Challenges in the clinical learning environment: experiences of final-year nursing students in a tertiary institution in Ghana

Challenges in the clinical learning environment: experiences of final-year nursing students in a tertiary institution in Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges in the clinical learning environment: experiences of final-year nursing students in a tertiary institution in Ghana Agani Afaya, Donald Babamomba Amenah, Nana Ataa Asamoah Akosuah, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9205409/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Clinical practicum is central to nursing education, yet suboptimal clinical learning environments can hinder competence development and readiness for practice. Evidence from sub-Saharan Africa remains limited, particularly on final-year students approaching transition to practice. This study explored final-year nursing students’ experiences of clinical practicum in Ghana and the strategies they use to navigate learning constraints. Methods An exploratory qualitative design was used. Twenty-four final-year nursing students from a Ghanaian tertiary institution were purposively recruited. Data were collected through twelve individual interviews and two focus group discussions, audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Reflexivity, collaborative coding, and an audit trail supported rigor. Results Two themes were generated: challenges in the clinical learning environment and coping strategies. Reported challenges included poor mentorship, limited hands-on opportunities, restricted access to protective equipment, theory–practice gaps, and language barriers. These constraints undermined confidence and perceived readiness. Students demonstrated resilience through self-directed learning and supportive staff relationships, with positive feedback fostering confidence and professional identity. Conclusion CLEs function as both barriers and formative spaces for learning. Strengthening mentorship, resource availability, and psychologically safe supervision is essential to optimizing students’ transition in resource-limited contexts. Clinical learning environment Nursing students Nursing education Clinical practicum Theory–practice gap Ghana Background Clinical nursing education is fundamental to preparing students for safe and competent professional practice ( 1 ). It provides practical experience for nursing students, allowing them to apply their theoretical knowledge in real-life situations. It also supports the development of competent, confident, and safe nursing professionals capable of delivering high-quality healthcare services upon graduation ( 2 ). Through practicum, nursing students acquire clinical judgment, psychomotor skills, communication skills, and professional skills ( 2 ). A central goal of nursing education is to facilitate meaningful clinical learning experiences that foster critical thinking, skill acquisition, and readiness for independent practice. However, despite its central role, the Clinical Learning Environment (CLE) remains a complex and often challenging setting for student learning. Global evidence indicates that between 40% and 75% of nursing students experience significant difficulties during clinical training ( 2 ). These challenges are commonly associated with the transition from classroom-based learning to real-world clinical settings. For instance, a study by Tang et al. in China reported moderate levels of transition shock among nursing students, reflecting notable adjustment difficulties during clinical practice ( 3 ). Similarly, Ko and Kim found that students frequently experience fear and anxiety when managing critically ill patients, largely due to reliance on simulation-based learning prior to clinical exposure ( 4 ). Evidence from Ayalew further highlights the magnitude of the problem, with 79.2% of students reporting at least one clinical learning challenge ( 2 ). These challenges are frequently more pronounced in low- and middle-income countries (LMICs), where resource constraints, workforce shortages, and limited supervisory support may undermine the quality of clinical education ( 5 , 6 ). Studies across Africa and Asia consistently document barriers such as inadequate clinical learning materials, shortages of preceptors, overcrowded placement sites, weak mentorship structures, and persistent theory–practice gaps ( 2 , 7 , 8 ). Additionally, a recent systematic review further identified negative staff attitudes, disrespectful treatment, discrimination, fear, heavy workload, and insufficient support systems as pervasive obstacles to effective clinical learning ( 9 ). This evidence underscores the vulnerability of the CLE as both a learning space and a professional socialization context. While these challenges affect nursing students broadly, emerging evidence suggests that they may be particularly pronounced among final-year students. This group occupies a critical transition point between supervised training and independent professional practice, where expectations for competence, responsibility, and decision-making are significantly heightened. Studies from diverse settings demonstrate that final-year students often face unique challenges during this period. For example, research from the United Kingdom reports that students in critical care placements sometimes feel excluded from learning opportunities and must actively seek participation in complex procedures ( 10 ). Similarly, findings from Singapore indicate that final-year students frequently experience uncertainty, stress, and feelings of being overwhelmed during their final clinical practicum, driven by perceived knowledge gaps, increased responsibility, and expectations to perform at a higher level of competence ( 11 ). These findings suggest that the transition to practice is not only academically demanding but also emotionally and professionally challenging. Despite growing international recognition of these issues, there remains limited qualitative evidence exploring how final-year nursing students experience and interpret these challenges within specific contexts. In Ghana, where nursing education plays a vital role in strengthening the health workforce, existing studies have primarily focused on structural and supervisory constraints ( 12 – 14 ), with less attention to students’ lived experiences, particularly at the point of transition into practice. This represents a critical gap, as experiences during the final year can significantly influence clinical competence, professional confidence, role socialization, and readiness for independent decision-making. Understanding these experiences is essential, as unaddressed challenges at this stage may not only affect educational outcomes but also have broader implications for patient safety, quality of care, and workforce retention. A context-specific exploration of final-year students’ experiences within the CLE is therefore necessary to inform targeted improvements in clinical supervision, educator preparation, and institutional policy. Accordingly, this study aimed to explore the challenges experienced by final-year nursing students within the clinical learning environment at a tertiary institution in Ghana. Methods Study design This study employed an exploratory qualitative research design to gain a rich, in-depth understanding of nursing students’ experiences during their clinical practicum. An exploratory qualitative approach is particularly appropriate when a phenomenon is insufficiently understood, context-dependent, and shaped by participants’ subjective meanings and interactions. This design allows researchers to capture nuanced perspectives, uncover unanticipated issues, and generate insights grounded in participants’ experiences that would be difficult to obtain with purely quantitative approaches ( 15 , 16 ). To enhance methodological rigor and transparency, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines ( 17 ), ensuring comprehensive documentation of the research process. Study Setting The study was conducted at the School of Nursing and Midwifery (SONAM) of the University of Health and Allied Sciences (UHAS) in Ho, Ghana. UHAS is a public, practice-oriented health sciences university established by an Act of Parliament (Act 828) in December 2011 to strengthen health workforce capacity and address critical shortages in Ghana’s healthcare sector. The university officially commenced academic activities in September 2012 and has since expanded into a multi-school institution offering a range of undergraduate and postgraduate health programs. UHAS operates two main campuses: its central administration in Ho and a second campus in Hohoe, which houses the School of Public Health. The university currently comprises several specialized schools, including Allied Health Sciences, Basic and Biomedical Sciences, Medicine, Nursing and Midwifery, Pharmacy, Public Health, Sports and Exercise Medicine, and Dentistry. The School of Nursing and Midwifery is one of the founding schools of UHAS. Established in the 2011/2012 academic year with an initial cohort of 50 students, SONAM has grown substantially and now enrolls over 4,650 students. The school offers training across multiple disciplines and is organized into three departments running four main programs: Nursing, Midwifery, Public Health Nursing, and Health Services Administration. Study Population The study population included final-year nursing students. This cadre of students is considered the most appropriate for sharing their clinical practicum experiences over time and for demonstrating their readiness to practice as clinicians since the start of their four years of study. The population of final-year nursing students at UHAS was 173 of whom 24 students who had undergone 6 to 8 clinical practical sessions were selected, ensuring that the data reflect genuine personal experiences from those willing and eager to share. Inclusion criteria Final year students (nursing level 400) at the School of Nursing and Midwifery were included. Final year students (nursing level 400) who agreed and consented to participate in the study were included. Exclusion criteria Those who did not attend the recommended clinical practicum sessions were excluded from the study. Postgraduate students were not included in the study Sample technique and sample size A purposive sampling method was used to recruit final-year nursing students from the School of Nursing and Midwifery who had completed 6 to 10 clinical placements and therefore had sufficient exposure to reflect meaningfully on clinical practicum experiences. This sampling approach was well-suited to this study because it enabled us to actively select participants with specific characteristics and experiences relevant to the research objective ( 18 , 19 ). The sample size was determined by the principle of data saturation, which was assessed iteratively through concurrent data collection and analysis ( 20 ). Recruitment and data collection Participant recruitment occurred between 01/11/2025 and 14/11/2025. During this period, eligible students were identified from departmental class lists and approached exclusively by members of the research team who held no teaching, supervisory, or evaluative relationship with the final-year cohort. Eligible students were approached individually outside scheduled class hours and provided with detailed information about the study, including its purpose, procedures, and voluntary nature. Those who expressed interest were given the opportunity to ask questions before providing written informed consent. Participants were informed of their right to withdraw at any stage without consequence. Of the 35 students approached, 24 consented and were enrolled; 11 declined without consequence. Data were collected through 12 individual semi-structured in-depth interviews (IDIs) and 2 focus group discussions (FGDs), each comprising 6 participants. This combination was grounded in the study's constructivist epistemological position, which holds that meaning is both individually constructed and socially negotiated ( 15 , 21 ). Individual interviews were used to elicit detailed, personal, and potentially sensitive accounts of students’ clinical learning experiences, including emotions, fears, coping strategies, and perceptions that participants might not freely disclose in front of peers. FGDs were used to examine how students collectively made sense of the CLE, to identify points of convergence and tension among participants, and to capture the social dimensions of learning that arise through interaction, agreement, disagreement, and mutual reflection. Using both approaches, therefore, allowed the study to capture individual depth and shared experience while strengthening the credibility and completeness of the findings. This methodological strategy has been used in comparable qualitative studies of nursing students' clinical learning experiences ( 22 , 23 ). This sequencing was intentional: conducting individual interviews first allowed participants to articulate personal experiences in a private, confidential space before being invited into group dialogue, thereby reducing the risk that group dynamics might suppress dissenting or sensitive accounts ( 24 , 25 ). FGDs were subsequently conducted with groups constituted to minimize conformity pressure; participants were allocated such that no group contained students from the same clinical rotation team or close friendship cluster, and groups were balanced by gender. The same semi-structured interview guide, developed from the literature on clinical practicum experiences and readiness for practice, guided both IDIs and FGDs ( 26 ). The guide covered key domains, including socio-demographic characteristics, clinical practicum experiences, challenges encountered during clinical practice, learning opportunities, and perceived readiness for professional practice. Open-ended questions and probes were used to encourage detailed reflection and allow exploration of emerging issues while maintaining alignment with the study objectives. IDIs and FGDs were conducted in quiet and comfortable settings within the university to promote openness, minimize interruptions, and ensure confidentiality. IDIs lasted 30–45 minutes, and FGDs lasted 45–60 minutes. All sessions were audio-recorded with participants' prior written permission and transcribed verbatim by members of the research team who were not involved in data collection, to reduce transcription bias. To further minimize power imbalances, all data collection activities were conducted by research team members who were trained in qualitative interviewing and who held no academic or supervisory responsibility for the participants. Data collection and preliminary analysis occurred concurrently, and recruitment continued until data saturation was reached ( 20 ). Data Analysis All interview recordings were transcribed verbatim and checked against the original audio files for accuracy. The transcripts from the IDIs and FGs were first coded separately to preserve the integrity of each dataset and to distinguish what was expressed in private, one-to-one accounts from what emerged through group interaction. An inductive thematic analysis approach was then applied following Braun and Clarke’s six-phase framework: familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the analytic report ( 27 ). This approach was appropriate because it enabled the generation of a rich, data-driven account of students' clinical practicum experiences without imposing a predetermined theoretical framework onto the data, thereby preserving fidelity to participants' meanings and perspectives ( 27 ). The analysis proceeded inductively and iteratively, with all team members engaging with the data across multiple cycles of reading, coding, and interpretation( 22 , 28 ). To address the methodological complexity of combining IDIs and FGDs data within a single thematic analysis, a structured two-stage analytical process was implemented, following recommendations for multimethod qualitative data integration ( 25 ). In the first stage, IDI transcripts and FGD transcripts were analyzed separately and in parallel by different analyst pairs within the research team. This separation preserved the integrity of each dataset and allowed the analytical team to identify patterns that were specific to individually narrated experience (IDIs) as distinct from those that emerged through collective social interaction (FGDs). For IDI data, analysis focused on the depth, nuance, and idiosyncratic nature of individual accounts. For FGD data, analysis was conducted at two levels: within-group analysis examined the internal dynamics and consensus or divergence within each group, while across-group analysis compared patterns emerging from Group 1 and Group 2. This two-level approach is necessary for the rigorous analysis of focus group data because group interaction itself constitutes data, and patterns generated through discussion may differ meaningfully from those expressed in individual accounts( 25 , 29 ). In the second stage, the separately generated codebooks from IDI and FGD data were brought together in a comparative integration meeting involving four members of the analytical team. At this stage, the two datasets were systematically compared to identify: (a) areas of convergence, where themes appeared consistently across both IDI and FGD data; (b) areas of complementarity, where FGD data added social or contextual dimensions to themes identified in IDI data; and (c) areas of divergence, where individual accounts differed from collectively expressed views. Divergent findings were not resolved by privileging one data source over another but were treated as analytically significant, reflecting the distinction between private experiences and socially negotiated understandings of the clinical learning environment. Where divergences were identified, they were documented in the audit trail and discussed until interpretive consensus was reached among the research team. Specifically, findings from IDIs and FGDs were largely convergent across the major themes. Rigor Rigor in this study was ensured through the systematic application of strategies to enhance trustworthiness across credibility, dependability, confirmability, and transferability ( 30 , 31 ). These criteria guided methodological and analytic decisions throughout the study. Credibility was strengthened through sustained engagement with participants and the use of probing and follow-up questions to elicit rich, detailed accounts of clinical practicum experiences. This approach enabled deeper exploration of participants’ perspectives and ensured that their meanings were accurately captured. Clarification and verification of responses during interviews further supported an accurate representation of participants’ viewpoints. Dependability was achieved by maintaining a transparent and well-documented research process. Detailed records of the study design, recruitment procedures, data collection processes, and analytic steps were kept, ensuring methodological clarity and replicability. An audit trail documenting coding decisions, theme development, and analytic reflections provided a clear account of how findings were derived from the data. Confirmability was enhanced through reflexive and collaborative analytic practices. The research team engaged in continuous reflexivity to identify and bracket personal assumptions and disciplinary preconceptions related to clinical education. Reflexive memos were maintained throughout the study, and regular analytic discussions among the research team promoted critical examination of interpretations and consensus in theme development, thereby minimizing individual bias. Transferability was supported by detailed, contextualized descriptions of the study setting, participant characteristics, and the clinical learning environment. Providing this contextual detail helps readers assess the relevance and applicability of the findings to similar nursing education contexts. Ethical Consideration Ethical approval for this study was obtained from the Research and Ethics Committee (REC) of the University of Health and Allied Sciences (UHAS) (Ref: UR042/0925). Ethical approval for the study was valid from October 5, 2025, to October 6, 2026. Administrative permission to conduct the study was also granted by the School of Nursing and Midwifery (SONAM). Written informed consent was obtained from all participants prior to data collection. Participants were provided with comprehensive information about the study’s purpose, procedures, potential risks and benefits, and the voluntary nature of participation. They were informed of their unrestricted right to decline participation or withdraw from the study at any stage without penalty or consequences. To protect participants’ privacy and confidentiality, unique identification numbers were assigned in place of names. All data were anonymized by removing identifying information from transcripts, records, and reports. Audio recordings and transcripts were securely stored in password-protected files accessible only to the research team. No personally identifiable information was included in any presentations or publications arising from the study. Findings Socio-demographic characteristics of participants A total of 24 final-year nursing students participated in the study, comprising 12 individual face-to-face interviews and 2 focus group discussions with 6 participants each. Participants were between 20 and 25 years of age and included 13 males and 11 females. Their major areas of study were diverse, with the most common being gerontology, nursing administration, and occupational health, followed by public health nursing, community health/community services, research, leadership, critical thinking, traditional medicine, health assessment, medical-surgical nursing, emergency nursing, paediatrics, child health, and surgical nursing. The number of clinical placements completed ranged from 4 to 8. Themes and sub-themes of nursing students’ clinical practical experiences Table 1 presents a summary of themes and sub-themes that emerged from the data collected. A total of two ( 2 ) themes and seven ( 7 ) subthemes were derived from the data analysis. Table 1 Presentation of Themes and Sub-Themes of Nursing Students’ Clinical Practical Experiences Themes Subthemes Theme 1 : Challenges faced by students during their clinical practice 1.1 Poor mentorship 1.2 Restricted access to protective equipment 1.3 Limited hands-on opportunities 1.4 Linking Theory into practice 1.5 Overcoming language barriers Theme 2 : Coping strategies 2.1 Self-motivation 2.2 Motivation from staff Theme 1: Challenges during their clinical practice Student nurses encountered a multitude of challenges during their clinical practice, including emotional stress, lack of support, limited access to equipment and protective gear, language barriers, and inadequate hands-on opportunities. These challenges not only affected their confidence but also their ability to provide effective patient care. Subtheme 1: Poor mentorship Many participants described negative experiences with mentorship that affected their learning and professional growth. They reported harsh communication, lack of guidance, and public criticism from clinical staff, which created a fearful environment and reduced their willingness to participate. One student expressed, Well, I’ll say some of the nurses who I was under, when you are too naive, some of them don’t give you the room to grow. (P1). Another added, I was always scared of making mistakes because if I did, the nurses might shout at me, and patients would think I’m not up to task. (P15). These comments illustrate how unsupportive mentorship can diminish students’ confidence and hinder their professional development. Subtheme 2: Restricted access to protective equipment Participants also highlighted the limited access to protective gear, particularly gloves, as a major source of frustration and anxiety. Many felt unsafe when they were denied protective equipment during procedures, which compromised both their well-being and patient safety. One participant explained, “When we are going in for clinicals, they take gloves. But when we are going to do something, and we want to go and take gloves, they will be like, ‘Oh, but not on gloves’ ” (P2). Another added, “The wearing of gloves and maybe wearing of protective gears, students are not allowed to wear anymore because they said we are misusing them” (P3). Such restrictions left students feeling undervalued and unprotected in the clinical environment. Subtheme 3: Limited hands-on opportunities Another prominent concern was the lack of sufficient practical exposure in specific clinical areas, such as mental health and critical care. Students reported feeling unprepared and passive during clinical placements, often observing rather than actively participating. One participant stated, Because we are students, they feel we don’t have the necessary skills and won't allow us to perform certain procedures. P12 “I feel unprepared for ICU situations. I haven’t had much exposure there.” ( P11) While another shared, “I feel I need more practical exposure in mental health interventions. (FGP 15) These responses suggest that limited hands-on practice restricted students’ confidence and readiness to handle complex or emotionally charged situations. Subtheme 4: Linking theory into practice A recurring issue raised by participants was the disconnect between theoretical knowledge and real-world application. Many felt that classroom instruction did not fully prepare them for the complexities and unpredictability of clinical environments. While theoretical understanding provided a foundation, the messiness and pace of actual practice often required improvisation and flexibility. …what they are being taught in school is not what they will be seeing at the ward. That is one of the major challenges they will face. (P1) At times in the clinical settings, some of the procedures do not follow what we are taught in class…but you are told that not all the equipment is available to follow it as we have been taught in class. (P12) These reflections illustrate the need for stronger integration between academic instruction and clinical exposure, ensuring that nursing education aligns more closely with the demands of modern healthcare practice. Subtheme 5: Overcoming language barriers Language barriers emerged as a further challenge, particularly in regions where patients spoke dialects unfamiliar to the students. Participants recounted instances where communication difficulties hindered effective care, forcing them to rely on others for translation. As one student described, Language barrier with patients in certain districts, and sometimes I had to rely on other staff to translate, and other times I just could not help the patient because I did not get a translator. (P11) Another echoed this, saying, Language barrier with patients was a real challenge. I had to rely on gestures or find translators. (FGP 22) These experiences underscore how language differences can impede nurse–patient interactions and the delivery of holistic care. Theme 2: Coping strategies during clinical practicum Despite these difficulties, some students adopted coping mechanisms centered on self-motivation and emotional regulation. They emphasized the importance of perseverance, viewing challenges as opportunities for growth and resilience. Subtheme 1: Self-motivation In spite of the difficulties they faced in their clinical practicum, the participants revealed tenacity and a robust spirit of self-directed learning. A few participants recounted how they pushed themselves internally to stay focused and hone their clinical skills, even when the chances for learning were few. Some took different approaches, such as watching clinical videos and using other study materials to make up for the lack of real practice. The students’ narration shows a slow but steady professional development, and they believe that with continuous exposure, determination, and time, their skills and knowledge will improve to a higher level of competence in their nursing roles. Some participants narrated: …even though I faced challenges during my clinical practicum, I still motivated myself to learn and be skillful. (P FG 14) At times, I had to watch clinical videos to improve my clinical skills when I wasn’t given the opportunity for hands-on procedures. (FGP 13) Well, I was like, since nursing is a profession we all can go in, I took that as with time I could get better. (P 1) Subtheme 2: Motivation from staff Participants reported that their confidence and motivation during clinical practice were significantly boosted by supportive preceptors. Positive feedback and approving remarks from preceptors made students feel acknowledged and appreciated as new professionals, which strengthened their nursing identity. Soothing direction, tolerance, and gently pointing out mistakes/corrections without reproaching a student resulted in a psychologically safe environment for learning where students felt free to inquire, do skill practice repeatedly, and learn from their mistakes. In short, the participants portrayed good supervision as a major enabling factor of learning, self-confidence, and professional development in a clinical learning setting. Some participants narrated: Supportive preceptors motivated me. One told me, ‘You have the heart of a nurse,’ and that stuck with me. Their encouragement made me believe in myself. (FGP 17) When I look confused in performing certain procedures, my supervisors do not shout at me but rather correct me calmly. Most of the time they are motivated to practice more. (P10) Discussion This study explored the experiences of final-year nursing students regarding challenges encountered within the clinical learning environment in Ghana, with particular attention to how these challenges shape learning, professional socialization, and readiness for independent practice. By focusing on students at a critical transition point between education and workforce entry, the study provides contextually grounded insights into systemic, interpersonal, and structural constraints affecting clinical education, while also illuminating the coping strategies students adopt to navigate these constraints. Overall, the findings reveal a clinical learning environment characterized by limited mentorship, restricted access to essential resources, insufficient hands-on learning opportunities, persistent theory–practice gaps, and communication barriers, counterbalanced by students’ resilience, self-motivation, and the presence of occasional supportive staff. The findings of this study revealed that structural inadequacies within the clinical learning environment, including shortages of protective equipment and limited procedural opportunities, significantly restricted students’ active participation in clinical practice. These findings echo previous evidence that such conditions erode experiential learning and delay readiness for independent practice. For instance, research among nursing students shows that resource scarcity and high student–preceptor ratios constrain meaningful participation in care delivery ( 2 , 8 , 9 , 32 ). Salifu et al. ( 12 ) further highlighted how chronic resource constraints, overreliance on clinical placement, and weak institutional coordination undermined both clinical teaching, skills acquisition, and competency assessment, thereby reinforcing students’ perceptions that clinical exposure is often observational rather than participatory. Improving students’ readiness for independent practice will require deliberate investment in essential clinical resources and enforceable supervision structures that enable consistent, hands-on participation in patient care. Beyond material constraints, poor mentorship emerged as a defining feature of students’ clinical experiences. Participants’ accounts of harsh communication, fear of humiliation, and lack of guidance reflect a clinical culture that prioritizes service delivery over teaching and fails to provide psychological safety for learners. This aligns with a growing body of evidence demonstrating that the quality of mentorship, not simply the quantity of placements, plays a decisive role in shaping students’ clinical learning outcomes ( 12 , 13 , 33 ). In Ghana, for instance, clinical preceptors are often overburdened, insufficiently prepared for instructional roles, and inadequately supported by educational institutions, conditions that limit effective supervision and feedback ( 33 ). Similar patterns have been reported internationally, in which negative staff attitudes and a lack of structured supervision contribute to fear, reduced confidence, and disengagement among nursing students ( 5 , 7 ). These reflect not only individual staff behaviors but also a system in which clinical teaching is under-resourced, under-recognized, and poorly governed. The difficulty students faced in linking theoretical knowledge to clinical practice represents one of the most enduring challenges in nursing education and was strongly reflected in this study. This finding reinforces long-standing concerns in Ghanaian nursing education, where curricula remain heavily theory-oriented and insufficiently aligned with clinical realities ( 14 , 34 ). What is noteworthy, however, is that students did not merely describe the theory–practice gap as a pedagogical inconvenience but as a source of moral and professional tension. Being taught ideal standards of care that could not be implemented in practice placed students in ethically ambiguous positions, particularly when deviations from protocol were normalized by senior staff. This nuance is less explicitly discussed in much of the existing literature, which often frames the theory–practice gap primarily as a technical or curricular problem. The findings, therefore, extend prior work by illustrating how this gap also shapes students’ professional identity formation and ethical reasoning. The emergence of language barriers as a salient challenge highlights the importance of contextual competence in nursing education. Students’ difficulties communicating with patients who spoke unfamiliar local dialects limited their ability to provide holistic and patient-centered care. While communication challenges are well-documented in multicultural and multilingual healthcare settings, they are less frequently foregrounded in studies of clinical learning in Ghana. This relative absence in the literature represents a notable gap, particularly given Ghana’s linguistic diversity and the emphasis on patient-centered care in contemporary nursing frameworks. The findings suggest that training in linguistic and cultural competence may be under-integrated into nursing curricula, despite its relevance to clinical effectiveness. Despite these challenges, students demonstrated considerable agency and resilience through self-motivation, peer learning, and responsiveness to supportive staff. These coping strategies mirror findings from other qualitative studies in Ghana and comparable contexts, where students compensate for institutional deficiencies through self-directed learning, observational learning, and informal peer mentorship ( 9 , 12 ). The reliance on clinical videos and independent study to supplement limited hands-on opportunities reflects adaptive learning behaviors but also underscores systemic failure to provide adequate supervised practice. An unexpected pattern in the findings was the disproportionate impact of individual supportive staff on students’ confidence and motivation. Even in otherwise challenging environments, brief affirmations or calm corrective feedback from preceptors significantly enhanced students’ sense of belonging and professional identity. This observation aligns with relational learning theories but contrasts with dominant narratives in the literature that often emphasize structural reforms over interpersonal dynamics ( 35 ). The finding suggests that while systemic change is essential, micro-level relational practices can have outsized effects on student learning and should not be overlooked in interventions to improve the clinical learning environment. Limitations This study has several limitations that should be considered when interpreting the findings. First, the study was conducted in a single tertiary institution in Ghana, which may limit the transferability of the findings to other nursing education contexts, particularly rural settings or private institutions where clinical learning conditions may differ. Nonetheless, the use of rich participant narratives and detailed contextual descriptions allows readers to assess the applicability of the findings to similar settings. Second, the findings are based on self-reported experiences of final-year nursing students and may therefore be subject to recall bias, emotional influences from recent clinical encounters, or social desirability bias. While these accounts may not reflect objective measures of clinical competence or institutional performance, they are valuable in capturing how students experience and interpret the clinical learning environment, which was central to the study’s purpose. Third, although focusing on final-year students strengthened the study by capturing perspectives at a critical transition point between education and professional practice, the exclusion of junior students, newly qualified nurses, and clinical preceptors limited the study's ability to provide a broader, multi-stakeholder understanding of the clinical learning environment. Finally, while the combination of individual interviews and focus group discussions enhanced the depth of the data, group dynamics within focus groups may have constrained the disclosure of particularly sensitive or dissenting experiences, despite efforts to create a safe and confidential environment. Conclusion This study provides an in-depth, context-specific understanding of the challenges and adaptive strategies experienced by final-year nursing students within the clinical learning environment of a tertiary institution in Ghana. The findings reveal a learning context marked by limited mentorship, constrained access to essential resources, insufficient hands-on opportunities, persistent theory–practice gaps, and communication barriers, all of which shape students’ confidence, competence development, and readiness for professional practice. Despite these systemic constraints, students demonstrated resilience through self-motivation, peer learning, and responsiveness to supportive clinical staff. The findings underscore that supportive mentorship, respectful communication, and psychologically safe learning environments can substantially enhance student engagement and professional identity formation, even in resource-limited contexts. Declarations Competing interest The authors declare that they have no competing interests in the conception, design, and execution of this study. Ethical approval and consent to participate The researchers sought ethical review and clearance from the Research Ethics Committee of the University of Health and Allied Sciences before commencing data collection. Written informed consent to participate was obtained from all of the participants in the study. The study followed the principles and guidelines of the Declaration of Helsinki. Consent to publish Not Applicable. Funding This study did not receive any funding. Author Contribution A.A. and D.B.A. conceived the study and led the data analysis and manuscript drafting. N.A.A.A., N.V.A., A.J.N.A., A.N.A.T., C.S., R.A.A., S.S.D., G.L, R.S.E.M., M.J., M.A.A., and S.M.S. conducted the literature search and contributed to writing the manuscript. All authors critically reviewed the manuscript for important intellectual content, contributed revisions, and approved the final version for submission. Acknowledgment Not applicable. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive and confidential nature of the participants’ personal information. However, de-identified data may be available from the corresponding author upon reasonable request, subject to ethics committee approval. References WHO. State of the world’s nursing report 2025 [Internet]. 2025 [cited 2026 Apr 20]. Available from: https://www.who.int/publications/i/item/9789240110236 Ayalew TL. Clinical learning challenges among nursing students at Wolaita Sodo University: prevalence and determinants. BMC Nurs. 2025;24:1265. 10.1186/s12912-025-03923-y. . Cited in PMID: 41088341. Tang Y, Chen X, Liao Y, Zheng T, Xiao Y, You Y. 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PLoS ONE. 2024;19:e0311285. 10.1371/journal.pone.0311285. . Cited in PMID: 39666693. Creswell JW, Creswell DJ. Research design: Qualitative, quantitative, and mixed methods approaches [Internet]. 5th ed. Thousand Oaks, CA, US: SAGE Publications Inc; 2017 [cited 2025 Dec 25]. Available from: https://scholar.google.com/citations?view_op=view_citation&hl=en&user=UzpIzvEAAAAJ&citation_for_view=UzpIzvEAAAAJ:J-pR_7NvFogC Sandelowski M. Whatever happened to qualitative description? Research in Nursing & Health [Internet]. 2000 [cited 2025 Apr 12];23:334–340. doi: 10.1002/1098-240X(200008)23:4%3C334::AID-NUR9%3E3.0.CO;2-G. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57. 10.1093/intqhc/mzm042. . Cited in PMID: 17872937. Creswell JW, Creswell JD. Research Design Qualitative, Quantitative, and Mixed Methods Approaches. [Internet]. 4th Edition. Newbury Park.: SAGE Publications Inc; 2017. Available from: https://www.scirp.org/reference/referencespapers?referenceid=2969274 Creswell J. Educational Research Planning: Planning, Conducting, and Evaluating Quantitative and Qualitative Research. 2011. Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, Burroughs H, Jinks C. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893–907. 10.1007/s11135-017-0574-8. . Cited in PMID: 29937585. Guba EG, Lincoln YS. In: Denzin NK, Lincoln YS, editors. Competing paradigms in qualitative research. Handbook of Qualitative Research. Thousand Oaks, CA: SAGE; 1994. S K PR. Challenges Experienced by Novice Undergraduate Nursing Students in Their Clinical Learning Environment: A Qualitative Study. Cureus. 2025;17:e97322. 10.7759/cureus.97322. . Cited in PMID: 41431515. Meyer R, Archer E, van Schalkwyk SC. Exploring the learning environment through an organizational theory lens: A case study from nursing education. J Educ Health Promot [Internet]. 2024;13:360. .jehp_1907_23. Cited in PMID: 39679041. Krueger R, Casey M. Focus Group Interviewing. 2015. pp. 506–534. Morgan DL. Basic and advanced focus groups. SAGE; 2018. Kobekyaa F, Naidoo JR. Collaborative clinical facilitation in selected nursing and midwifery colleges in Northern Ghana. Health SA. 2023;28:2121. 10.4102/hsag.v28i0.2121. . Cited in PMID: 37064650. Braun V, Clarke V. Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher. Int J Transgender Health [Internet]. 2023;24:1–6. 10.1080/26895269.2022.2129597 . [cited 2026 Jan 9];. Tambunan EH. Theory-Practice Gap During Clinical Learning: A Descriptive Qualitative Study of Nursing Students’ Experiences and Perceptions. J Caring Sci. 2024;13:74–81. 10.34172/jcs.33251. . Cited in PMID: 39318732. Kitzinger J. Qualitative research. Introducing focus groups. BMJ [Internet]. 1995 [cited 2026 Mar 9];311:299–302. 10.1136/bmj.311.7000.299 . Cited in PMID: 7633241. Kumar S, Barolia DR, Petrucka DP, Ali MAA, RIGOR:. THE ASSESSMENT OF TRUSTWORTHINESS. Kashf Journal of Multidisciplinary Research [Internet]. 2025 [cited 2026 Jan 9];2:10–19. 10.71146/kjmr204 Stewart H, Gapp R, Harwood I. Exploring the Alchemy of Qualitative Management Research: Seeking Trustworthiness, Credibility and Rigor Through Crystallization. Qualitative Rep. 2017;1–19. 10.46743/2160-3715/2017.2604 . Rajeswaran L. Clinical Experiences of Nursing Students at a Selected Institute of Health Sciences in Botswana. Health Sci J [Internet]. 2017. 10.21767/1791-809X.1000471 . [cited 2026 Jan 14];10. Boakye DS, Amoah VMK, Boateng EA, Antwi J, Yeboah J, Owusu J. Qualitative study on nurse preceptors’ preparedness, roles and familiarity with the basic principles of teaching and learning in a district hospital in Ghana. BMJ Open. 2025;15:e090743. 10.1136/bmjopen-2024-090743. . Cited in PMID: 39900424. Yarney L. Balancing Academia with Clinical Proficiency in the Training of Nurses at the University Level: The Case of Ghana. Int J Nurs Educ [Internet]. 2021. 10.37506/IJONE.V13I1.13321 . [cited 2026 Jan 2]. Fryling MJ, Johnston C, Hayes LJ. Understanding Observational Learning: An Interbehavioral Approach. Anal Verbal Behav [Internet]. 2011 [cited 2026 Mar 23];27:191–203. doi: 10.1007/BF03393102. Cited in PMID: 22532764. Additional Declarations No competing interests reported. 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01:39:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9205409/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9205409/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108978187,"identity":"539e1172-121f-4ddb-b4bd-4d959d425343","added_by":"auto","created_at":"2026-05-11 11:34:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":272041,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9205409/v1/953322e3-47f2-474f-a906-46a6729d5ef8.pdf"},{"id":108966054,"identity":"4489b12c-edf7-46ec-8127-864a4096c0e1","added_by":"auto","created_at":"2026-05-11 09:41:17","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19081,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-9205409/v1/133bdb597b12ee4cd5747bc8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges in the clinical learning environment: experiences of final-year nursing students in a tertiary institution in Ghana","fulltext":[{"header":"Background","content":"\u003cp\u003eClinical nursing education is fundamental to preparing students for safe and competent professional practice (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It provides practical experience for nursing students, allowing them to apply their theoretical knowledge in real-life situations. It also supports the development of competent, confident, and safe nursing professionals capable of delivering high-quality healthcare services upon graduation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Through practicum, nursing students acquire clinical judgment, psychomotor skills, communication skills, and professional skills (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A central goal of nursing education is to facilitate meaningful clinical learning experiences that foster critical thinking, skill acquisition, and readiness for independent practice. However, despite its central role, the Clinical Learning Environment (CLE) remains a complex and often challenging setting for student learning.\u003c/p\u003e \u003cp\u003eGlobal evidence indicates that between 40% and 75% of nursing students experience significant difficulties during clinical training (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These challenges are commonly associated with the transition from classroom-based learning to real-world clinical settings. For instance, a study by Tang et al. in China reported moderate levels of transition shock among nursing students, reflecting notable adjustment difficulties during clinical practice (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Similarly, Ko and Kim found that students frequently experience fear and anxiety when managing critically ill patients, largely due to reliance on simulation-based learning prior to clinical exposure (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Evidence from Ayalew further highlights the magnitude of the problem, with 79.2% of students reporting at least one clinical learning challenge (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese challenges are frequently more pronounced in low- and middle-income countries (LMICs), where resource constraints, workforce shortages, and limited supervisory support may undermine the quality of clinical education (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Studies across Africa and Asia consistently document barriers such as inadequate clinical learning materials, shortages of preceptors, overcrowded placement sites, weak mentorship structures, and persistent theory\u0026ndash;practice gaps (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Additionally, a recent systematic review further identified negative staff attitudes, disrespectful treatment, discrimination, fear, heavy workload, and insufficient support systems as pervasive obstacles to effective clinical learning (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This evidence underscores the vulnerability of the CLE as both a learning space and a professional socialization context.\u003c/p\u003e \u003cp\u003eWhile these challenges affect nursing students broadly, emerging evidence suggests that they may be particularly pronounced among final-year students. This group occupies a critical transition point between supervised training and independent professional practice, where expectations for competence, responsibility, and decision-making are significantly heightened. Studies from diverse settings demonstrate that final-year students often face unique challenges during this period. For example, research from the United Kingdom reports that students in critical care placements sometimes feel excluded from learning opportunities and must actively seek participation in complex procedures (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Similarly, findings from Singapore indicate that final-year students frequently experience uncertainty, stress, and feelings of being overwhelmed during their final clinical practicum, driven by perceived knowledge gaps, increased responsibility, and expectations to perform at a higher level of competence (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These findings suggest that the transition to practice is not only academically demanding but also emotionally and professionally challenging.\u003c/p\u003e \u003cp\u003eDespite growing international recognition of these issues, there remains limited qualitative evidence exploring how final-year nursing students experience and interpret these challenges within specific contexts. In Ghana, where nursing education plays a vital role in strengthening the health workforce, existing studies have primarily focused on structural and supervisory constraints (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), with less attention to students\u0026rsquo; lived experiences, particularly at the point of transition into practice. This represents a critical gap, as experiences during the final year can significantly influence clinical competence, professional confidence, role socialization, and readiness for independent decision-making.\u003c/p\u003e \u003cp\u003eUnderstanding these experiences is essential, as unaddressed challenges at this stage may not only affect educational outcomes but also have broader implications for patient safety, quality of care, and workforce retention. A context-specific exploration of final-year students\u0026rsquo; experiences within the CLE is therefore necessary to inform targeted improvements in clinical supervision, educator preparation, and institutional policy. Accordingly, this study aimed to explore the challenges experienced by final-year nursing students within the clinical learning environment at a tertiary institution in Ghana.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study employed an exploratory qualitative research design to gain a rich, in-depth understanding of nursing students’ experiences during their clinical practicum. An exploratory qualitative approach is particularly appropriate when a phenomenon is insufficiently understood, context-dependent, and shaped by participants’ subjective meanings and interactions. This design allows researchers to capture nuanced perspectives, uncover unanticipated issues, and generate insights grounded in participants’ experiences that would be difficult to obtain with purely quantitative approaches (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). To enhance methodological rigor and transparency, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e), ensuring comprehensive documentation of the research process.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted at the School of Nursing and Midwifery (SONAM) of the University of Health and Allied Sciences (UHAS) in Ho, Ghana. UHAS is a public, practice-oriented health sciences university established by an Act of Parliament (Act 828) in December 2011 to strengthen health workforce capacity and address critical shortages in Ghana’s healthcare sector. The university officially commenced academic activities in September 2012 and has since expanded into a multi-school institution offering a range of undergraduate and postgraduate health programs. UHAS operates two main campuses: its central administration in Ho and a second campus in Hohoe, which houses the School of Public Health. The university currently comprises several specialized schools, including Allied Health Sciences, Basic and Biomedical Sciences, Medicine, Nursing and Midwifery, Pharmacy, Public Health, Sports and Exercise Medicine, and Dentistry.\u003c/p\u003e \u003cp\u003eThe School of Nursing and Midwifery is one of the founding schools of UHAS. Established in the 2011/2012 academic year with an initial cohort of 50 students, SONAM has grown substantially and now enrolls over 4,650 students. The school offers training across multiple disciplines and is organized into three departments running four main programs: Nursing, Midwifery, Public Health Nursing, and Health Services Administration.\u003c/p\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study population included final-year nursing students. This cadre of students is considered the most appropriate for sharing their clinical practicum experiences over time and for demonstrating their readiness to practice as clinicians since the start of their four years of study. The population of final-year nursing students at UHAS was 173 of whom 24 students who had undergone 6 to 8 clinical practical sessions were selected, ensuring that the data reflect genuine personal experiences from those willing and eager to share.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eFinal year students (nursing level 400) at the School of Nursing and Midwifery were included.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFinal year students (nursing level 400) who agreed and consented to participate in the study were included.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eThose who did not attend the recommended clinical practicum sessions were excluded from the study.\u003c/p\u003e \u003c/li\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cli\u003e\u003cp\u003ePostgraduate students were not included in the study\u003c/p\u003e\u003c/li\u003e\u003c/div\u003e\u003c/ul\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eSample technique and sample size\u003c/h2\u003e \u003cp\u003eA purposive sampling method was used to recruit final-year nursing students from the School of Nursing and Midwifery who had completed 6 to 10 clinical placements and therefore had sufficient exposure to reflect meaningfully on clinical practicum experiences. This sampling approach was well-suited to this study because it enabled us to actively select participants with specific characteristics and experiences relevant to the research objective (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). The sample size was determined by the principle of data saturation, which was assessed iteratively through concurrent data collection and analysis (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \n\u003ch3\u003eRecruitment and data collection\u003c/h3\u003e\n\u003cp\u003eParticipant recruitment occurred between 01/11/2025 and 14/11/2025. During this period, eligible students were identified from departmental class lists and approached exclusively by members of the research team who held no teaching, supervisory, or evaluative relationship with the final-year cohort. Eligible students were approached individually outside scheduled class hours and provided with detailed information about the study, including its purpose, procedures, and voluntary nature. Those who expressed interest were given the opportunity to ask questions before providing written informed consent. Participants were informed of their right to withdraw at any stage without consequence. Of the 35 students approached, 24 consented and were enrolled; 11 declined without consequence.\u003c/p\u003e \u003cp\u003eData were collected through 12 individual semi-structured in-depth interviews (IDIs) and 2 focus group discussions (FGDs), each comprising 6 participants. This combination was grounded in the study's constructivist epistemological position, which holds that meaning is both individually constructed and socially negotiated (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Individual interviews were used to elicit detailed, personal, and potentially sensitive accounts of students’ clinical learning experiences, including emotions, fears, coping strategies, and perceptions that participants might not freely disclose in front of peers. FGDs were used to examine how students collectively made sense of the CLE, to identify points of convergence and tension among participants, and to capture the social dimensions of learning that arise through interaction, agreement, disagreement, and mutual reflection. Using both approaches, therefore, allowed the study to capture individual depth and shared experience while strengthening the credibility and completeness of the findings. This methodological strategy has been used in comparable qualitative studies of nursing students' clinical learning experiences (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). This sequencing was intentional: conducting individual interviews first allowed participants to articulate personal experiences in a private, confidential space before being invited into group dialogue, thereby reducing the risk that group dynamics might suppress dissenting or sensitive accounts (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFGDs were subsequently conducted with groups constituted to minimize conformity pressure; participants were allocated such that no group contained students from the same clinical rotation team or close friendship cluster, and groups were balanced by gender. The same semi-structured interview guide, developed from the literature on clinical practicum experiences and readiness for practice, guided both IDIs and FGDs (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). The guide covered key domains, including socio-demographic characteristics, clinical practicum experiences, challenges encountered during clinical practice, learning opportunities, and perceived readiness for professional practice. Open-ended questions and probes were used to encourage detailed reflection and allow exploration of emerging issues while maintaining alignment with the study objectives.\u003c/p\u003e \u003cp\u003eIDIs and FGDs were conducted in quiet and comfortable settings within the university to promote openness, minimize interruptions, and ensure confidentiality. IDIs lasted 30–45 minutes, and FGDs lasted 45–60 minutes. All sessions were audio-recorded with participants' prior written permission and transcribed verbatim by members of the research team who were not involved in data collection, to reduce transcription bias. To further minimize power imbalances, all data collection activities were conducted by research team members who were trained in qualitative interviewing and who held no academic or supervisory responsibility for the participants. Data collection and preliminary analysis occurred concurrently, and recruitment continued until data saturation was reached (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAll interview recordings were transcribed verbatim and checked against the original audio files for accuracy. The transcripts from the IDIs and FGs were first coded separately to preserve the integrity of each dataset and to distinguish what was expressed in private, one-to-one accounts from what emerged through group interaction. An inductive thematic analysis approach was then applied following Braun and Clarke’s six-phase framework: familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the analytic report (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). This approach was appropriate because it enabled the generation of a rich, data-driven account of students' clinical practicum experiences without imposing a predetermined theoretical framework onto the data, thereby preserving fidelity to participants' meanings and perspectives (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). The analysis proceeded inductively and iteratively, with all team members engaging with the data across multiple cycles of reading, coding, and interpretation(\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo address the methodological complexity of combining IDIs and FGDs data within a single thematic analysis, a structured two-stage analytical process was implemented, following recommendations for multimethod qualitative data integration (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). In the first stage, IDI transcripts and FGD transcripts were analyzed separately and in parallel by different analyst pairs within the research team. This separation preserved the integrity of each dataset and allowed the analytical team to identify patterns that were specific to individually narrated experience (IDIs) as distinct from those that emerged through collective social interaction (FGDs). For IDI data, analysis focused on the depth, nuance, and idiosyncratic nature of individual accounts. For FGD data, analysis was conducted at two levels: within-group analysis examined the internal dynamics and consensus or divergence within each group, while across-group analysis compared patterns emerging from Group 1 and Group 2. This two-level approach is necessary for the rigorous analysis of focus group data because group interaction itself constitutes data, and patterns generated through discussion may differ meaningfully from those expressed in individual accounts(\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the second stage, the separately generated codebooks from IDI and FGD data were brought together in a comparative integration meeting involving four members of the analytical team. At this stage, the two datasets were systematically compared to identify: (a) areas of convergence, where themes appeared consistently across both IDI and FGD data; (b) areas of complementarity, where FGD data added social or contextual dimensions to themes identified in IDI data; and (c) areas of divergence, where individual accounts differed from collectively expressed views. Divergent findings were not resolved by privileging one data source over another but were treated as analytically significant, reflecting the distinction between private experiences and socially negotiated understandings of the clinical learning environment. Where divergences were identified, they were documented in the audit trail and discussed until interpretive consensus was reached among the research team. Specifically, findings from IDIs and FGDs were largely convergent across the major themes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRigor\u003c/h2\u003e \u003cp\u003eRigor in this study was ensured through the systematic application of strategies to enhance trustworthiness across credibility, dependability, confirmability, and transferability (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). These criteria guided methodological and analytic decisions throughout the study. Credibility was strengthened through sustained engagement with participants and the use of probing and follow-up questions to elicit rich, detailed accounts of clinical practicum experiences. This approach enabled deeper exploration of participants’ perspectives and ensured that their meanings were accurately captured. Clarification and verification of responses during interviews further supported an accurate representation of participants’ viewpoints. Dependability was achieved by maintaining a transparent and well-documented research process. Detailed records of the study design, recruitment procedures, data collection processes, and analytic steps were kept, ensuring methodological clarity and replicability. An audit trail documenting coding decisions, theme development, and analytic reflections provided a clear account of how findings were derived from the data.\u003c/p\u003e \u003cp\u003eConfirmability was enhanced through reflexive and collaborative analytic practices. The research team engaged in continuous reflexivity to identify and bracket personal assumptions and disciplinary preconceptions related to clinical education. Reflexive memos were maintained throughout the study, and regular analytic discussions among the research team promoted critical examination of interpretations and consensus in theme development, thereby minimizing individual bias. Transferability was supported by detailed, contextualized descriptions of the study setting, participant characteristics, and the clinical learning environment. Providing this contextual detail helps readers assess the relevance and applicability of the findings to similar nursing education contexts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEthical Consideration\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003c/p\u003e\u003cp\u003e for this study was obtained from the Research and Ethics Committee (REC) of the University of Health and Allied Sciences (UHAS) (Ref: UR042/0925). Ethical approval for the study was valid from October 5, 2025, to October 6, 2026. Administrative permission to conduct the study was also granted by the School of Nursing and Midwifery (SONAM). Written informed consent was obtained from all participants prior to data collection. Participants were provided with comprehensive information about the study’s purpose, procedures, potential risks and benefits, and the voluntary nature of participation. They were informed of their unrestricted right to decline participation or withdraw from the study at any stage without penalty or consequences. To protect participants’ privacy and confidentiality, unique identification numbers were assigned in place of names. All data were anonymized by removing identifying information from transcripts, records, and reports. Audio recordings and transcripts were securely stored in password-protected files accessible only to the research team. No personally identifiable information was included in any presentations or publications arising from the study.\u003c/p\u003e "},{"header":"Findings","content":"\u003ch2\u003eSocio-demographic characteristics of participants\u003c/h2\u003e\u003cp\u003e A total of 24 final-year nursing students participated in the study, comprising 12 individual face-to-face interviews and 2 focus group discussions with 6 participants each. Participants were between 20 and 25 years of age and included 13 males and 11 females. Their major areas of study were diverse, with the most common being gerontology, nursing administration, and occupational health, followed by public health nursing, community health/community services, research, leadership, critical thinking, traditional medicine, health assessment, medical-surgical nursing, emergency nursing, paediatrics, child health, and surgical nursing. The number of clinical placements completed ranged from 4 to 8.\u003c/p\u003e\u003ch2\u003eThemes and sub-themes of nursing students’ clinical practical experiences\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents a summary of themes and sub-themes that emerged from the data collected. A total of two (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) themes and seven (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e) subthemes were derived from the data analysis.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePresentation of Themes and Sub-Themes of Nursing Students’ Clinical Practical Experiences\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eTheme 1\u003c/b\u003e: Challenges faced by students during their clinical practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1.1 Poor mentorship\u003c/p\u003e \u003cp\u003e1.2 Restricted access to protective equipment\u003c/p\u003e \u003cp\u003e1.3 Limited hands-on opportunities\u003c/p\u003e \u003cp\u003e1.4 Linking Theory into practice\u003c/p\u003e \u003cp\u003e1.5 Overcoming language barriers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eTheme 2\u003c/b\u003e: Coping strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2.1 Self-motivation\u003c/p\u003e \u003cp\u003e2.2 Motivation from staff\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003ch2\u003eTheme 1: Challenges during their clinical practice\u003c/h2\u003e\u003cp\u003eStudent nurses encountered a multitude of challenges during their clinical practice, including emotional stress, lack of support, limited access to equipment and protective gear, language barriers, and inadequate hands-on opportunities. These challenges not only affected their confidence but also their ability to provide effective patient care.\u003c/p\u003e\u003ch2\u003eSubtheme 1: Poor mentorship\u003c/h2\u003e\u003cp\u003eMany participants described negative experiences with mentorship that affected their learning and professional growth. They reported harsh communication, lack of guidance, and public criticism from clinical staff, which created a fearful environment and reduced their willingness to participate. One student expressed,\u003c/p\u003e\u003cp\u003e \u003cem\u003eWell, I’ll say some of the nurses who I was under, when you are too naive, some of them don’t give you the room to grow.\u003c/em\u003e (P1).\u003c/p\u003e\u003cp\u003eAnother added,\u003c/p\u003e\u003cp\u003e \u003cem\u003eI was always scared of making mistakes because if I did, the nurses might shout at me, and patients would think I’m not up to task.\u003c/em\u003e (P15).\u003c/p\u003e\u003cp\u003eThese comments illustrate how unsupportive mentorship can diminish students’ confidence and hinder their professional development.\u003c/p\u003e\u003ch2\u003eSubtheme 2: Restricted access to protective equipment\u003c/h2\u003e\u003cp\u003eParticipants also highlighted the limited access to protective gear, particularly gloves, as a major source of frustration and anxiety. Many felt unsafe when they were denied protective equipment during procedures, which compromised both their well-being and patient safety. One participant explained,\u003c/p\u003e\u003cp\u003e \u003cem\u003e“When we are going in for clinicals, they take gloves. But when we are going to do something, and we want to go and take gloves, they will be like, ‘Oh, but not on gloves’\u003c/em\u003e” (P2).\u003c/p\u003e\u003cp\u003eAnother added,\u003c/p\u003e\u003cp\u003e \u003cem\u003e“The wearing of gloves and maybe wearing of protective gears, students are not allowed to wear anymore because they said we are misusing them”\u003c/em\u003e (P3).\u003c/p\u003e\u003cp\u003eSuch restrictions left students feeling undervalued and unprotected in the clinical environment.\u003c/p\u003e\u003ch2\u003eSubtheme 3: Limited hands-on opportunities\u003c/h2\u003e\u003cp\u003eAnother prominent concern was the lack of sufficient practical exposure in specific clinical areas, such as mental health and critical care. Students reported feeling unprepared and passive during clinical placements, often observing rather than actively participating. One participant stated,\u003c/p\u003e\u003cp\u003e \u003cem\u003eBecause we are students, they feel we don’t have the necessary skills and won't allow us to perform certain procedures.\u003c/em\u003e P12\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I feel unprepared for ICU situations. I haven’t had much exposure there.” (\u003c/em\u003eP11)\u003c/p\u003e\u003cp\u003eWhile another shared,\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I feel I need more practical exposure in mental health interventions.\u003c/em\u003e (FGP 15)\u003c/p\u003e\u003cp\u003eThese responses suggest that limited hands-on practice restricted students’ confidence and readiness to handle complex or emotionally charged situations.\u003c/p\u003e\u003ch2\u003eSubtheme 4: Linking theory into practice\u003c/h2\u003e\u003cp\u003eA recurring issue raised by participants was the disconnect between theoretical knowledge and real-world application. Many felt that classroom instruction did not fully prepare them for the complexities and unpredictability of clinical environments. While theoretical understanding provided a foundation, the messiness and pace of actual practice often required improvisation and flexibility.\u003c/p\u003e\u003cp\u003e \u003cem\u003e…what they are being taught in school is not what they will be seeing at the ward. That is one of the major challenges they will face. (P1)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eAt times in the clinical settings, some of the procedures do not follow what we are taught in class…but you are told that not all the equipment is available to follow it as we have been taught in class. (P12)\u003c/em\u003e \u003c/p\u003e\u003cp\u003eThese reflections illustrate the need for stronger integration between academic instruction and clinical exposure, ensuring that nursing education aligns more closely with the demands of modern healthcare practice.\u003c/p\u003e\u003ch2\u003eSubtheme 5: Overcoming language barriers\u003c/h2\u003e\u003cp\u003eLanguage barriers emerged as a further challenge, particularly in regions where patients spoke dialects unfamiliar to the students. Participants recounted instances where communication difficulties hindered effective care, forcing them to rely on others for translation. As one student described,\u003c/p\u003e\u003cp\u003e\u003cem\u003eLanguage barrier with patients in certain districts, and sometimes I had to rely on other staff to translate, and other times I just could not help the patient because I did not get a translator.\u003c/em\u003e (P11)\u003c/p\u003e\u003cp\u003eAnother echoed this, saying,\u003c/p\u003e\u003cp\u003e \u003cem\u003eLanguage barrier with patients was a real challenge. I had to rely on gestures or find translators.\u003c/em\u003e (FGP 22)\u003c/p\u003e\u003cp\u003eThese experiences underscore how language differences can impede nurse–patient interactions and the delivery of holistic care.\u003c/p\u003e\u003ch2\u003eTheme 2: Coping strategies during clinical practicum\u003c/h2\u003e\u003cp\u003eDespite these difficulties, some students adopted coping mechanisms centered on self-motivation and emotional regulation. They emphasized the importance of perseverance, viewing challenges as opportunities for growth and resilience.\u003c/p\u003e\u003ch2\u003eSubtheme 1: Self-motivation\u003c/h2\u003e\u003cp\u003eIn spite of the difficulties they faced in their clinical practicum, the participants revealed tenacity and a robust spirit of self-directed learning. A few participants recounted how they pushed themselves internally to stay focused and hone their clinical skills, even when the chances for learning were few. Some took different approaches, such as watching clinical videos and using other study materials to make up for the lack of real practice. The students’ narration shows a slow but steady professional development, and they believe that with continuous exposure, determination, and time, their skills and knowledge will improve to a higher level of competence in their nursing roles.\u003c/p\u003e\u003cp\u003eSome participants narrated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e…even though I faced challenges during my clinical practicum, I still motivated myself to learn and be skillful. (P FG 14)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eAt times, I had to watch clinical videos to improve my clinical skills when I wasn’t given the opportunity for hands-on procedures. (FGP 13)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWell, I was like, since nursing is a profession we all can go in, I took that as with time I could get better.\u003c/em\u003e (P 1)\u003c/p\u003e\u003ch2\u003eSubtheme 2: Motivation from staff\u003c/h2\u003e\u003cp\u003e Participants reported that their confidence and motivation during clinical practice were significantly boosted by supportive preceptors. Positive feedback and approving remarks from preceptors made students feel acknowledged and appreciated as new professionals, which strengthened their nursing identity. Soothing direction, tolerance, and gently pointing out mistakes/corrections without reproaching a student resulted in a psychologically safe environment for learning where students felt free to inquire, do skill practice repeatedly, and learn from their mistakes. In short, the participants portrayed good supervision as a major enabling factor of learning, self-confidence, and professional development in a clinical learning setting. Some participants narrated:\u003c/p\u003e\u003cp\u003e\u003cem\u003eSupportive preceptors motivated me. One told me, ‘You have the heart of a nurse,’ and that stuck with me. Their encouragement made me believe in myself. (FGP 17)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen I look confused in performing certain procedures, my supervisors do not shout at me but rather correct me calmly. Most of the time they are motivated to practice more.\u003c/em\u003e (P10)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the experiences of final-year nursing students regarding challenges encountered within the clinical learning environment in Ghana, with particular attention to how these challenges shape learning, professional socialization, and readiness for independent practice. By focusing on students at a critical transition point between education and workforce entry, the study provides contextually grounded insights into systemic, interpersonal, and structural constraints affecting clinical education, while also illuminating the coping strategies students adopt to navigate these constraints. Overall, the findings reveal a clinical learning environment characterized by limited mentorship, restricted access to essential resources, insufficient hands-on learning opportunities, persistent theory\u0026ndash;practice gaps, and communication barriers, counterbalanced by students\u0026rsquo; resilience, self-motivation, and the presence of occasional supportive staff.\u003c/p\u003e \u003cp\u003eThe findings of this study revealed that structural inadequacies within the clinical learning environment, including shortages of protective equipment and limited procedural opportunities, significantly restricted students\u0026rsquo; active participation in clinical practice. These findings echo previous evidence that such conditions erode experiential learning and delay readiness for independent practice. For instance, research among nursing students shows that resource scarcity and high student\u0026ndash;preceptor ratios constrain meaningful participation in care delivery (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Salifu et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) further highlighted how chronic resource constraints, overreliance on clinical placement, and weak institutional coordination undermined both clinical teaching, skills acquisition, and competency assessment, thereby reinforcing students\u0026rsquo; perceptions that clinical exposure is often observational rather than participatory. Improving students\u0026rsquo; readiness for independent practice will require deliberate investment in essential clinical resources and enforceable supervision structures that enable consistent, hands-on participation in patient care.\u003c/p\u003e \u003cp\u003eBeyond material constraints, poor mentorship emerged as a defining feature of students\u0026rsquo; clinical experiences. Participants\u0026rsquo; accounts of harsh communication, fear of humiliation, and lack of guidance reflect a clinical culture that prioritizes service delivery over teaching and fails to provide psychological safety for learners. This aligns with a growing body of evidence demonstrating that the quality of mentorship, not simply the quantity of placements, plays a decisive role in shaping students\u0026rsquo; clinical learning outcomes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In Ghana, for instance, clinical preceptors are often overburdened, insufficiently prepared for instructional roles, and inadequately supported by educational institutions, conditions that limit effective supervision and feedback (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Similar patterns have been reported internationally, in which negative staff attitudes and a lack of structured supervision contribute to fear, reduced confidence, and disengagement among nursing students (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These reflect not only individual staff behaviors but also a system in which clinical teaching is under-resourced, under-recognized, and poorly governed.\u003c/p\u003e \u003cp\u003eThe difficulty students faced in linking theoretical knowledge to clinical practice represents one of the most enduring challenges in nursing education and was strongly reflected in this study. This finding reinforces long-standing concerns in Ghanaian nursing education, where curricula remain heavily theory-oriented and insufficiently aligned with clinical realities (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). What is noteworthy, however, is that students did not merely describe the theory\u0026ndash;practice gap as a pedagogical inconvenience but as a source of moral and professional tension. Being taught ideal standards of care that could not be implemented in practice placed students in ethically ambiguous positions, particularly when deviations from protocol were normalized by senior staff. This nuance is less explicitly discussed in much of the existing literature, which often frames the theory\u0026ndash;practice gap primarily as a technical or curricular problem. The findings, therefore, extend prior work by illustrating how this gap also shapes students\u0026rsquo; professional identity formation and ethical reasoning.\u003c/p\u003e \u003cp\u003eThe emergence of language barriers as a salient challenge highlights the importance of contextual competence in nursing education. Students\u0026rsquo; difficulties communicating with patients who spoke unfamiliar local dialects limited their ability to provide holistic and patient-centered care. While communication challenges are well-documented in multicultural and multilingual healthcare settings, they are less frequently foregrounded in studies of clinical learning in Ghana. This relative absence in the literature represents a notable gap, particularly given Ghana\u0026rsquo;s linguistic diversity and the emphasis on patient-centered care in contemporary nursing frameworks. The findings suggest that training in linguistic and cultural competence may be under-integrated into nursing curricula, despite its relevance to clinical effectiveness.\u003c/p\u003e \u003cp\u003eDespite these challenges, students demonstrated considerable agency and resilience through self-motivation, peer learning, and responsiveness to supportive staff. These coping strategies mirror findings from other qualitative studies in Ghana and comparable contexts, where students compensate for institutional deficiencies through self-directed learning, observational learning, and informal peer mentorship (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The reliance on clinical videos and independent study to supplement limited hands-on opportunities reflects adaptive learning behaviors but also underscores systemic failure to provide adequate supervised practice.\u003c/p\u003e \u003cp\u003eAn unexpected pattern in the findings was the disproportionate impact of individual supportive staff on students\u0026rsquo; confidence and motivation. Even in otherwise challenging environments, brief affirmations or calm corrective feedback from preceptors significantly enhanced students\u0026rsquo; sense of belonging and professional identity. This observation aligns with relational learning theories but contrasts with dominant narratives in the literature that often emphasize structural reforms over interpersonal dynamics (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The finding suggests that while systemic change is essential, micro-level relational practices can have outsized effects on student learning and should not be overlooked in interventions to improve the clinical learning environment.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations that should be considered when interpreting the findings. First, the study was conducted in a single tertiary institution in Ghana, which may limit the transferability of the findings to other nursing education contexts, particularly rural settings or private institutions where clinical learning conditions may differ. Nonetheless, the use of rich participant narratives and detailed contextual descriptions allows readers to assess the applicability of the findings to similar settings. Second, the findings are based on self-reported experiences of final-year nursing students and may therefore be subject to recall bias, emotional influences from recent clinical encounters, or social desirability bias. While these accounts may not reflect objective measures of clinical competence or institutional performance, they are valuable in capturing how students experience and interpret the clinical learning environment, which was central to the study\u0026rsquo;s purpose. Third, although focusing on final-year students strengthened the study by capturing perspectives at a critical transition point between education and professional practice, the exclusion of junior students, newly qualified nurses, and clinical preceptors limited the study's ability to provide a broader, multi-stakeholder understanding of the clinical learning environment. Finally, while the combination of individual interviews and focus group discussions enhanced the depth of the data, group dynamics within focus groups may have constrained the disclosure of particularly sensitive or dissenting experiences, despite efforts to create a safe and confidential environment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides an in-depth, context-specific understanding of the challenges and adaptive strategies experienced by final-year nursing students within the clinical learning environment of a tertiary institution in Ghana. The findings reveal a learning context marked by limited mentorship, constrained access to essential resources, insufficient hands-on opportunities, persistent theory\u0026ndash;practice gaps, and communication barriers, all of which shape students\u0026rsquo; confidence, competence development, and readiness for professional practice. Despite these systemic constraints, students demonstrated resilience through self-motivation, peer learning, and responsiveness to supportive clinical staff. The findings underscore that supportive mentorship, respectful communication, and psychologically safe learning environments can substantially enhance student engagement and professional identity formation, even in resource-limited contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interest\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests in the conception, design, and execution of this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe researchers sought ethical review and clearance from the Research Ethics Committee of the University of Health and Allied Sciences before commencing data collection. Written informed consent to participate was obtained from all of the participants in the study. The study followed the principles and guidelines of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent to publish\u003c/h2\u003e \u003cp\u003eNot Applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study did not receive any funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.A. and D.B.A. conceived the study and led the data analysis and manuscript drafting. N.A.A.A., N.V.A., A.J.N.A., A.N.A.T., C.S., R.A.A., S.S.D., G.L, R.S.E.M., M.J., M.A.A., and S.M.S. conducted the literature search and contributed to writing the manuscript. All authors critically reviewed the manuscript for important intellectual content, contributed revisions, and approved the final version for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgment\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the sensitive and confidential nature of the participants\u0026rsquo; personal information. However, de-identified data may be available from the corresponding author upon reasonable request, subject to ethics committee approval.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. State of the world\u0026rsquo;s nursing report 2025 [Internet]. 2025 [cited 2026 Apr 20]. 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Cited in PMID: 22532764.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical learning environment, Nursing students, Nursing education, Clinical practicum, Theory–practice gap, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-9205409/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9205409/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eClinical practicum is central to nursing education, yet suboptimal clinical learning environments can hinder competence development and readiness for practice. Evidence from sub-Saharan Africa remains limited, particularly on final-year students approaching transition to practice. This study explored final-year nursing students\u0026rsquo; experiences of clinical practicum in Ghana and the strategies they use to navigate learning constraints.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn exploratory qualitative design was used. Twenty-four final-year nursing students from a Ghanaian tertiary institution were purposively recruited. Data were collected through twelve individual interviews and two focus group discussions, audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Reflexivity, collaborative coding, and an audit trail supported rigor.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwo themes were generated: challenges in the clinical learning environment and coping strategies. Reported challenges included poor mentorship, limited hands-on opportunities, restricted access to protective equipment, theory\u0026ndash;practice gaps, and language barriers. These constraints undermined confidence and perceived readiness. Students demonstrated resilience through self-directed learning and supportive staff relationships, with positive feedback fostering confidence and professional identity.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCLEs function as both barriers and formative spaces for learning. Strengthening mentorship, resource availability, and psychologically safe supervision is essential to optimizing students\u0026rsquo; transition in resource-limited contexts.\u003c/p\u003e","manuscriptTitle":"Challenges in the clinical learning environment: experiences of final-year nursing students in a tertiary institution in Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 09:37:54","doi":"10.21203/rs.3.rs-9205409/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"279280164337604406431561317305342644276","date":"2026-05-17T18:57:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-16T11:44:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141599833205183813972382281797597335185","date":"2026-05-03T21:56:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-01T05:42:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-01T03:41:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-05-01T03:36:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56f77070-0b58-416b-8c71-84b80a8ab1e4","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"279280164337604406431561317305342644276","date":"2026-05-17T18:57:24+00:00","index":58,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-16T11:44:44+00:00","index":57,"fulltext":""},{"type":"reviewerAgreed","content":"141599833205183813972382281797597335185","date":"2026-05-03T21:56:34+00:00","index":43,"fulltext":""},{"type":"reviewersInvited","content":"25","date":"2026-05-01T05:42:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-01T03:41:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-05-01T03:36:02+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T09:37:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 09:37:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9205409","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9205409","identity":"rs-9205409","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}