational stigma adversely affects their views on their future professional roles, their autonomy in decision-making, and the perceived value of their work. These detrimental beliefs influence their self-assessment and exacerbate their negative feelings towards their chosen career, potentially contributing to reduced workforce retention and diminished interest in nursing careers. Consequently, it is essential to place greater emphasis on enhancing the professional competence of nursing interns and to take proactive measures to mitigate the harmful effects of occupational stigma, alongside supporting them in applying their knowledge and developing their clinical skills.

Method

This study employs a descriptive qualitative research methodology, using the Stigma-Identity-Threat model as its theoretical framework. The study involved 14 nursing students on clinical rotation at a university in Wenzhou, Zhejiang Province. Semi-structured interviews were conducted to collect data on the students’ experiences of and evaluations of clinical stigmatisation, and thematic analysis was used to analyse the findings.

Results

This study identified four themes and 10 subthemes related to experiences of stigmatisation among nursing students during their clinical rotations. The four themes include stigma-triggering factors, perception and evaluation of social status, the physical and psychological experience of occupational stigma, and coping strategies and qutcomes in relation to occupational stigma.

Conclusion

During clinical rotations, nursing students often encounter numerous instances of professional stigma. Deep-rooted stereotypes and labels associated with the nursing profession, frequent conflicts between nurses and patients during clinical practice, patients’ lack of trust in nursing students’ professional competence, as well as the students’ own unique personality traits and varying levels of psychological resilience—all these factors can influence nursing students’ perception and evaluation of professional stigma. When nursing students encounter occupational stigma, their bodies instinctively produce involuntary reactions, such as unexplained increases in heart rate or involuntary sweating; simultaneously, they may also actively engage in voluntary responses, such as regulating their emotions or restructuring their cognition to alleviate internal stress or actively seeking external support. However, if nursing students are exposed to a stigmatising environment for an extended period, their professional identity may gradually become undermined, potentially influencing their career choices.

Trial registration

Not applicable.

Introduction

Goffman [1]introduced the academic concept of stigma in psychological research, defining it as “a disfiguring attribute.” This characteristic does not constitute a stigma in itself; it only becomes one when it is disparagingly labelled due to failing to meet social norms or expectations. As research has advanced, scholars have categorised stigma based on various criteria, expanding the notion across multiple domains to elucidate a range of phenomena. For instance, stigma can be classified according to the characteristics of the stigmatised individual, including gender, occupational, geographical, welfare, organisational, and disease-related stigmas [2]. Among these, the concept of “dirty work” serves as a source of occupational stigma. Hughe [3] previously classified dirty work into three categories based on the nature of the tasks involved: moral, social, and physical. However, it is important to note that “dirty work” is distinct from occupational stigma. Occupational stigma pertains to the public’s negative perceptions of specific occupations regarding their physical, social, moral, or emotional attributes, whereas “dirty work” directly relates to the content of the job itself. Both practitioners and external observers recognise these perceptions, which create varying degrees of awareness of professional stigma [4].

Nurse occupational stigma is when people in general look down on nurses’ professional behaviour, traits, social standing, and connections with patients [5]. Long-standing stigma against nursing exists in Chinese society. The public views nursing as “serving others” and views it as “tainted” due to traditional views. Nurses frequently come into contact with patients’ excrement and bodily fluids, leading the public to label the profession as “tainted” on a physical level [6]; Frequent conflicts between nurses and patients, as well as patient and family suspicion and distrust, have further burdened the nursing profession with moral “taint” [7, 8]. This one-sided perception is likely to cause cognitive biases and a generalization effect, as the public extrapolates the wrongdoing of a few nurses to the entire nursing profession. In the age of new media, information spreads quickly, and the media’s excessive focus on, misinterpretation of, and sensationalized reporting of negative incidents involving medical staff has further stigmatized the nursing profession and completely distorted the public’s objective view of nurses’ professional identity [9–12]. Internal professional issues have added to public perceptions and stigmatized the profession. Nurses are neglected and underrepresented in resource allocation and professional advancement in the healthcare system. These multi-layered professional biases and lack of respect have stigmatized nursing, making it challenging for nurses to earn social and professional respect [13]. Stigma associated with one’s occupation has a considerable effect on the nursing field. It harms nurses’ professional identity and feeling of success, and it also makes them feel inadequate makes them less responsible and engaged at work, and hurts nurse-patient interactions and treatment outcomes [14, 15]. Additionally, occupational stigma is a major reason for the lack of qualified nurses, leading to higher rates of nurses quitting or changing careers, which exacerbates the shortage and complicates the smooth operation of healthcare services [16]. Consequently, eradicating occupational stigma and cultivating an atmosphere of equity and respect is vital for the robust advancement of the nursing profession.

Nursing students are a unique and important demographic in medical education. Their transition from theoretical learning to clinical practice is critical: they have acquired systematic nursing theory and basic procedures but have not yet been licensed. They are the primary reserve force for future nurses and learn clinical skills through observational training and clinical rotations. Students’ professional awareness, mindset, and clinical performance affect the quality of nursing care during clinical rotations, talent retention, and the profession’s long-term growth [17]. Transitional nursing students endure more academic and clinical responsibilities. More than other students, nursing students must master professional knowledge and practical skills and address real-world challenges like communication, unexpected risks, and role adaptation in high-pressure, ever-changing clinical environments. Due to negative social opinions about nursing, nursing students are more likely to be exposed to negative information about their profession during their studies and clinical rotations, according to research [18]. Occupational stigma affects nursing students without clear professional values more significantly. Nursing students are more sensitive to social stereotypes and occupational biases than licensed nurses because their professional perceptions and self-identity are still developing. Long-term stigma might make students doubt the nursing profession’s prospects, their autonomy, and its usefulness. Such experiences can make them doubt their major, impair their professional identity and sense of belonging, and exacerbate their nursing attitude [19, 20]. Stigma causes psychological stress and resource depletion, so nursing students often use passive coping strategies and withdraw from the profession, including not attending clinical rotations, fluctuating academic performance, and losing their professional identity. Some students even consider switching majors or abandoning nursing, which reduces nursing talent and industry resources [21]. Consequently, while teaching nursing interns, it is imperative to facilitate the integration of theoretical knowledge with practical application and to cultivate robust clinical skills, while simultaneously prioritising the enhancement of professional competence and the reduction of occupational stigma. At now, research on occupational stigma in nursing in China remains limited, predominantly concentrating on male nurses. There is a dearth of research investigating nursing interns’ feelings of occupational stigma, and qualitative studies addressing this adverse effect are particularly insufficient.

Major and Brien [22]came up with the Stigma-Identity Threat Model, which says that people with a low social identity are more likely to confront events that could be stigmatising. Their perception of stigma is shaped by three factors: collective representation denotes a shared perception of status among stigmatised groups; in this context, it pertains to the prevalent stereotypical views of the nursing profession that cause nursing students to develop common negative perceptions. Situational cues denote the diverse contexts that elicit various forms of occupational stigmatisation; nursing students primarily investigate their experiences of stigmatising situations during hospital internships. Personal characteristics encompass factors such as an individual’s sensitivity to stigma and group identity, which affect their perception and evaluation of a situation. Different nursing students assess stigmatisation in distinct ways, resulting in two categories of responses: Nonvolitional responses, which encompass physiological arousal and primal emotions as the body’s assessment of threats; and volitional responses, which involve deliberate attempts to manage emotions, cognition, behaviour, and physiology to navigate situations or environments perceived as stressful. Refer to Fig. 1 for specifics. To date, no research has used this model to look into how nursing interns have been stigmatised. This study utilises a descriptive qualitative research methodology, employing the Stigma Identity Threat Model to examine the stigma experiences of nursing students. The study seeks to get a more profound comprehension of participants’ experiences and coping mechanisms about stigma, consequently offering scientific insights to assist nursing educators in formulating successful intervention techniques.

Fig. 1.

Diagram of the stigma-identity threat model

Subjects and methods

Research design

This study adopted the hybrid deductive-inductive theme analysis method established by Fereday and Muir-Cochrane [23] to analyze the interview data. Drawing on Major and O’Brien’s [22] stigma-identity threat model as its theoretical underpinning, the study extracted the model’s major characteristics to produce a semi-structured interview guide and gave a theoretical analytical perspective for understanding the research findings. In order to retain an open analytical approach, the study first used deductive coding based on theoretical aspects during the coding phase. In order to balance the guiding value of the theoretical framework with the local authenticity of the raw data, the study used bottom-up inductive coding to find new themes that naturally emerged from the data rather than restricting the analysis of the raw interview transcripts to the model’s predefined constructs. The research complies with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Research subjects

This study was performed in May 2025, with nursing students from a university in Zhejiang as research participants; these students were engaged in placements nationwide. Prior to conducting the interviews, this study first gave a questionnaire survey comprising general demographic and sociological data for nursing interns, as well as the Occupational Stigma Scale and the Communication Anxiety Scale. The study uses purposive sampling mixed with maximum diversity sampling to choose research participants. The research team carefully took into account various geographic and cultural backgrounds in addition to demographic characteristics like gender, age, and the location of the internship hospitals to guarantee the sample was representative and diverse. In the end, interview subjects were nursing interns who scored higher than the norm on the Occupational Stigma Scale and lower than the mean on the Communication Anxiety Scale. The inclusion criteria were: (1) full-time undergraduate nursing students doing clinical placements for the first time, and (2) a clinical placement duration of no less than 10 months. Exclusion criteria included: (1) those with severe psychiatric disorders or mental diseases; (2) individuals who had withdrawn from or taken a leave of absence from their education. All subjects willingly engaged in the study based on informed consent. Before the interviews, the researcher went over the study protocol and any safety measures with the participants in detail. After getting their written agreement, they were officially added to the study sample.

Sample size

The sample size was established based on the idea of data saturation, which dictates that recruitment stops when no new topics arise throughout the interviews. This study included 14 respondents, numbered consecutively from N1 to N14, based on this criterion for later analysis and citation.

Interview guide

This study principally synthesises the Stigma Identity Threat Model by correlating interview themes with the theoretical framework. The study examined the theoretical language through the theoretical dimensions of Collective representation, Situational cues, Personal characteristic, and Nonvolitional responses, volitional responses, Outcomes. Simultaneously, via a literature study, the research team coordinated several internal conversations and proactively solicited expert insights from authorities in nursing education, finally developing pragmatic interview themes. To ensure the scientific rigour and efficacy of the interview guide, the study team recruited a small cohort of undergraduate nursing students (n = 4) to perform preliminary interviews. The formal interview guide, which is displayed in Table 1, was made after carefully and thoroughly changing the questions in the guide based on what the participants said during the pilot interviews.

Table 1.

Interview guide

Theoretical dimension	Theoretical linguistics	Interview questions
Collective representation	The widespread perception that the nursing profession is undervalued by society	1. What have you heard about the nursing profession?
Situational cues	In certain situations, people may view a nurse’s role with disdain	2.What instances of unequal treatment did you encounter during your internship? Can you describe the circumstances at the time? 3.When engaging with patients and their families, do you ever concern yourself that your identity may affect how others perceive you?
Personal characteristic	Sensitivity to stigma	4.During your placement, did you feel that anyone may have held a particular perception of you due to your status as a student nurse?
	Individual differences	5. Do you feel that your sense of self-worth was acknowledged during your internship༟ 6. Do you feel that you received a reasonable level of support during your internship?
Nonvolitional responses	Physical reaction	7. During your placement, if you perceive that others are treating you with prejudice due to your status as a student nurse, would you notice a physical reaction in your body?
volitional responses	Emotions and Cognition	8. Faced with a situation like this, how would you adjust your mindset in the moment? Could you please share the strategies you would consider adopting afterwards to address it?
Outcomes	Career Choice and Professional Identity	9. Have your career plans shifted since you began your internship? If they have, could you share the reasons behind this change?

Data collection

This study collected data via semi-structured interviews. To ensure the study was effective and feasible, the research team used Tencent Meeting to conduct online interviews with nursing students who are scattered following their assignments. The researchers explained the study’s goals, methodology, and purpose in writing and speech before the interviews. This included anonymizing data, protecting privacy, and allowing participants to withdraw at any time. We only obtained written consent after verifying informed consent. The Tencent Meeting recording feature recorded the entire interview, including pauses and emotions. After double-encryption, audio files were saved on another server. The researcher adjusted the question order based on the discourse, staying impartial to avoid leading questions. No participants dropped out of the trial. Only the researcher and interviewee were there. This study employed a non-continuous comparison method, in which interview data were coded and compared in batches rather than analyzed individually and in real time; when, after multiple rounds of comparison, three consecutive interviewees failed to yield any new themes, the data were deemed to have reached information saturation, and the interviews were terminated.

Data analysis

After the interviews, the interviewer obeyed the rule of timeliness and typed out the audio recordings word for word within 24 h to make detailed written records. Two researchers independently and carefully reviewed the transcribed texts to ensure that they were correct and trustworthy. After that, the confirmed texts were brought to the qualitative analysis software Nvivo 14.0 so they could be organised in a systematic way. Content analysis was the main method used during the data analysis phase. Sentence-by-sentence and paragraph-by-paragraph analysis and breakdown of all raw interview transcripts were used in this study, and open, native coding was performed while totally putting aside any theoretical framework. The coding process strictly adhered to a bottom-up, data-driven approach, relying entirely on the respondents’ authentic statements to distil indigenous, native codes. The study systematically extracted and tagged meaningful statements from the text and carried out preliminary induction. In the end, the process led to the creation of an initial native coding system specific to the local care context.

A consideration of ethics

This study was conducted in accordance with the principles of the Declaration of Helsinki, and the study protocol was approved by the hospital’s ethics committee (ethics approval number 2024-203-K-170-01).

Quality control

The researcher gave the interviewee a full and detailed explanation of important information, such as the research goals, the rules of confidentiality, and the idea of voluntary participation, before the interview started. This procedure was done to make the interviewee feel comfortable and free to speak. This approach made sure that people could say what they really thought and felt. The researcher used communication skills like active listening and sympathetic answers during the interviews to get important information from what the interviewee said. At suitable intervals, the researcher used probing questions to encourage the subject to provide a more complete explanation, resulting in rich, detailed, and meaningful narrative data. Two academics meticulously checked the transcribed material for accuracy and reliability. After that, the confirmed texts were organized in NVivo 14.0, a qualitative analysis software. A non-constant comparison technique was used throughout the analytic process. Each time a new code was found, it was carefully compared to previous codes and to other interview transcripts. Through this process of comparison, themes were constantly improved and fine-tuned to ensure that they accurately captured the main ideas of the research.

Results

General information

There were 14 people who were interviewed. The interviews were between 22 and 24 years old, and there were 4 men and 10 women. The interviewees had a wide range of plans for their careers after graduation. Five said they wanted to continue their education, three said they wanted to work in Grade A tertiary hospitals, two said they wanted to work in Grade B secondary hospitals, two said they wanted to work in other fields, one said they wanted to work in non-clinical roles within the nursing sector, and one said they wanted to work in community-related roles. Table 2 shows specific general information.

Table 2.

General information on interviewees(N = 14)

Coding	Gender	Age	Career Planning
1	Female	22	Further education
2	Female	22	Grade A tertiary hospitals
3	Female	23	Further education
4	Male	23	Grade A tertiary hospitals
5	Female	22	Further education
6	Female	22	Grade B secondary hospital
7	Female	23	Further education
8	Male	22	Further education
9	Female	24	Non-clinical nursing work
10	Male	22	Grade A tertiary hospitals
11	Female	22	Working in other sectors
12	Male	22	Community hospital
13	Female	23	Grade B secondary hospital
14	Female	22	Working in other sectors

Themes

The study performed a preliminary synthesis, removing redundant, invalid, and semantically ambiguous content after methodically extracting and tagging significant sentences from the text. This procedure finally resulted in the construction of an original, first coding system adapted to the local care setting, giving a solid foundation of raw data to facilitate later thematic clustering and category refinement. The results of the open-ended initial coding are given in Table 3. By repeatedly comparing and consolidating all initial codes, we inductively developed secondary and core themes, thereby establishing a localized thematic analysis framework based on the raw data. Ultimately, four themes were identified: (1) stigma-triggering factors; (2) perception and Evaluation of Social Status; (3) physical and psychological experiences of occupational stigma; and (4) Coping Strategies and Outcomes in Relation to Occupational Stigma. These themes comprise 10 subthemes, as indicated in Table 4.

Table 3.

Intinal coding

Initial Coding	Original Representative Statement
Undervaluation of Nursing Skills	N6: “We had a patient who had soiled the bed. The family member asked, ‘Could one of you nurses come clean the mess up?’ I replied, ‘You can ask an orderly to take care of it.’ He retorted, ‘Isn’t that your job?’”
Doubts About Clinical Competence	N4: “Sometimes, as soon as patients hear you’re a trainee, they won’t let you give them an injection.”
Discrimination Based on Nursing Education Level	N1: “Some patients, upon learning that I have a bachelor’s degree, seem puzzled and ask, ‘Why go to all that trouble to get an education just to become a nurse?’ or assume that all nurses have only a vocational high school or technical school diploma.”
Difficulty Adapting to Clinical Practice	N3: “At first, I felt like the pace in the clinical setting was incredibly fast, and it was challenging to adjust right away. I really didn’t expect nursing work to be so exhausting, especially during night shifts.”
Assignment of Dirty, Tiring, and Complex Tasks	N11: “Working in the ICU was a real shock to me. I often had to deal with patients’ bodily waste, which I hadn’t expected, and it made me feel really uncomfortable.”v
Unequal Treatment of Patients	N7: “But from the patients’ perspective, it might not be that way; they might place a little more trust in doctors.”
Nursing Students Assigned a Large Volume of Menial Tasks	N6: “I feel like after going through those ten months, that sense of value gets a bit worn down.”
Lack of Organizational Support	N11: “We don’t get paid, yet we have to rent our own apartments and cover our own expenses. The financial pressure is really quite heavy.”
Impact of Doctor-Patient Conflicts	N8: “It was after the family members came and caused a scene last time—at first I was really scared and felt that my personal safety was at risk. ”
Physical Discomfort and Reactions	N7: “After this, I’m even less interested in nursing. I feel unsafe when a patient argues; I become uncomfortable and my heart races.”
Negative Emotional Experiences	N9: “Sometimes I really do worry about making mistakes. When I think back on times I’ve been treated unfairly and how my supervisor didn’t stand up for me, I get anxious before I start work—I even lie awake at night.”
Seeking Support from Clinical Instructors	N5: “There’s a mentor who teaches me so much every time he gives guidance, so I find him particularly charismatic and look up to him immensely. He’s someone who has left a deep impression on me, and I’d very much like to learn from him.”
Reinforcing the Meaning of the Nursing Profession	N3: “I often tell myself that nursing is a profession that demands a strong sense of mission—one that is best suited to those with a deep sense of responsibility—and that saving lives and treating the injured brings a great sense of fulfilment
Avoiding Clinical Procedures	N1: “I just don’t work as enthusiastically as I did when I first started my work placement; I feel that as long as I can get through it without any problems, that’ll be fine.”
Lowered career expectations	N13: “I chose to work in a hospital because I reckon the nursing sector offers better job prospects and more job security.”
Regret choosing nursing as a major	N4: “Sometimes I regret that I didn’t do well in my A-levels, which meant my choice of degree programmes was very limited, so I ended up choosing this one. If I could do it all over again, I probably wouldn’t choose this program.”
Contemplating a career change or resignation	N2: “I’m just thinking about finding a job first, and there’s a possibility I might not stick with nursing afterward.”

Table 4.

Summary of topics

Topic	Subtopic	Initial Coding
Stigma-triggering factors	External stigmatizing label	Undervaluation of Nursing Skills
		Doubts About Clinical Competence
		Discrimination Based on Nursing Education Level
	The Reality of Clinical Practice	Difficulty Adapting to Clinical Practice
		Assignment of Dirty, Tiring, and Complex Tasks
	Different ways patients treat doctors and nurses	Unequal Treatment of Patients
Perception and Evaluation of Social Status	The erosion of professional value	Nursing Students Assigned a Large Volume of Menial Tasks
	Perceived imbalance in occupational status	Lack of Organizational Support
		Impact of Doctor-Patient Conflicts
The Physical and Psychological Experience of Occupational Stigma	Physiological expenditure	Physical Discomfort and Reactions
	Emotional exhaustion	Negative Emotional Experiences
Coping Strategies and Outcomes in Relation to Occupational Stigma	Proactive and adaptive response	Seeking Support from Clinical Instructors
		Reinforcing the Meaning of the Nursing Profession
	Passive-defensive response	Avoiding Clinical Procedures
		Lowered career expectations
	Changes in professional identity	Regret choosing nursing as a major
		Contemplating a career change or resignation

Theme 1: stigma-triggering factors

External stigmatizing label

Some nursing students indicated that they typically experience external stigma and stereotypes from society, patients, and online discussions. Some people think that nursing doesn’t require much education or technical expertise, and these designations consistently hurt the professionalism, educational value, and social prestige of nursing jobs. Nursing students internalise these as feelings of professional shame and self-doubt, which makes them even more unsure about their careers and more alone.

N1: Some patients, upon learning that I have a bachelor’s degree, seem puzzled and ask, ‘Why go to all that trouble to get an education just to become a nurse?’ or assume that all nurses have only a vocational high school or technical school diploma

N4: Sometimes, as soon as patients hear you’re a trainee, they won’t let you give them an injection

N6: We had a patient who had soiled the bed. The family member asked, ‘Could one of you nurses come clean the mess up?’ I replied, ‘You can ask an orderly to take care of it.’ He retorted, ‘Isn’t that your job?

N9: Because the entry requirements for nursing used to be relatively low, many members of the general public perceive nursing as a profession requiring little education, with no barriers to entry—just like a waiter or a janitor. That’s how they view nurses

The reality of clinical practice

When they started the clinical practice phase, some of the nursing students who were interviewed specifically mentioned that they had a major reality check. They had little exposure to in-depth clinical practice during their academic education, instead concentrating mostly on theoretical knowledge and specific professional abilities. Their initial views of the nursing profession as a technological discipline and their feeling of professional dignity in real-world work situations were challenged by the “dirty work” and “gruelling tasks” they unavoidably experienced during their clinical rotations.

N3: At first, I felt like the pace in the clinical setting was incredibly fast, and it was challenging to adjust right away. I really didn’t expect nursing work to be so exhausting, especially during night shifts

N11: Working in the ICU was a real shock to me. I often had to deal with patients’ bodily waste, which I hadn’t expected, and it made me feel really uncomfortable

N14: The task wasn’t what I expected after my clinical rotation. I thought nursing was only giving injections and setting up IVs, but working at the clinic showed me we also provide basic daily care

Different ways patients treat doctors and nurses

During their clinical rotations, nursing students frequently see inequalities in the professional trust that is placed in various professions. Patients and their families frequently exhibit a natural regard and trust for physicians while keeping a skeptical attitude toward nursing students. Not only is this asymmetry in trust a prevalent difficulty in clinical interactions, but it also originates from stereotypes connected with professional identities in healthcare settings. For this reason, it is a significant contributor to the perceived professional stigma that nursing students encounter.

N7: But from the patients’ perspective, it might not be that way; they might place a little more trust in doctors

N8: I always notice a clear difference in how patients treat nurses versus how they treat doctors

N11: But in the patients’ eyes, doctors hold a higher status than nurses. If a doctor says something will work and a nurse says it definitely won’t, patients treat them completely differently. “Additionally they generally feel that doctors are a step above nurses

Theme 2: perception and evaluation of social status

The erosion of professional value

Some nursing students have observed that their work during clinical rotations is highly repetitive and relies on a limited set of technical skills. Consequently, they find it difficult to experience genuine personal fulfilment and growth from their daily tasks. This diminishes their enthusiasm for their profession and conveys an unspoken message: that nursing is merely mindless physical labour. Furthermore, while nursing students first recognized the noble value of the nursing profession, their sense of identification with and respect for it fell dramatically after experiencing stigmatization.

N1: Since I’m still just an intern, the teachers don’t let me do much—just some fairly basic tasks. There are many procedures I’d like to perform, but I don’t get the chance, so I feel like I haven’t really been able to contribute much

N6: I feel like after going through those ten months, that sense of value gets a bit worn down

N7: Constantly collecting vital signs, testing blood sugar, and running errands feels menial. I spent all day doing nebuliser treatments as a respiratory intern. From clocking in until clocking out, I only did nebulisers

Perceived imbalance in occupational status

Some nursing students claim that their rights and professional status are frequently treated unfairly: during their clinical rotations, they must engage in clinical work for extended periods of time without receiving compensation, and they must also pay for various living expenses, including rent, on their own; hospital administrators frequently support patients in disputes between nursing staff and patients, failing to uphold students’ rights in an impartial and fair manner; and when disputes between patients and medical staff escalate, nursing students frequently find themselves in situations where their personal safety is not guaranteed. Due to various practical constraints and sentiments of injustice, these many irrational situations have caused nursing students to experience bad professional emotions.

N8: It was after the family members came and caused a scene last time—at first I was really scared and felt that my personal safety was at risk

N9: I think the healthcare system doesn’t support nurses enough. Every time a patient files a complaint, the nursing department demands the nurse apologize instead of analyzing the facts or helping the nurse explain and comfort the patient

N11: We don’t get paid, yet we have to rent our own apartments and cover our own expenses. The financial pressure is really quite heavy

Theme 3: The Physical and Psychological Experience of Occupational Stigma

Physiological expenditure

According to some nursing students, unpredictable shift patterns—particularly frequent night shifts and high-intensity clinical work—are directly linked to persistent physical fatigue and declining health. Furthermore, nurses’ bodies tend to react to professional stigma before their minds do when faced with patient-nurse confrontations, especially when they sense patients’ mistrust and contempt. These reactions may manifest as physical symptoms, including a rapid heartbeat, trembling hands, or even cold sweats.

N7: After this, I’m even less interested in nursing. I feel unsafe when a patient argues; I become uncomfortable and my heart races

N8: Some procedures were unfamiliar to me during my placement. I felt helpless when patients wouldn’t let me do things; inserting an IV cannula, which is a thin tube placed into a vein for medication or fluids, would make my palms sweat with nerves

N14: Night shifts are very busy, especially with many cardiac monitoring patients. I was so busy from the start of my shift until the end that I didn’t have an opportunity to eat, and I had a stomach cramp from hunger that lasted for hours

Emotional exhaustion

According to some nursing students participating in clinical placements, the ongoing emotional rejection and denial of their dignity during their placements have had a severe psychological impact on them, resulting in depressive and anxious feelings. In addition, it may simultaneously trigger emotional and sleep issues such as work-related anxiety and insomnia, leading to significant psychological strain.

N9: Sometimes I really do worry about making mistakes. When I think back on times I’ve been treated unfairly and how my supervisor didn’t stand up for me, I get anxious before I start work—I even lie awake at night

N12: I’m here to learn and serve, but some patients and their families treat me like a servant, ordering me around and verbally abusing and nitpicking me. When I feel wronged, I question why I’m doing this

Theme 4: coping strategies and outcomes in relation to occupational stigma

Proactive and adaptive response

Some nursing students actively reconstruct their perception of the profession to counteract the impact of threats to their professional identity after experiencing stigmatisation. Specifically, this manifests as a reinforcement, at the level of values, of the sacred mission and sense of responsibility inherent in nursing to save lives and alleviate suffering; they draw emotional support from the social recognition that nursing and medical professions command within their families; and they take the rigorous and professional demeanour of their clinical supervisors as a model for their professional development.

N3: I often tell myself that nursing is a profession that demands a strong sense of mission—one that is best suited to those with a deep sense of responsibility—and that saving lives and treating the injured brings a great sense of fulfilment

N5: There’s a mentor who teaches me so much every time he gives guidance, so I find him particularly charismatic and look up to him immensely. He’s someone who has left a deep impression on me, and I’d very much like to learn from him

N13: Most of the supervisory staff are really dedicated and responsible; they truly do share their expertise with us without holding anything back, which I found pretty heartwarming. It’s not as though seniors in every profession are willing to offer their wisdom so generously

Passive-defensive response

After encountering occupational stigma, some nursing students are more likely to adopt a rebellious mindset and use passive-aggressive tactics to protect themselves from discrimination. Other nursing students endure prolonged discrimination and unfair treatment from patients and their families, leading them to develop an avoidance mentality: their initial enthusiasm for clinical work gradually wanes, and they deliberately avoid various clinical procedures to reduce the likelihood of facing stigma again. Others decide to stay in the field because nursing pay is relatively stable, but their professional aspirations and career expectations have significantly decreased; if this trend persists, it will negatively affect their long-term career development.

N1:I just don’t work as enthusiastically as I did when I first started my work placement; I feel that as long as I can get through it without any problems, that’ll be fine

N4: When it comes to looking for a job, I reckon you’d probably find other roles just as tiring, and the pay might not even match what you can earn in the nursing sector, so I think it’s better to stick with this profession

N13: I chose to work in a hospital because I reckon the nursing sector offers better job prospects and more job security

Changes in professional identity

Some nursing students have claimed that, after encountering stigmatization during their clinical rotations, they occasionally regret the career route they have chosen. This pattern of “passive choice” causes them to feel uncomfortable about their career trajectory early in their training; once they meet occupational stigmatization, they may grow to regret their career choice, and some nursing students even consider abandoning this career route.

N2: I’m just thinking about finding a job first, and there’s a possibility I might not stick with nursing afterward

N4: Sometimes I regret that I didn’t do well in my A-levels, which meant my choice of degree programmes was very limited, so I ended up choosing this one. If I could do it all over again, I probably wouldn’t choose this program

N14: I do feel a bit of regret about choosing nursing. Now that my placements

Discussion

This study examines the stigmatization experiences of student nurses using the Stigma-Identity Threat Model. First, the study found that student nurses feel stigmatized in their line of work due to three main causes: the external stigmatizing label, the reality of clinical practice, and different ways patients treat doctors and nurses. The model defines “collective representations” as long-standing industry stereotypes and prejudices formed at the societal level; real-life encounters, such as patients’ resistance to procedures performed by student nurses and the high-intensity clinical internship environment, are categorized as situational characteristics. These include educational bias and the negative image of the nursing profession shaped by the media. These act as on-site cues that immediately cause student nurses to feel threatened by their identities. The aforementioned results show the application of the model’s key dimensions to nursing interns in China by validating the routes through which these two types of cues produce stigmatized identity threat from the viewpoint of a local sample of student nurses. The comprehensive stigma-related identity threat model also contains a personal cue dimension, which refers to variances in stigma perception stemming from individual elements such as personality traits. However, because the primary emphasis of this study was on nursing students with high stigma sensitivity, the group’s consistent and acute experience of stigma obscured personalized cognitive differences at the personality level; as a result, themes pertaining to personal cues could not be identified. Considering the current status of the nursing sector in China, different external stigmatizing labels—represented by educational prejudice—are common, with educational bias being a particularly important concern [24, 25]. While the scale of graduate nursing education in China continues to expand, nursing students still frequently face negative comments regarding their educational background during clinical internships, and some medical professionals remain entrenched in the stereotype that “nursing is a profession requiring a lower level of education [26, 27].” According to a number of nursing students surveyed, patients and their families frequently harbor prejudices and treat them unfairly because of their educational background. In addition to undermining nursing students’ professional dignity, such views also fail to recognize their sustained academic accomplishments [28]. Therefore, eliminating the public’s educational biases toward the nursing profession should be a significant goal for nursing educators. The unfavorable professional image conveyed by the media is another key cause of external stigma. Relevant international studies indicate that the portrayal of nurses on film and television is often limited to basic nursing procedures and passively following doctors’ orders [24]; Hildegart’s [9] review also points out that modern media depictions of the nursing profession have long been predominantly negative, presenting a one-sided view of the profession’s daily routine while ignoring the comprehensive professional standards and requirements of the nursing role [29], thereby continuously misleading public perception. Even though nursing students had previously been exposed to some unfavorable information about the field through online social media prior to their clinical rotations, it was their first-hand encounters with patients and their families, as well as their firsthand observation of the unfavorable stereotypes that were circulating online, that acted as the catalyst for their perception of occupational stigma and had a significant psychological impact. Patients and their families generally have a high level of trust in doctors, but they frequently doubt nurses’ professional competence and qualifications to perform procedures. Social media perpetuates the long-standing stereotype that “nurses lack professional independence,” exacerbating this imbalance of trust [24, 28]. They frequently directly oppose or hinder standard nursing treatments once they discover that the person doing them is a nursing student [30], which is a common cause of occupational stigma for nursing students.

A survey by Mei [31] of nursing students doing clinical rotations in China’s Inner Mongolia region found that their perceived occupational benefits were above average, which contradicts this study. This variance is mostly due to regional development variations in economic levels, healthcare infrastructure, and clinical workloads. Student nurses in different regions have different professional experiences and opinions of the nursing profession due to differences in work settings, clinical teaching methods, and internship benefit schemes. In this study, nursing students entering clinical practice face heavy work pressure, and the unpaid internship model requires them to pay rent and living expenses, which worsens their negative views of the nursing profession. Some internship students still value nursing and have a positive outlook. Educational institutions and clinical preceptorship teams can be role models.

The “identity threat appraisals” component of the stigma threat theory model is consistent with the study’s result that nursing students form entirely new negative opinions about the worth and standing of the nursing profession following various stigmatizing experiences. The negative thoughts and self-evaluations that nursing students have about their professional nursing identity and social standing following stigmatizing experiences in clinical settings are referred to as the “identity threat evaluation” dimension. During clinical rotations, nursing students often spend extended periods performing repetitive, basic, and low-skill nursing tasks—such as measuring blood pressure and monitoring body temperature—making it difficult to fully apply the extensive theoretical knowledge and specialized practical skills they have systematically studied during their academic training. Students gradually begin to have serious misgivings about the fundamental principles of the nursing profession as a result of this gap between theory and practice [30, 32, 33]. Carvello’s [34] study suggests that the mismatch between theory and practice is as frequent among nursing students in Italy, who often discover themselves passively adapting to clinical methods. This implies that nursing students may reconsider and undervalue the professional value of nursing due to the substantial discrepancy between theoretical training and clinical practice. Additionally, prior research [35–37] has demonstrated that during clinical rotations, nursing students often encounter a variety of institutional and emotional stressors. Nursing students often encounter emotional rejection from patients and their families. It is challenging for nurses to obtain the respect and professional recognition they deserve in their nursing work because of the high-intensity work speed and stressful environment of doctor-patient interactions, which consistently undermine their professional dignity. According to the nursing students in this study, clinical institutional arrangements made their internship challenges even worse. The unpaid internship model required them to cover their own living expenses and rent, resulting in a clinical internship environment that was marked by “high workload and low support” [38–40]. As a result, nursing students’ assessments of identity danger are consistently triggered by typical signs of a stigmatizing atmosphere, such as inadequate social recognition and a lack of governmental support for clinical placements. This study further explains the operational features and localization mechanisms of the Stigma-Identity Threat Model among Chinese nursing students by causing them to consistently internalize derogatory labels associated with the profession and undervalue its worth and social standing.

The unconscious physical and psychological stress that nursing students experience due to stigma aligns with the “volitional response” dimension of the Stigma-Identity Threat Model. Student nurses undergo sustained psychological and behavioral changes through cognitive processing as they confront the physical and psychological strain, along with an identity crisis that stems from occupational stigma. These changes—referred to as “involitional responses”—can effectively predict various career outcomes. Faced with the physical and mental hardship and identity crises induced by professional stigma, nursing students did not remain fully passive but instead created several coping techniques. During their clinical practice, when they completed meaningful nursing duties, they typically confirmed the relevance of their vocation, considering nursing as a noble calling committed to “saving lives and healing the wounded” While working with their clinical instructors, nursing students not only methodically gain substantial and specialized nursing information and abilities but also unconsciously experience the unique appeal and value of the nursing profession through everyday encounters [41]. Research by ISKINM [42] indicates that by effectively mastering nursing procedural skills and achieving personal growth and progress, nursing students can gradually build confidence in their professional abilities; this self-affirmation helps them resist the stigma of being viewed as “inferior” in their profession. The unfavorable beliefs and experiences arising from stigmatization might lead some nursing students to demonstrate severe occupational avoidance behaviors, a poor attitude toward their work, regret over their career decision, and a predisposition to abandon the profession [43]. Due to a prolonged lack of acknowledgment from patients, family members, and even the broader public during clinical practice, sustained negative feedback causes nursing students to gradually lose their enthusiasm and initiative in clinical work. As a result, they actively avoid clinical nursing responsibilities and purposefully limit their hands-on practice, which is a common occupational avoidance tactic. When it comes to their professional self-perception, these nursing students consistently diminish their professional expectations, career aspirations, and professional goals. They may even feel a great deal of regret about their choice to major in nursing, discounting both the effort they put into their studies and their career choice [44, 45]. Although some nursing students may choose to remain in the business temporarily due to its practical advantages—such as consistent income and a high tolerance for errors—most no longer construct long-term, clear career development objectives [46]. They often view the nursing profession as a temporary stepping stone, lacking a sense of professional belonging and motivation to fully commit to the field. At the same time, they acquire a strong wait-and-see attitude concerning leaving and a latent tendency to resign. The professional identity and enthusiasm of nursing personnel are the primary intrinsic motivations for guaranteeing the quality of clinical nursing services and improving the accuracy of nursing practice, according to existing research. In addition to low job motivation, a lack of initiative in service delivery, and high rates of burnout, the negative professional perspective that nursing students develop throughout their clinical rotations also causes talent drain and recurring thoughts of leaving [47]. This situation leads to several problems, such as a drop in the general enthusiasm of the nursing workforce, a lack of professional drive, and poor talent retention. In the end, the situation directly affects the standardization, professionalism, and quality of clinical nursing services, seriously impedes the development of a tiered nursing workforce, and negatively affects the quality of talent cultivation and the long-term sustainable development of the nursing industry [48, 49].

Therefore, educational institutions, clinical teaching units, and society at large must create a multifaceted, cooperative intervention system to lessen nursing students’ experiences of occupational stigma and improve their professional identities. Nursing schools must promote pre-clinical practice and ongoing practical training for nursing students. To help students become acquainted with the clinical work environment, operational models, and professional realities before they formally begin clinical internships, the curriculum should include phased observations, scenario simulations, and pre-employment training [50]. This will help students cope with workplace stress and initial disappointment. To help nursing students develop an objective and rational understanding of the profession and strengthen their psychological resilience when confronted with clinical prejudice and injustice, professional values courses should systematically incorporate courses on coping with professional setbacks, stigma awareness counseling, and stress management in addition to traditional positive professional empowerment and role model education. Second, at the clinical teaching level, the supervision management system should be strengthened to enhance clinical instructors’ understanding of humanistic teaching and their sense of responsibility. Instructors should promptly intervene to provide guidance and positive support when nursing students encounter patient skepticism, verbal prejudice, or unfair treatment, thereby safeguarding the professional dignity and legitimate rights of student nurses and mitigating the cumulative impact of negative incidents. At the same time, clinical departments can create a welcoming and respectful clinical teaching environment by telling patients and their families about the educational benefits and job responsibilities of student nurses. This lessens discrimination and resistance resulting from biases related to trust by assisting patients in viewing student nurses’ clinical procedures in a logical manner. To prevent problems like professional withdrawal and lowered career aspirations, nursing schools can also offer focused psychological counseling services, regularly screen for stress related to internships and provide psychological support, and act quickly to address negative mental states and occupational burnout resulting from extended experiences of stigma among nursing students [51]. Lastly, the public’s stereotype that the nursing profession is “low-skilled” can be dispelled by promoting the professional essence, technical value, and social significance of nursing work through various public education channels. This will improve the public’s overall perception of the nursing profession [52]. This method lowers the sources of occupational stigma for nursing students from an external perspective and helps them form solid and positive ideas about their career development.

Limitations

This study has several drawbacks. Specifically, the scope of the study was limited to a single university, and it did not adequately account for changes in teaching techniques and clinical placement arrangements among universities. Furthermore, all of the study’s respondents were nursing students who had selected a profession with a high degree of occupational stigma; these students are more likely to aggressively express their emotions, which may skew the sample toward unfavorable viewpoints. It is challenging for the study to accurately reflect the overall experiences of all nursing students in clinical placements because of the substantial danger of self-selection bias. Second, there is a significant imbalance in the gender ratio of the study participants, with a higher proportion of female nursing students. This makes it difficult to conduct an in-depth analysis of potential differences between male and female nursing students regarding perceptions of occupational stigma, coping strategies, and professional identity. Third, this study employed qualitative research methods, and the data itself is inherently subjective. It is susceptible to the influence of the participants’ personal views, emotional states, and the researcher’s own perspective, which may compromise the objectivity and reproducibility of the findings. Future research could expand the sample’s scope, optimise the gender composition, and incorporate quantitative research methods to more comprehensively and objectively reveal the mechanisms underlying the formation of occupational stigma among nursing interns and identify effective intervention pathways.

Conclusion

To systematically create a thorough framework of nursing students’ experiences with occupational stigma, this study collected raw narrative data from nursing students through semi-structured interviews. It then used a mixed deductive-inductive thematic analysis approach in conjunction with non-continuous comparison to complete data coding and analysis. The findings show that the main causes of nursing students’ perception of external occupational stigma are patients’ unfair treatment of physicians and nurses as well as their perception of an imbalance in the social status of the profession; extended exposure to perceived stigma further triggers a number of detrimental physical and psychological experiences, including physiological exhaustion and emotional burnout; and students adopt a variety of coping strategies in response to ongoing pressure related to stigma, a process that is accompanied by dynamic changes in their professional identities. This study expanded and enhanced the empirical foundation for the application of the Stigma-Identity Threat Model to young nursing interns by elucidating the mechanisms through which occupational stigma emerges and functions among nursing interns. It did this by using the Stigma-Identity Threat Model as its central theoretical framework and authentic narratives from domestic clinical internship settings.

Addressing Occupational Stigma, A multi-level support system is needed: at the societal level, media campaigns and public awareness initiatives should promote the professional value of nursing jobs, demolishing preconceptions like “manual labour” and lowering nursing students’ stigmas. Education and therapeutic settings must develop positive practical environments. Nursing students need emotional support and direction from clinical teachers, peers, and psychological counselling, as well as better skill training. Increased autonomous practice under instructor instruction will enable nursing students to respond to scepticism with professional competence, acquire confidence, and strengthen their professional identities.

Abbreviations

COREQ

Consolidated Criteria for Reporting Qualitative Research

Author contributions

Xintian Wang Writing – original draft, Writing – review & editing， Investigation, Formal analysis. Sisi Jiang, Writing – review & editing, Investigation, Formal analysis. Jiating Wang, Writing – review & editing. Huanle Yu, Writing – review & editing. Rui Zhou, Writing – review & editing, Xiao Wang, Writing – review & editing. Yuyang Li, Writing – review & editing. Ya Lin Wang, Writing – review & editing. Nuo Lin, Writing – review & editing. Yuanyuan Shi Writing – review & editing. Jing Wang Writing – review & editing. Xi Zhang, Writing – review & editing. Peihua Zhang, Writing – review & editing. Xiaoqiong Huang, Supervision, Writing – review & editing, project administration. All authors read and approved the final manuscript.

Funding

The Zhejiang Provincial Department of Education’s provided funding for this study [grant number Y202457320 ].

Data availability

Participants only consent to the use of their data for specific research purposes and do not authorize us to use it for other purposes, including data sharing. We respect and comply with their wishes and are therefore unable to provide data sharing.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki, and the study protocol was approved by the hospital’s ethics committee (ethics approval number 2024-203-K-170-01).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.