Exploring nursing intern students' experiences of stress and resilience during internship using photovoice

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This study aimed to explore the nursing intern students' experiences of stress and resilience during internship using photovoice. Methods This study employed a phenomenological investigation using photovoice, focusing on the stressors and coping mechanisms of 14 nursing interns from the King Khalid University, Abha and Khamis Muhsayt branches during the last three months of their internship. The nursing interns, comprising 14 individuals with an equal male to female ratio, took between 5 to 7 photographs that they felt best represented their experience during the internship. After taking these photographs, the participants engaged in individual and group semi-structured interviews discussing the photos and narratives. The interviews were recorded and then transcribed word for word. Thematic analysis was conducted by two researchers. Rigor was maintained by researchers’ reflexivity, participant photo narrative review, and an independent inquiry audit. Results The study revealed six key themes: interns experienced significant stress from the Weight of Responsibility and the Emotional Rollercoaster of patient care. However, they found Strength in Connection through peer and mentor support, engaged in Self-Care and Reflection, and gained Perspective through the Lens of photovoice. Interns also provided Recommendations for Support, advocating for systemic changes to improve the internship experience. Conclusion This photovoice study revealed that nursing interns face significant stress from heavy responsibility and emotional challenges, but find crucial support through connections with peers and mentors. They actively use self-care and reflect on their experiences, leading to calls for systemic changes like enhanced mentorship and stress management resources to create a more supportive internship environment. Nursing Interns Stress Resilience Photovoice Phenomenology Introduction The experiences of nursing intern students during their internships is very relevant for placing nursing education and professionalism in context. While clinical practice is part of the components of the nursing education, certain research suggests that students are falling short of adequate clinical practice experience (Alemi et al., 2021 ). In Saudi Arabia, internships are a very crucial phase of clinical practice that students have to face following the education phase and different stressors of this phase may exert a considerable influence on their mental health and professional competence. An emerging requirement for nursing students is to complete a minimum of 960 hours of internship during the last year of the bachelor’s degree program (Alanazi et al., 2023 ). This enables them to broaden their clinical scope, utilize critical thinking in different contexts, and exhibit competency in both clinical practice and theory (Alanazi et al., 2023 ). Research has investigated the phenomenon of stress in nursing students and its correlation to insufficient preparation for the real-life clinical practice which tends to worsen the stress levels (Williams, 2014 ; Zheng et al., 2022 ). This stress hampers the students' physical and mental health and, in turn, the quality of care received by patients as these students do not deliver to their best potential (Zheng et al., 2022 ). Therefore, investigating the coping strategies and stress factors of nursing internship students is important for designing proper educational interventions that will improve their experience. A gap exists in literature analyses surrounding the stressors nursing intern students experience during their internships. They encounter many barriers, including a lack of resources, qualified personnel, and even the opportunity to learn (Fathi & Ibrahim, 2023). Roughly one half of the academic commitment for nursing students which is approximately 50% of the entirety of the course structure deals with clinical practice. These barriers can undermine a nurse's ability to provide appropriate care and can serve to establish a detrimental environment for education. Although some studies have examined the stress experienced by nursing students in various contexts, few have concentrated on the specific problems associated with internship (Aryuwat et al., 2022 ; Alzayyat & Al-Gamal, 2014 ). For example, Blomberg et al. ( 2014 ) explained that around 50% of nursing students had increased levels of anxiety and stress while undergoing clinical practice however, the precise causes of this stress and anxiety during internships is a question that remains unanswered. Moreover, although resilience is considered a protective element that reduces stress, the specific processes by which resilience functions in relation to nursing internship experiences require more exploration (Aryuwat et al., 2022 ; Abdallah et al., 2023 ). This literature demonstrates an absence that shows the necessity of deep focus into nursing intern student’s experiences and pinpointing stressors and resilience aids to incorporate into nursing education. Moreover, recognizing the experience of stress and resiliency among nursing intern students is more than just concern for their academic success. It relates a great deal with the future of nursing as a profession. With the advancements in nursing, students should be guided on how to effectively manage stress and build resiliency (Kim et al., 2021; Wheeler & Phillips, 2019). According to the literature, fostering resilience through planned interventions can positively impact the mental health status and professional efficacy of nursing students (Abbaszadeh et al., 2023); Khanmohammadi et al., 2020). When addressing the multidisciplinary complexities of internships, educational institutions can provide comprehensive support systems which promote the well-being of students and improve the quality of care provided to patients (Cheung et al., 2016). Hence, this study intends to address the information gap by studying the subtle experiences of nursing intern students which will result in more effective nursing education policy and planning. Nursing intern students' experiences of stress and their resiliency construction during internships remains largely unexplored. Reviewed literature did highlight on considerable sources of stress and the need for resiliency, however, the students’ specific experiences in this critical transition phase remain inadequately studied. This study was designed to address these gaps and, in so doing, help to inform nursing education practices and improve nursing students’ wellbeing, and thereby as well, the healthcare system. The training of future nurses has to incorporate professional self-care as coping skills and resilience building techniques for stress management will be paramount in the nursing field. This study meets this aspect by offering interventions that are grounded in evidence-based practice which can be used to develop programs meant to build resilience and cope with stress. Hence, this study aimed to explore the nursing intern students' experiences of stress and resilience during internship using photovoice. Methods Research Design This study employed qualitative-phenomenological design using photovoice to encouraging the participants to reflect on their photos, discuss the meanings behind them, and create narratives that contextualize their experiences. Participants/Sampling The participants were the 14 students (7 females and 7 males). Special focus was given to the participants who undertook nursing in the hospitals as interns for the last six months of their internship. This phase is specifically selected because these interns have a fair amount of experience with the profession and have started to build some coping strategies to deal with the associated stressors. Inclusion criteria combines enrollment into the second portion of the internship, effective communication skills in English, and the ability to provide informed consent. Exclusion criteria eliminates first-six months’ interns, non-English speakers, subjects unable to give informed consent, individuals with cognitive or physical barriers that restrict their participation in the photovoice approach process such as moderate to severe sight impairment, and previously participated subjects in photovoice studies. The recruited participants were contacted through their nursing schools branch. Setting This study was conducted at the King Khalid University, College of Nursing particularly at the Abha and Khamis Muhsayt branch. The data collection took place in a private room in the university. This ensured a comfortable and confidential environment for participants to share their experiences. Only the participants and the researchers were present during the interviews. Data Collection The study commenced with an approved Institutional Review Board (IRB) at King Khalid University. Upon recruitment, participants received training on purposeful photography as a research tool, ethical photography of privacy and anonymization, and narrative building practice through images. Participants further engaged in photo journals where they took 5–7 pictures depicting their experiences of stress and coping. These photos and narratives were discussed in individually so that participants can explain their photos and then group discussion was conducted to expand on the meaning of their photos. The interviews were conducted in a face-to face, recorded, transcribed verbatim, and anonymized. Data was collected from December 2024 to January 2025. The data was collected through semi-structured interviews conducted with the help of an interview guide detailing open-ended questions and prompts (See supplemental file 1). The main question was “How do nursing intern students experience and visually represent the interplay of stress and resilience during their internship experiences with sub questions. For instance, “What are the primary sources of stress identified by nursing intern students during their internships, as visually depicted through their photographs? What strategies and resources do nursing intern students utilize to foster resilience during their internships, and how are these reflected in their photographs?”. This guide was pilot-tested with four people with similar characteristics as the target population to ascertain clarity and relevance. No follow up interviews were held. Consent from the participants was obtained before undertaking any audio recording of the interview to ensure all transcripts and analyses would be accurate. All interviews were recorded. Researchers also took some brief field notes after each interview so that their observations contextualized and enhanced the interpretation of the data. Interview length varied between 50 and 60 minutes. Throughout the process of the study, the idea of data saturation was evident, and further interviews were not conducted after new insights diminished. Two researchers coded the interview transcripts on their own using a tree structure which evolved from their initial framework and dictated the subsequent analysis. As previously mentioned, in the derived data, a deeper level thematic analysis was done. Due to confidentiality, participants did not receive the opportunity to validate the final conclusions, however, they were shown their photo narratives to ensure they were accurately represented. Quotations from participants are included for every theme presented in the findings as evidence and reasoning, fully number coded to each participant. The consistency of the information and data collected clearly encapsulates the most critical and prominent aspects. Each major theme is discussed in detail, along with comprehensive context and supporting quotations. Some themes are lesser and very simple, as well as cases that are different from the general observation, depicting the softer side and changing dynamics of the interns to what they faced during internship are also put forward. Narrative Reflection This study examining stress and coping strategies of nursing interns was conducted by a team of PhD prepared qualitative researchers. All of whom are faculty in a nursing program at a university and have extensive experience in photovoice methods. All of the researchers, while caring for the wellbeing of nursing students and all the issues that surround them, had a neutral stance towards the participants. The researchers and the interns who participated in the study had no contacts prior to the study. The participants were informed that the researchers were nursing faculty interested in the impact of the internship on the interns. It was clear to the participants that the researchers were after the interns’ viewpoints on aspects of stress and coping during the internship. However, participants were not told any other personal intentions or objectives that may have existed beyond the stated purpose of the research. The researchers composed of three males and eight females had significant expertise in conducting qualitative interviews and narrative-driven data analysis. Every single researcher had received specific training in photovoice approaches so that they adhered to strict protocols of administering and analyzing the collected data. Although the nursing faculty colleagues’ professional background certainly informed their context regarding the nursing internship, they made considerable attempts to alleviate bias. The research team understood that teaching nursing could potentially bias their analysis and thus practiced reflexivity. They deliberated on the assumptions they held with regards to intern’s stress and coping mechanisms, accepted those assumptions, and then systematically set them aside during data analysis. The researchers tended to be most concerned with the phenomenon of nursing internship because these interns encounter difficulties which, if not correctly managed, can adversely affect the student's success and well-being. While this impression may have shaped the theories and predictions of the phenomena, it was equally important and beneficial for the study as well as the research question have such interpretation. The intent of this study was to make it very clear that these individuals, their education and experience could affect the data, so trustworthiness and accuracy of the study could be achieved. Ensuring Rigor In this study, the following strategies were used to enhance the rigor of the study. Credibility is an important concept of trustworthiness in qualitative research and has to be dealt with first. Participants did not fully check their interview transcripts for all information because of confidentiality issues, but they were provided an opportunity to check their photo narratives to ensure that their visuals and written pieces captured what they intended. Such an effort ensured that participants had access to their contributions and made modifications where necessary. Moreover, researchers actively engaged in regular reflexivity exercises where they asked themselves what biases or stereotypes, they held during the research. This understanding mitigated the effects of the researchers’ backgrounds as nursing faculty on the research interpretation. Trustworthiness was approached differently with the use of an inquiry audit conducted by external qualitative researcher. Rather, this audit aimed at determining whether the available data confirmed the results, analyses, and conclusions drawn from it. The document offered traces of reasoning that raised the level of clarity and credibility concerning how data was collected, analyzed, and interpreted, known as the audit trail. This account of the research process, including the steps taken in collecting the data and coding it, developing themes, and other decisions made, provided an opportunity to verify the conclusions of the study. While the study investigated the phenomenological aspects of the interns’ lived experiences, this audit trail showed that there was no possibility of making up such explanations, thus ‘defending’ the outcome of the study. This mixture of reflexivity, participant photo narratives, and independent inquiry guarantees the trustworthiness of this research study. Thematic Analysis This photovoice study utilized various methods for data analysis. At first, the photographs were assessed for common images and patterns within them with the aim of capturing the participants’ representations of their experiences. At the same time, the participants’ provided and transcribed speech narratives underwent content examination for recurring themes and meanings. Afterwards, an analysis was undertaken that focused on identifying comprehensive themes, fully capturing the participants’ experiences by combining interpretation of the visual data and the narrative accounts. NVivo 14 was used for organization and coding of the merged visual and narrative data, thus improving the accuracy and speed of the thematic analysis. Results There is an equal number of male and female (7 males and 7 females) nursing interns in this study. Their age ranges from 20–23 years old. Most of them were decked in the medical and surgical wards. Table 1 presents the themes, subthemes and narratives of the 14 participants. Table 1 Themes, subthemes and narratives of the participants. Theme and Definition Subtheme and Definition Code Photo and Narratives Theme 1: The Weight of Responsibility : This theme captures an high level of stress of the interns that stems from the floor burdened responsibility often placed on them their self evaluated level of readiness surpasses their own expectations. Subtheme 1.1: Feeling Overwhelmed : The state of feeling as if the tasks and obligations one has to fulfill is unreasonable. Responsibility Overload Participant 3: Photo: Medical-Surgical books piled on top of each other. Narrative: “It felt as though there was no end to those books. Every single book is an intern’s life story that is important which made me feel utterly burden." Participant 7: Photo: Vulnerable hands injecting intramuscular on deltoid area. Narrative: ‘I cannot believe that I am still shivering despite my six months of internship. My hands often trembled so hard and at times I am worrying I might injure the patient. Indeed, I was tensed”. Participant 12: Photo: Intern in break room, head in hand Narrative “I felt that I simply needed a break. The demands along with anxiety of error consumed me with anxiety especially anticipating what is next procedure to be done in my area” Theme 2: The Emotional Rollercoaster : This theme clearly studies the emotional crises faced as a result of the internship experience, including suffering, death, and complex situations with patients. Subtheme 2.1: Emotional Toll. -The adverse sympathy and feeling inflicted by the pain of the patient and having to deal with tough medical situations. Emotional Burden Participant 1: Photo: Picture of a darkened corridor of a hospital. Narrative: “This corridor depicts the environment where my experience as intern takes place. It is where my intense work shifts start. In my everyday going here, there was so much pain and suffering that it was difficult to leave it behind.” Participant 5: Photo: Intern crying. Narrative: “You know, I was affected more than I thought by the passing of a patient, which made me doubt my perceived strength if I will be really good nurse. Inshallah, I will overcome this emotion” Participant 10: Photo: Reflection of an intern on a stainless-steel medicine cabinet. Narrative: “What I saw in my reflection was seem so fatigue and feel very burden with the things in here [referring to the photo]. It made me emotionally down”. Theme 3: Finding Strength in Connection : This theme emphasizes the importance of social support and mentorship in building resilience. Subtheme 3.1: The Power of Support : The role of peer support and mentorship in navigating the challenges of the internship. Supportive Relationships Participant 2: Photo: Intern laughing with a fellow intern. Narrative: "My classmates were my lifeline and I feel very comfortable working and sharing with them ideas. We supported each other through everything." Participant 6: Photo: Intern talking with a nurse mentor. Narrative: "My mentor’s guidance especially my seniors as well as the nurses were invaluable. All of them shared their own experiences and helped me go through and overcome difficult situations." Participant 11: Photo: Group of interns celebrating together. Narrative: “You know in our family, we celebrated the small victories, the same here in internship program. Or in my nursing career… It helped us stay positive and motivated." Theme 4: Self-Care and Reflection : This theme explores the strategies interns use to manage stress and maintain their well-being. Subtheme 4.1: Coping Mechanisms : The various methods interns employ to manage stress and maintain their mental and emotional health. Self-Preservation Participant 4: Photo: Intern doing arm stretching. Narrative: "Stretching my arms up helped me de-stress and reconnect with myself. It is very relaxing especially when we have a lot of patients”. Participant 8: Photo: Intern reading a book in a quiet corner. Narrative: "Taking time for myself was essential. It helps me think more ideas afterwards. I needed to recharge and escape the hospital environment for a while." Participant 13: Photo: Intern journaling. Narrative: "I always do this… I mean…writing down my thoughts and feelings helped me process my experiences and gain perspective. You know, I use my journaling as part of my everyday life”. Theme 5: Gaining Perspective through the Lens : This theme reflects how the photovoice methodology prompted deeper reflection and self-awareness among participants. Subtheme 5.1: Enhanced Self-Awareness : The impact of the photovoice process on interns' understanding of their own experiences and coping strategies. Reflective Practice Participant 14: Photo: A cluttered workspace vs. a clean, organized one: Narrative: Taking the photos made me more aware of the things that were causing me stress, but also the resources I was using to cope." Participant 13: A photo of a support system (friends, family, mentors) vs. a photo of the intern alone. Narrative: "Sharing my photos and stories with the group helped me realize that I wasn't alone in my struggles than facing alone my struggles. That is why it hurts me a when friends are not helping us in times of our much needed time. Participant 9: A photo of the group sharing their photos and stories Narrative: …It gave me a voice to share my experiences and advocate for change. I wish we have more of this as an activity in the University. Theme 6: Bridging the Gap: Recommendations for Support: In this theme, the interns’ comments as regards support systems and building resilience have been encapsulated. Subtheme 6.1: Recommendations for Change : Suggestions that interns provided with regard to internships and support systems that are meant to build resilience Supporting Internships. Systemic Change Participant 13: A photo of a supportive team environment, such as nurses and interns collaborating on a task. Narrative: “I believe that these forms of assistance would be effective. Alhamdullilhah the hospitals should enhance other services for interns, including counseling or stress management workshops.” Participant 3: A photo of a group of interns and mentors participating in a workshop or training session. Narrative: …It would be beneficial to have more experienced nurses available for interns to de-brief after difficult shifts.” Participant 2: A photo of a nurse and an intern talking together: Narrative: …I have been so vocal about this that the nursing school and the hospital need to collaborate in order to provide a more positive and less challenging environment for the interns.” Theme 1: The weight of responsibility. This theme refers to the lived experience of intern stress and its complexity, which yields an overwhelming burden of responsibility. The photographs of interns alongside their narratives serve as important sources because they offer a glimpse, so to speak, of the essence of their reality. This enables one to go beyond mere description and understand their experience. Subtheme 1.1 Feeling overwhelmed as a subtheme concerns the phenomenon of "Responsibility Overload," which explains the felt burden and how it is expressed. Participant 3, for instance, presents a photograph of enormous medical books, citing… “It felt as though…” utterly burdened.” As Participant 3 claims, “I was tensed” [when doing injection]. This narrative goes hand in hand with the image and serves to showcase how the participant imagines their encounter undermined their knowledge. Such exemplification gives life to abstract notions of pressure. In the case of photovoice of participant 7 trembling hands during the injection alongside, "I was tensed" serves to metaphorically express her fear but also anxiety and vulnerability during a very practical task. Finally, Participant 12 reveals the image of an intern lying in a breakroom while claiming, “I simply needed a break.” This photovoice shows the feeling of exhaustion that elevation anxiety gives. The image and narrative serve to illustrate the lack of motivation. Overall, it captures assignments that seem to surpass one’s ability using a photovoice-phenomenology technique describing “Responsibility Overload.” The combination of narratives and images showing piled books, shaking hands, and a hunched attitude highlight overwhelming feeling of burden, tension, and fatigue. All these elements are meant to put the towering weight of the pressure interns experience into perspective. Theme 2: The emotional rollercoaster This theme offers insights into the emotional lives of the interns during their internship period, highlighting the pain of suffering, death, and the nuanced situations of patients. Using photovoice-phenomenology approaches, we examine the emotional crises they undergo, studying not simply what is observable but rather the very essence of their emotional reality. Subtheme 2.1: Emotional toll further elicit some aspects of “Emotional Burden” which occurs on the interns and their adverse sympathy and feeling harm caused due to pain inflicted upon the patients and the other various medical predicaments. The photograph of Participant 1, a darkened hospital corridor serves as a metaphor for the interns’ emotional journey. The interns’ starting statement, “This corridor depicts the environment where my experience as an intern takes place. It is where my intense work shifts start. In my everyday going here, there was so much pain and suffering that it was difficult to leave it behind”, explains immersion into an all-encompassing environment filled with pain. The photovoice component bears witness to this burdening environment and makes it more tangible than suffering. The corridor is not simply a place; it is now a lived space of burden. Participant 5’s photograph depicting an intern in tears brings out the emotional facets involved in patient death. The quote, “You know, I was affected more than I thought by the passing of a patient, which made me doubt my perceived strength if I will be really good nurse. Inshallah, I will overcome this emotion,” speaks to the lived uncertainty and vulnerability of the intern. Such an unaltered grief and make the impact of patient loss tangible. The photograph speaks to a captured lived emotional crisis. Participant 10’s photograph, reflection of an intern on a stainless-steel medicine cabinet, reminds us of extreme fatigue and accumulated emotional burden. Their quote, “What I saw in my reflection was seem so fatigue and feel very burden with the things in here [referring to the photo]. It made me emotionally down,” illustrates the intern’s struggle and exhaustion internally. The photovoice approach allows us to see the intern the way the intern sees herself and her emotional state through her own reflection. The reflection qualitatively captures a live emotional experience. These photovoice showcase the emotional vulnerabilities of the interns. Participant 1’s darkened corridor embodies the almost omnipresent agony within. The tears of a participant 5 and her self-reflection after a patient died is suggestive of the heavy burden loss can bring. In the case of participant 10, her reflective image and the accompanying narrative reveals a state of inner fatigue and overall self-exhaustion which can be felt. Theme 3: Finding Strength in Connection This theme focuses on an intern’s finding of social support and mentorship, which facilitated their resilience as they navigated through their internship. Subtheme 3.1: The Power of Support focuses on the supportive relationships that help interns manage which helps highlight peer support and mentorship. Participant 2’s photograph, interns laughing together, shows the face of peer support, its lifeline. Their narrative goes," My classmates were my lifeline and I feel very comfortable working and sharing with them ideas. We supported each other through everything". The photo voice element depicts the joy of and the connection that these relationships provide. The photo marks a phrase of shared joy, which offers support. Participant 6’s photograph shows an intern in conversation with a nurse mentor speaking to the significance and value of mentorship. “My mentor’s guidance especially my seniors as well as the nurses were invaluable. All of them shared their own experiences and helped me go through and overcome difficult situations,” as stated in their narrative, means the reality of mentorship and wisdom is richer than assumed. The nature of photovoice provides the evidential impact of mentorship in the intern’s journey. The photograph represents a captured moment of the lived experience of guidance and learning. Participant 11’s photograph depicts a group of interns rejoicing which captures the importance of celebrating milestones, however small they may be. “You know, in our family we celebrated the small victories…he same here in internship program. Or in my nursing career…” It helped us stay positive and motivated, “as highlighted in their narrative,” states the experienced phenomenon of motivation and joy. The intern's enhanced motivation is one of the consequences of phenomena photovoice. The photograph represents a celebrated moment of encouragement. Overall, “Finding Strength in Connections” no longer is an abstract idea but a lived experience which they have deeply pondered upon in relation to their coping mechanisms. Theme 4: Self-Care and Reflection This theme analyzes the interns’ active strategies utilized towards achieving their wellbeing using self-care and reflection which showcases the techniques they use to navigate the stress of their internship. Subtheme 4.1: Coping Mechanisms as a subtheme explains the preservation methods that the interns employed during the internship that aided their emotional and mental health coping strategy. Interns underscore coping mechanisms which help in preserving health and sanity while completing the exceedingly demanding tasks characterizing the internship. For participant 4, the photograph of an intern stretching serves as an image that directly correlates to their visual narrative, “Stretching my arms up helped me de-stress and reconnect with myself. It is very relaxing especially when we have a lot of patients.” Here, the experience of relief and peace of mind through enhanced movement in the arms and upper body speaks volumes when describing what seasoned interns have to go through flawlessly executing the tasks assigned to them. The intern is witnessing first hand the myriad of benefits that derive from simply stretching. Stretching improves their well-being in more ways than one, both physically and psychologically, and this photograph demonstrates this synthesis. The participant 8 photovoice ‘An intern reading in a quiet corner’ illustrates an intern’s solitude and mental escape. As Participant 8 explains, “Taking time for myself was essential. It helps me think more ideas afterwards. I needed to recharge and escape the hospital for the environment for a while,” the account portrays the necessity for emotional and mental space. The methodology gives us insight into how the intern purposefully attempted to create a personal retreat. The photograph depicts a moment when it was possible to mentally recharge. Participant 13 draws another aspect of intern personal experience as ‘an intern journaling’ for reflecting the strong process of emotions. Their narrative, “I always do this, writing down my thoughts and feeling helped me process my experiences and gain perspective. You know I use my journaling as a part of my everyday life,” illuminates the side of journaling where it serves as emotional regulation and self reflection. With photovoice the viewer is able see to the Self of the intern – the inner world that matters. The photovoice captures a reflecting moment of self through contemplation. Using the photovoice-phenomenological approach, it is clear that ‘Self-Care and Reflection’ is not simply a concept but an active practice for these interns. The images and stories self-reported show how they practice self-care in their drastically different and personally unique ways during an internship that is markedly demanding. Overall, the theme examines self-reflection and self-awareness located within the photovoice process. Interns were able to crystallize their coping and emotional experiences through the narration and capturing of their experiences. We apply a photovoice-phenomenological lens to broaden the scope of self-awareness into the lived experience. Theme 5: Gaining Perspective through the Lens : This theme reflects how the photovoice methodology prompted deeper reflection and self-awareness among participants. Subtheme 5.1 Enhanced Self-Awareness the “reflective practice” in photovoice is understood as a practice that enables a person to reflect on what they captured. Participant 14’s narration, “Taking the photos made me aware of the things that were causing me stress, but also the resources I was using to cope,” as well as the cluttered workspace photo alongside the organized workspace photo built a narrative that reveal astoundingly transforming experience. These clips demonstrate the process of attaining clarity though the utilization of conscious reflection. The intern was able to make visible what had previously only existed internally, in relation to stress and coping. In summary these photographs together with the narrative constitute an attained moment of self realization. Participant 13’s pictures on a support system against isolation, in addition to the quote, “Sharing my pictures as well as experiences with the group made me understand that I was not alone in my struggles... This is why it hurts me when my friends are not helping us during times we need that help most,” emphasizing the experience of bridging social isolation through shared experiences. The images along with the quote support the understanding of the significance that social support means for the person’s lived experience. The photos and quote spotlight an event in life when support is required and how important it is. The picture of photovoice participants sharing their work, Participant 12 complemented with:” It was empowering just to be a participant of the photovoice. It gave me an opportunity to articulate my experiences and look for change. We need more of this in the University,” show the phenomenon of collectively lived experience of participant empowerment and narrative advocacy. The participants were able to share their narratives and seek for change which the internship provided, thus portraying the power of shared experiences. The photo and quote expose us to the event in life that contextualizes and depicts power. Theme 6: Bridging the Gap ,” is not just a set of recommendations, rather it is the meaning that the intern’s selection of photographs expresses: a wish for a more holistic supportive and proactive approach to their internship. The photographs without understanding context of their accompanying stories give rise to urgency for change within the systemic setup. The interns were able to contemplate on their experiences, reflect on their self-perception, and mobilize for action through the methodology of photovoice. Subtheme 6.1: Recommendations for Change integrates Interns' Systemic Change thoughts focusing on Support for Internships Systemic Change.” This portion finalizes Interns’ recommendations for Interns Resilience Building Persistence within Structural Constraints supporting system for advanced advocacy through allowing for advanced restructuring of supporting institutions. The interns’ suggestions were elucidated drawing directly from Participant 14’s narrative: “I personally believe these forms of support would work. Alhamdulillah Interns within our hospitals should be offered other forms of assistance such as counseling and stress management workshops.” This suggestion, alongside Participant 13’s photograph depicting a positive team environment, suggest greater desire of supportive institutional settings. The photograph and statement depicts a lived moment of advocating change at the institutional level, capturing their voice. Participant 2's photograph depicting a nurse talking with an intern and the internally experienced need of voice Participants 11's quote, “I have been so vocal about this that the nursing school and the hospital needs to find a more positive and less challenging way for the interns,” exposes participants' developed and collaborative case. The photograph and the narrative present a moment of active advocacy for the changes needed to work, and those required to frame an integrated approach. The evidence presented speaks to what is achievable through the doing of photo-voice as with this skeletal account of photo-voice in the preceding chapters. What is of concern is whether, devoid of context to assist in fostering the changes that are required, interns’ trainees remain mere respondents. The photo and the quote highlight advocates have not the skeletal support necessary for collaborative institutional change. Discussion This study aimed to explore the nursing intern students' experiences of stress and resilience during internship using photovoice. The theme of "The Weight of Responsibility" in nursing internships encapsulates the significant stress experienced by nursing intern students, primarily due to the heavy responsibilities placed upon them. This stress is exacerbated by their self-evaluated readiness, which often exceeds their actual preparedness for the demands of clinical practice. Interns frequently report feeling overwhelmed by the multitude of tasks and obligations they must fulfill, leading to heightened anxiety and emotional strain. Intern nursing students face a myriad of stressors during their internships, with employment-related stress being identified as a primary concern. Zheng et al. highlight that the increasing number of nursing graduates contributes to this stress, as students feel pressured to perform at levels that may not align with their training or experience (Zheng et al., 2022 ). This sentiment is echoed by earlier scholars who found that the mental strain experienced by nursing interns, particularly during the COVID-19 pandemic, was profound, necessitating immediate psychological support (Eweida et al., 2020). The pandemic has intensified feelings of inadequacy and anxiety among nursing students, as they grapple with the dual challenges of learning and providing care in a high-stakes environment (Zhao et al., 2021). The subtheme on ‘Feeling Overwhelmed’ is especially important, as numerous nursing students report that their workload is unreasonable in both volume and complexity. This overwhelming feeling is not just an individual impression but something that is backed up by evidence. For example, it was point out that nursing students are often stressed because of their assignments and workload which can produce a state of feeling overwhelmed (Noureen et al., 2019 ). In the same fashion, it was discussed how the online learning that came with the pandemic has been an additional burden as students try to learn new ways of doing things while ensuring clinical competencies (Chang et al. 2022 ). The accumulation of these factors can cause a great deal of psychological damage, and goes on to detail how nurses during the pandemic have mental health issues (Galehdar, 2020). Moreover, the concept of being overwhelmed is examined more closely by researchers stating that the emotional weight of nursing can contribute to the feeling of being overwhelmed as general well-being and professional self-image (Kabigting, 2019 ). The changeover between student and intern is not easy because many interns undergo severe stress in their first year due to the possibility of making mistakes and being unable to cope with the responsibilities placed on them (Gaundan & Mohammadnezhad, 2018). As noted, the professional experiences of nursing intern students during the internship period is accompanied by lifting a huge load of responsibility that often leads to being overwhelmed. This is one of the most important phenomenon which needs further detailed investigation and is clearly justified by existing literature, the sources of psychological stress nursing students endure in education and clinical practice. The nursing education system must adapt to such changes and provide clinical nursing students with the necessary support to increase resiliency to psychological stressors. Through the lens of ‘The Emotional Rollercoaster’, nursing internships outline the detrimental emotional turmoil that nursing students undergo during their clinical practice. This theme is particularly important in understanding the suffering which is caused by witnessing patient suffering, demise, and intricacies in medical management The subtheme “Emotional Toll” captures specifically sympathy induced negative emotions, and emotional distress that nurse interns are faced with as they experience the hardships of caring for patients. There are nursing students who are required to cope with emotionally sensitive situations that involve managing patient pain and death. As noted nurses have to comprehend the complex suffering of the patients which is very engaging (Younas & Inayat, 2023). This can cause emotional anguish as interns deal with their own patients’ pain and suffering. Added to this is the fact that nurses have to act professional while they deal with feelings of empathy and sadness, an issue that is referred to as ‘compassion in nursing practice’ (Younas & Maddigan, 2019). The emotional burden of caring for patients with complex needs can lead to what is termed compassion fatigue where the nurse’s emotional reserve is summarily used up, making it difficult to provide compassionate care (Mok et al., 2020). In addition, the emotional aspects that nursing students have to deal with are not exclusively linked to patient interactions alone. Performing in a high-stakes situation can lead to overwhelming psychological stress. Accordingly, nursing students frequently report feeling inadequate, especially in dealing with the emotional aspects of caring for seriously ill patients. These students often become overwhelmed with feelings of powerlessness and emotional exhaustion (Hedenstrom et al., 2021). Even interns suffer from the emotional burden of being fearful to make mistakes in important situations, a form of anxiety which, as discussed in the context of resilience in nursing education, often accompanies self-doubt (Tur-Porcar et al., 2020). Such feelings must be dealt with in a resilient manner to be able to cope with the emotions, enabling nursing students to focus on the intricacies of patient care without risking their mental health (Venkatesan, 2020). The consequences left behind by the COVID-19 pandemic has exacerbated the psychical crises suffered by nursing students. An atmosphere full of anxiety and stress presents itself, caused by the previously unseen challenges nursing interns experience during patient care (Zhongxiang et al., 2020). Internally, students are suffering more than ever because of life threatening feeling and heat, increasing their feelings of helplessness (Lin et al, 2021 ). Clinical environments need support systems where students can receive adequate guidance to mentor them through their experiences to help them cope (Mikkonen et al., 2021). To this end, nursing interns have to deal with significant emotional challenges due to their interpersonal responsibilities in caring for patients. Nursing students have to deal with the mix of empathy, compassion, and clinical practice - the most difficult phase. The theme “Finding Strength in Connection” emphasizes the aspect of social support and mentorship during the internship period, that immensely enhances the resilience of nursing interns. This theme stands out in particular because nursing students face immense emotional and professional development challenges during their internship period, and supportive networks have the potential to greatly help. The subtheme “The Power of Support” illustrates these connections and networks as important aides in the stressors of practicing with patients. Social support has been cited as one of the most critical components in building resilience among nursing students, more so during adverse conditions like the COVID-19 pandemic. Scholars have highlighted the ecological model of resilience, which suggests that maintaining resilience in times of crisis necessitates social support and resource exchanges (Drach-Zahavy et al. 2021 ). These findings highlight the strong social support nursing students receive from their peers, and how this impacts stress and demonstrates the need for supportive networks as well as mentorship in the clinical setting. Furthermore, it was indicated that nursing students, who had help from co-workers while interning, had higher rates of personal resilience” (Garderen & Leeuwen, 2021). This system of support reduces feelings of detachment while simultaneously creating an increased sense of community between students, which is important for their emotional health. Supportive teachers and peers can offer a compassionate atmosphere in which students feel encouraged to voice their worries, seek help, and increase their learning and skill development during the study. It suffices to say that mentorship bears critical import in nursing education. Althaqafi et al ( 2019 ) identifies that at the onset of the internship phase, mentorship paradigms should be instituted for ease of clinical practice and the advancement of students in nursing scope. These programs grant interns from nursing schools access to veteran nurses who can facilitate their understanding of intricacies involved in patient care. Such mentoring drives learning and skill development but also increases the levels of self confidence and self-efficacy among nursing students. In addition, students of nursing need to have ample time to think and talk about the emotional issues that confront them. It was enunciated that students require spaces to talk about their experiences, whether through formal reflection seminars or informal conversations with peers and supervisors (Weurlander et al., 2018 ). To sum up, the sub theme of “Finding Strength in Connection” captures the essence of social support and mentorship as critical factors that help nursing interns to cultivate resilience. Nursing students are able to tackle the emotional and professional difficulties of their internships through peer support, mentorship programs, and positive interactions with their educator. Such linkages improve not only their learning but their overall health and most importantly, their capacity to adapt in the future nursing profession, which is a tenacious one. The subtheme ‘coping mechanisms’ scrutinizes the techniques interns employ in dealing with the emotional and psychological aspects of their role. This is concerns nursing interns as it highlights the stressors emerging from patient responsibilities, the burdening emotions that come with suffering, and the high pressure to consistently perform. Accordingly, maintaining reflective journals as a form of reflective practice, greatly augments the decision making and problem solving skills of nursing students (Sürücü, 2021). Interns are enabled to analyze their experiences, which enhances their comprehension of their emotional triggers, enabling them to control their stress in the future. Emphasis is placed on the nursing student’s strategies to effectively balance stressors and challenges for mental and emotional well being during internships. This is important because it addresses the coping strategies that are necessary to maintain resilience for the multitude of challenges faced in clinical environments. The theme “Self-care and reflection” narrows down to focus on the subtheme coping mechanisms. Besides, the inequivocable necessity for these support systems to be integrated within the coping strategies is notable. It has been argued that all educational and training programs must go beyond the self-care and mental health issue and formulate plans for teaching nursing student’s self-care and crisis management skills (de Bot & de Vos, 2022). This is especially important considering the emotional strain that nursing students face which has intensified during the pandemic. Students can more readily handle the challenges of clinical practice if the educational institutions prepare them with appropriate coping mechanisms. Apart from peer assistance, self-care also plays an important role in supporting the mental health of nursing interns. The workplace stress can be mitigated through protective mechanisms such as support networks or other positive forms of communication that can be built (Silva et al., 2020 ). These mechanisms serve to promote more than just coping; they also build identity and community among nursing students and significantly safeguard their emotional health. Supporting nursing program interns assists them in coping with the emotional aspects of patient care, thereby improving their self-efficacy. In essence, “Self-Care and Reflection” highlights the coping strategies that nursing interns utilize to mitigate stress and promote their health and well-being. Reflective practice, positive coping strategies, and structured supportive process aid nursing students in handling the emotional and psychological realities of their internship. in adapting to a self-caring approach while attending to nursing education, interns' resiliency would be improved which in turn leads to appropriate patient care and greater job satisfaction. The theme of “Gaining Perspective through the Lens” describes how the photovoice methodology affects the circling nursing interns, especially on self-reflection and self-interpretation of their experiences. This aspect of the theme is important because it demonstrates how the photovoice process allows interns to reflect more deeply on the coping strategies that they used during their clinical training. The subtheme “Enhanced Self-Awareness” addresses how the photovoice process impacts interns self-emotion as well as self-psychology to the challenges they encounter. Photovoice has been shown to be a strong means of increasing self-awareness among respondents by allowing them to document their experiences visually and recall their emotions. Researchers like Rania et al ( 2022 ) explain that the photovoice methodology constructively enables critical reflection to be reframed and for the participants to interact with their experiences meaningfully. This approach promotes coping at the individual level while nurturing group benevolence and discussion. In doing so nursing interns, through photography, self-expression captures what they feel and the problems they face and as a result, gain an understanding of their emotions and self-regulatory strategies. Similarly, a research aimed at analyzing photovoice as a stigma alleviating measure among healthcare students validates the implications of self-awareness and self-claimed schema as relief generated from photovoice (Tippin & Maranzan, 2022). Looking at the studies, the participants are able to tell their experiences by framing stories which address problems that are confronted and coping strategies which improve self awareness. The theme “Gaining Perspective through the Lens” shows how the photovoice method helps nursing interns to reflect on themselves more deeply. As nurses, interns need to focus on critical reflection, and narrative construction in a “story” format further supports their understanding of their emotions and how they cope. This helps further personal resilience but just as importantly, building a community of practice that promotes the wellbeing of nursing students while they prepare for practice. The subtheme “recommendations for Support" summarizes the perspectives shared by nursing interns regarding the support systems that could help them build endurance during their internships. This theme appears particularly important, because it captures how interns perceive existing systems, and how those systems can be made more responsive to their needs and overall wellness. The subtheme "Recommendations for Change" captures the specific, actionable comments made by interns regarding the structure and support them during their internship. Interns have noted the necessity of holistic support systems which consider the emotional and mental burdens trainees are likely to endure during their clinical practice sessions. Alodhialah et al. (2024) brought light to the fact that nurses have emotional issues which need urgent attention especially during periods of high stress, for example, in palliative care. Their research results indicate that there is a need for health care organizations to take the initiative in formulating emotional resilience support systems, the same could also apply for nursing internships. This involves the provision of mental health care, counseling, and mentorship to assist interns to cope with the emotional intricacies acquired while dealing with patients. Moreover, it was emphasizing the relevance of community resilience for supporting people experiencing mental health difficulties (Lestari & Yusuf, 2018). Together with other insights, these approaches can be integrated into nursing internship programs where supportive community building among interns is useful for resiliency enhancement. Nursing programs can make interns feel more connected and less lonely in their experiential learning by fostering environments that promote collaboration and mutual assistance. Such communities can be established through organized peer-facilitated mentorship schemes and forums where interns discuss their challenges and ways of coping with them. Interns have further suggested that the curriculum of the internship should include structured reflection and debriefing sessions. These sessions allow the interns to reflect on their experiences and share how these experiences affected them, as well as learn ways to cope with them. This is in agreement with earlier research highlighting the role of social support in building resilience in people who experience great hardship (Wu et al., 2024). Contemplative nursing practices that aim at discussing the effects of clinical practice on the intern’s psyche make it simpler for the intern to cope with the stressful realities of nursing. Moreover, faculty and mentors play an equally important role in providing direction and support. The effectiveness of support systems is determined by mentorship which gives and receives feedback openly (Carrad et al., 2022). Interns have already pointed out the lack of such mentorship programs, via which seasoned nurses may help, provide advice, share coping methods, and give them emotional aid. Such mentors are very important in helping interns accept the challenges of patient care and aid in their changes in professional self-concepts. It is important to carry out the wellness programs directed towards self-care and stress management. Interns have stated how they require workshops and trainings that help them practice stress management and overall well being. This resonates with what earlier research stating that the need for internal support systems to be more focused upon in order to improve performance and resilience (Kurniawan et al., 2024). If such wellness initiatives are incorporated into nursing internships, the interns are bound to be more appreciative of their mental health and learn positive coping methods. To sum up, the “Bridging the Gap and Recommendations for Support underscored the special aspects raised by nursing interns regarding what type of support is needed to build resilience during the internship. Community resilience building through comprehensive supportive structures, guided reflection, mentoring, and wellness interventions, is what makes nursing education improve the students’ internship experience. These changes, which stem from the interns, also positively impact the quality of healthcare services provided as well as the nursing profession's future. Study implications This study has considerable consequences for nursing education, practice, and future inquiries. Nursing education focuses more on integrating resilience training, enhancing clinical preparedness, and incorporating reflection and debriefing sessions. Mentorship programs should be established together with emotional intelligence training to help interns cope with their stressful experiences. Stress management and self-care instruction as part of wellness initiatives are also important. As the method photovoice has been recognized for reflection, self awareness, and other areas, it should be accepted for a greater focus. Healthcare organizations also need to work towards building and maintaining supportive structures, increasing access to mental health services, and controlling intern workloads. Community fostering, as well as fighting compassion fatigue, is largely essential in a supportive clinical environment. Future research should concentrate on the longitudinal effects, comparative best practice studies, and quantitative studies of the interventions' effectiveness. Due consideration also needs to be given to the culture and sustainability of photovoice changes. Supporting nursing interns and helping them develop resilience, alongside addressing these implications, we improve the quality of health care. Study limitations Although this analysis sheds light onto the lived experiences of nursing intern students using a qualitative-phenomenological photovoice design, certain issues stand out. The study has very limited general scope due to its sample size consisting of only 14 individuals, and the interns placed at a selected university branch during the later part of their internship. Moreover, participants were not able to corroborate the final coded interview transcripts due to confidentiality issues and therefore may have inconsistencies with the way the narratives are interpreted, although the photo narratives were corroborated. In addition, although the researchers reflexively participated and performed an external inquiry audit, they brought with them as nursing faculty a certain set of unconscious assumptions. Moreover, the requirements set out for participation which included proficiency in English may have prevented attendance from several non-English speaking interns aiding in the study. Although photovoice is a participatory approach that has its merits, participants’ ability to represent their experiences using visuals could be highly nuanced and subjective, the nature of photos interprets even the most complex emotions having a limitation. Lastly, ensuring confidentiality is key, but complete anonymity becomes difficult in small qualitative studies. Overall, the absence of follow-up interviews could have restricted the scope of opinion gathered, even though data saturation was attained. Future researchers will need to try and overcome these challenges using larger, heterogeneous samples, multi-method approaches, and considering longitudinal designs. Conclusion This photovoice study revealed the surprising nuances of nursing internships, uncovering that interns endure significant amounts of stress because of their hefty responsibilities and emotional burden of patient care. Also, the study brought to light the importance of social support, peer and mentorship relationships proved to be central spokes to the wheels in overcoming these problems. Interns utilized self-care treatment techniques and reflective practices, made possible through photovoice technology which heightened their self-awareness. Finally, the study provided actionable recommendations to systemic mentorship structures and stress management initiatives, as well as for better coordinated joint activities between schools and hospitals in order to promote a more favorable environment for emerging nursing professionals. Abbreviations ERC - Ethic Review Committee IRB- Institutional Review Board KKU - King Khalid University PhD - Philosophical Doctor Declarations Ethics approval and consent to participate Ethical approval was granted by the Ethics Research Committee (ERC) Institutional Review Board (IRB) of King Khalid University (KKU). The research team confirmed that all methods were performed in accordance with relevant guidelines and regulations under the Helsinki Declaration. Further, informed consent was obtained from all subjects. Consent for publication Participants provided informed consent for participation in the study, and explicit consent for the publication of anonymized data was obtained. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to participant confidentiality. Data are available from the corresponding author upon reasonable request. Competing Interests The authors declare that they do not have a competing interest. Funding This research was funded by the Princess Nourah bint Abdulrahman University Researchers supporting project (No. PNURSP2025R875), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia. Authors' contributions EP, SRS, RHA, MSA, Conceptualization, Methodology, Data collection, Formal analysis, writing – original draft, Writing – review & editing. NAA, AG, JG, BAJ, FG, AJD Data collection, Formal analysis, Writing – review & editing. Acknowledgments The authors would like to acknowledge the support of the Princess Nourah bint Abdulrahman University Researchers supporting project (No. PNURSP2025R875), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia. Clinical trial number: not applicable References ‌Abbaszadeh, M., Tavakkol Aghayari Hir, Mahnaz Jabraeili, & Ebrahim Mohammadpour. (2023). The impact of organizational education on nurses’ career resilience during the COVID-19 pandemic. Research and Development in Medical Education , 12 , 2–2. https://doi.org/10.34172/rdme.2023.33107 Abdallah, B., Ali, R., & Ali, A. (2023). Nursing Students’ Perception of Stress and Resilience during Their Clinical Training. Minia Scientific Nursing Journal , 014 (1), 59–66. https://doi.org/10.21608/msnj.2023.238647.1082 Alanazi, F. J., Alenezi, M. H. M., Alanazi, A. A. N., & Alanazi, T. S. R. (2023). Do internship students do well in a clinical environment? A qualitative naturistic study. Belitung nursing journal, 9(6), 539–546. https://doi.org/10.33546/bnj.2938 Alemi M, Rezanejad A, Marefat B. Exploring the reasons behind Iranian TEFL graduate students’ academic failure. Profile: Issues in Teachers’ Professional Development. 2021; 23:151–66 ‌Alodhialah, A. M., Almutairi, A. A., & Almutairi, M. (2024). Exploring Nurses’ Emotional Resilience and Coping Strategies in Palliative and End-of-Life Care Settings in Saudi Arabia: A Qualitative Study. Healthcare , 12 (16), 1647. https://doi.org/10.3390/healthcare12161647 Althaqafi, S., Alhatimi, H., Almalki, A., Alyamani, O., & Banakhar, M. (2019). Nursing students’ clinical practice experience during the internship year at different hospitals: a qualitative study. American Journal of Nursing Science, 8(5), 255. https://doi.org/10.11648/j.ajns.20190805.18 Alzayyat, A., & Al-Gamal, E. (2014). A review of the literature regarding stress among nursing students during their clinical education. International Nursing Review , 61 (3), 406–415. https://doi.org/10.1111/inr.12114 ARDA SÜRÜCÜ, H. (2021). Clinical Decision Making, Problem Solvig and Autonomy for Nursing Students Attending an Internship Training Program: A Comparative Study. MAS Journal of Applied Sciences , 7 (7). https://doi.org/10.52520/masjaps.91 Aryuwat, P., Asp, M., Lövenmark, A., Radabutr, M., & Holmgren, J. (2022). An integrative review of resilience among nursing students in the context of nursing education. Nursing Open, 10(5), 2793-2818. https://doi.org/10.1002/nop2.1559 Blomberg, K., Bisholt, B., Engström, A., Ohlsson, U., Sundler, A., & Gustafsson, M. (2014). Swedish nursing students' experience of stress during clinical practice in relation to clinical setting characteristics and the organisation of the clinical education. Journal of Clinical Nursing, 23(15-16), 2264-2271. https://doi.org/10.1111/jocn.12506 Cai, Z., Cui, Q., Liu, Z., Li, J., Gong, X., Liu, J., … & Wang, G. (2020). Nurses endured high risks of psychological problems under the epidemic of covid-19 in a longitudinal study in wuhan china. Journal of Psychiatric Research, 131, 132-137. https://doi.org/10.1016/j.jpsychires.2020.09.007 ‌Carrad, A., Aguirre‐Bielschowsky, I., Rose, N., Charlton, K., & Reeve, B. (2022). Food system policy making and innovation at the local level: Exploring the response of Australian local governments to critical food systems issues. Health Promotion Journal of Australia , 34 (2). https://doi.org/10.1002/hpja.626 Chang, C., Chung, M., & Yang, J. (2022). Facilitating nursing students' skill training in distance education via online game-based learning with the watch-summarize-question approach during the covid-19 pandemic: a quasi-experimental study. Nurse Education Today, 109, 105256. https://doi.org/10.1016/j.nedt.2021.105256 ‌Cheung, T., Wong, S., Wong, K., Law, L., Ng, K., Tong, M., Wong, K., Ng, M., & Yip, P. (2016). Depression, Anxiety and Symptoms of Stress among Baccalaureate Nursing Students in Hong Kong: A Cross-Sectional Study. International Journal of Environmental Research and Public Health , 13 (8), 779. https://doi.org/10.3390/ijerph13080779 ‌de Bot, C. M. A., & de Vos, A. J. B. M. (2022). Three-Questions-Method for Coping with the Emotional Burden of Nurses and Nursing Students during COVID-19. International Journal of Environmental Research and Public Health , 19 (11), 6538. https://doi.org/10.3390/ijerph19116538 Drach‐Zahavy, A., Goldblatt, H., Admi, H., Blau, A., Ohana, I., & Itzhaki, M. (2021). A multi‐level examination of nursing students' resilience in the face of the covid‐19 outbreak: a cross‐sectional design. Journal of Advanced Nursing, 78(1), 109-120. https://doi.org/10.1111/jan.14951 ‌Eweida, R. S., Rashwan, Z. I., Desoky, G. M., & Khonji, L. M. (2020). Mental strain and changes in psychological health hub among intern-nursing students at pediatric and medical-surgical units amid ambience of COVID-19 pandemic: A comprehensive survey. Nurse Education in Practice , 49 , 102915. https://doi.org/10.1016/j.nepr.2020.102915 Galehdar, N., Toulabi, T., Kamran, A., & Heydari, H. (2020). Exploring nurses' perception of taking care of patients with coronavirus disease (covid‐19): a qualitative study. Nursing Open, 8(1), 171-179. https://doi.org/10.1002/nop2.616 ‌Gaundan, D., & Mohammadnezhad, M. (2018). Intern-Nurses’ Perception on Transition at Labasa Hospital, Fiji: A Qualitative Study. Journal of Nursing and Health Studies , 03 (01). https://doi.org/10.21767/2574-2825.100031 ‌Hedenstrom, M. L., Sneha, S., Nalla, A., & Wilson, B. (2021). Nursing Student Perceptions and Attitudes Toward Patients With Cancer After Education and Mentoring: Integrative Review. JMIR Cancer , 7 (3), e27854. https://doi.org/10.2196/27854 Kabigting, E.-N. R. (2019). The Humanbecoming Concept Inventing Model: Feeling Overwhelmed. Nursing Science Quarterly , 32 (3), 214–218. https://doi.org/10.1177/0894318419845401 ‌Khanmohammadi, S., Hajibeglo, A., Rashidan, M., & Bekmaz, K. (2020). Relationship of resilience with occupational stress among nurses in coronavirus ward of Khatam Al-Anbia Hospital, Gonbad Kavous, 2020. Neuropsychiatria I Neuropsychologia , 15 (1-2), 1–6. https://doi.org/10.5114/nan.2020.97397 ‌Kim, S. C., Sloan, C., Montejano, A., & Quiban, C. (2021). Impacts of Coping Mechanisms on Nursing Students’ Mental Health during COVID-19 Lockdown: A Cross-Sectional Survey. Nursing Reports , 11 (1), 36–44. https://doi.org/10.3390/nursrep11010004 ‌Kurniawan, A., Haliah Haliah, & Andi Kusumawati. (2024). Internal Control Analysis and Fraud Prevention Efforts in Public Sector Accounting. East Asian Journal of Multidisciplinary Research , 3 (11). https://doi.org/10.55927/eajmr.v3i11.11809 Lin, Y., Hu, Z., Danaee, M., Alias, H., & Wong, L. P. (2021). The Impact of the COVID-19 Pandemic on Future Nursing Career Turnover Intention Among Nursing Students. Risk Management and Healthcare Policy , 14 , 3605–3615. https://doi.org/10.2147/RMHP.S322764 ‌Mikkonen, K., Tomietto, M., Tuomikoski, A., Miha Kaučič, B., Riklikiene, O., Vizcaya‐Moreno, F., Pérez‐Cañaveras, R. M., Filej, B., Baltinaite, G., Cicolini, G., & Kääriäinen, M. (2021). Mentors’ competence in mentoring nursing students in clinical practice: Detecting profiles to enhance mentoring practices. Nursing Open , 9 (1). https://doi.org/10.1002/nop2.1103 Noureen, S., Hussain, M., Afzal, M., & Gilani, S. (2019). Relationship of nursing students stress and their personal response to stress in learning environment. JHMN. https://doi.org/10.7176/jhmn/62-01 Rania, N., Coppola, I., Brucci, M., & Pinna, L. (2022). Enhancing empowerment in young adults during the COVID-19 era in Italy through the Photovoice technique. Current Psychology . https://doi.org/10.1007/s12144-022-03635-5 ‌Retno Lestari, & Yusuf, A. (2018). Developing community resilience as a supporting system in the care of people with mental health problems in Indonesia. Indian Journal of Public Health Research & Development , 9 (11), 1687–1687. https://doi.org/10.5958/0976-5506.2018.01685.6 Silva, S., Baptista, P., Silva, F., Almeida, M., & Soares, R. (2020). Resilience factors in nursing workers in the hospital context. Revista Da Escola De Enfermagem Da Usp, 54. https://doi.org/10.1590/s1980-220x2018041003550 ‌Tippin, G. K., & Maranzan, K. A. (2022). Photovoice as a Method to Reduce the Stigma of Mental Illness Among Health Care Students. Health Promotion Practice , 23 (2), 331–337. https://doi.org/10.1177/15248399211057152 ‌Tur Porcar, A. M., Cuartero Monteagudo, N., Gea-Caballero, V., & Juárez-Vela, R. (2020). Resilience Scale Psychometric Study. Adaptation to the Spanish Population in Nursing Students. International Journal of Environmental Research and Public Health , 17 (12), 4602. https://doi.org/10.3390/ijerph17124602 ‌Venkatesan, L. (2020). Effectiveness of Integrated Teaching Involving Patients as Teachers (PAT) Vs Traditional Teaching (TT) upon Cognitive Behaviour of Nursing Students at TamilNadu, India. International Egyptian Journal of Nursing Sciences and Research , 0 (0), 6–9. https://doi.org/10.21608/ejnsr.2020.30805.1003 Weurlander, M., Lönn, A., Seeberger, A., Broberger, E., Hult, H., & Wernerson, A. (2018). How do medical and nursing students experience emotional challenges during clinical placements?. International Journal of Medical Education, 9, 74-82. https://doi.org/10.5116/ijme.5a88.1f80 ‌Wheeler, K., & Phillips, K. E. (2019). The Development of Trauma and Resilience Competencies for Nursing Education. Journal of the American Psychiatric Nurses Association , 27 (4), 107839031987877. https://doi.org/10.1177/1078390319878779 Williams, K. (2014). An exploratory study: reducing nursing students stress levels facilitate perceived quality of patient care. Open Journal of Nursing, 04(07), 512-519. https://doi.org/10.4236/ojn.2014.47054 ‌Wu, Y., Guo, Z., Zhang, D., Wang, Y., & Wang, S. (2024). Sleep Quality and Suicidal Ideation in Adolescent Depression: A Chain Mediation Effect of Perceived Social Support and Resilience. Clinical Psychology & Psychotherapy/Clinical Psychology and Psychotherapy , 31 (2). https://doi.org/10.1002/cpp.2990 Yaseen Fathi K, Ibrahim RH. Factors influencing integration of theory into practice in clinical skills acquisition among nursing students. Inform Med Unlocked. 2023; 37:101181 ‌Younas, A., & Maddigan, J. (2019). Proposing a policy framework for nursing education for fostering compassion in nursing students: A critical review. Journal of Advanced Nursing , 75 (8), 1621–1636. https://doi.org/10.1111/jan.13946 ‌Younas, A., & Shahzad Inayat. (2023). Alleviating suffering of individuals with multimorbidity and complex needs: A descriptive qualitative study. Nursing Ethics , 31 (2-3). https://doi.org/10.1177/09697330231191280 ‌Zhao, Y., Zhou, Q., Li, J., Luan, J., Wang, B., Zhao, Y., Mu, X., & Chen, H. (2021). Influence of psychological stress and coping styles in the professional identity of undergraduate nursing students after the outbreak of COVID‐19: A cross‐sectional study in China. Nursing Open , 8 (6), 3527–3537. https://doi.org/10.1002/nop2.902 Zheng, Y., Jiao, J.-R., & Hao, W.-N. (2022). Stress levels of nursing students: A systematic review and meta-analysis. Medicine , 101 (36), e30547. https://doi.org/10.1097/md.0000000000030547 Additional Declarations No competing interests reported. Supplementary Files Englishquestionnaire.docx Cite Share Download PDF Status: Published Journal Publication published 07 Aug, 2025 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 30 Jun, 2025 Reviews received at journal 18 Jun, 2025 Reviewers agreed at journal 06 Jun, 2025 Reviews received at journal 18 Apr, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviewers invited by journal 27 Mar, 2025 Editor assigned by journal 27 Mar, 2025 Editor invited by journal 24 Mar, 2025 Submission checks completed at journal 23 Mar, 2025 First submitted to journal 23 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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University","correspondingAuthor":false,"prefix":"","firstName":"Sahar","middleName":"Rafdan","lastName":"Alsharani","suffix":""},{"id":440227968,"identity":"4e983b90-06c0-4c9f-8703-c883c66323cb","order_by":2,"name":"Sumathi Robert Shanmugam","email":"","orcid":"","institution":"Princess Nourah bint Abdulrahman University","correspondingAuthor":false,"prefix":"","firstName":"Sumathi","middleName":"Robert","lastName":"Shanmugam","suffix":""},{"id":440227969,"identity":"71198794-287f-466c-bae2-8970e23f7302","order_by":3,"name":"Reem Humaidi Alalawi","email":"","orcid":"","institution":"King Khalid University","correspondingAuthor":false,"prefix":"","firstName":"Reem","middleName":"Humaidi","lastName":"Alalawi","suffix":""},{"id":440227970,"identity":"17526f7e-cbbf-4989-aa98-af6b7d8f0265","order_by":4,"name":"Maha Sanat Alreshidi","email":"","orcid":"","institution":"University of Hail","correspondingAuthor":false,"prefix":"","firstName":"Maha","middleName":"Sanat","lastName":"Alreshidi","suffix":""},{"id":440227971,"identity":"9c5885af-b346-4e43-8724-3341de81a305","order_by":5,"name":"Nojoud Abdullah Alrashidi","email":"","orcid":"","institution":"University of Hail","correspondingAuthor":false,"prefix":"","firstName":"Nojoud","middleName":"Abdullah","lastName":"Alrashidi","suffix":""},{"id":440227972,"identity":"8db7e2a7-7f1b-481f-8136-c0fa1e26087c","order_by":6,"name":"Analita Gonzales","email":"","orcid":"","institution":"University of Tabuk","correspondingAuthor":false,"prefix":"","firstName":"Analita","middleName":"","lastName":"Gonzales","suffix":""},{"id":440227973,"identity":"dd8ce2bd-a817-46cf-a441-635c111a6f4e","order_by":7,"name":"Jeneth Gutierez","email":"","orcid":"","institution":"University of Tabuk","correspondingAuthor":false,"prefix":"","firstName":"Jeneth","middleName":"","lastName":"Gutierez","suffix":""},{"id":440227974,"identity":"8bb93232-691d-405b-9ad4-65af271deecf","order_by":8,"name":"Benito Areola","email":"","orcid":"","institution":"Shaqra University","correspondingAuthor":false,"prefix":"","firstName":"Benito","middleName":"","lastName":"Areola","suffix":""},{"id":440227975,"identity":"0b1b1ac5-de77-41e4-8024-bb5a28c89780","order_by":9,"name":"Ferdinand 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University","correspondingAuthor":false,"prefix":"","firstName":"Allen","middleName":"Joshua","lastName":"Dominguez","suffix":""}],"badges":[],"createdAt":"2025-03-09 11:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6188343/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6188343/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-03701-w","type":"published","date":"2025-08-07T15:56:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88814021,"identity":"d53129e3-3c29-4c42-926a-142e7cae97bc","added_by":"auto","created_at":"2025-08-11 16:00:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1220235,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6188343/v1/93efb229-87b9-47f7-80e0-f8d1c98cd083.pdf"},{"id":80523132,"identity":"a7386a2a-80e9-4989-b6f8-cc0b79119ac3","added_by":"auto","created_at":"2025-04-14 09:24:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16725,"visible":true,"origin":"","legend":"","description":"","filename":"Englishquestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-6188343/v1/1610b3a54f5bc68fd925b595.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring nursing intern students' experiences of stress and resilience during internship using photovoice","fulltext":[{"header":"Introduction","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe experiences of nursing intern students during their internships is very relevant for placing nursing education and professionalism in context. While clinical practice is part of the components of the nursing education, certain research suggests that students are falling short of adequate clinical practice experience (Alemi et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In Saudi Arabia, internships are a very crucial phase of clinical practice that students have to face following the education phase and different stressors of this phase may exert a considerable influence on their mental health and professional competence. An emerging requirement for nursing students is to complete a minimum of 960 hours of internship during the last year of the bachelor\u0026rsquo;s degree program (Alanazi et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This enables them to broaden their clinical scope, utilize critical thinking in different contexts, and exhibit competency in both clinical practice and theory (Alanazi et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Research has investigated the phenomenon of stress in nursing students and its correlation to insufficient preparation for the real-life clinical practice which tends to worsen the stress levels (Williams, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Zheng et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This stress hampers the students' physical and mental health and, in turn, the quality of care received by patients as these students do not deliver to their best potential (Zheng et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Therefore, investigating the coping strategies and stress factors of nursing internship students is important for designing proper educational interventions that will improve their experience.\u003c/p\u003e \u003cp\u003eA gap exists in literature analyses surrounding the stressors nursing intern students experience during their internships. They encounter many barriers, including a lack of resources, qualified personnel, and even the opportunity to learn (Fathi \u0026amp; Ibrahim, 2023). Roughly one half of the academic commitment for nursing students which is approximately 50% of the entirety of the course structure deals with clinical practice. These barriers can undermine a nurse's ability to provide appropriate care and can serve to establish a detrimental environment for education. Although some studies have examined the stress experienced by nursing students in various contexts, few have concentrated on the specific problems associated with internship (Aryuwat et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Alzayyat \u0026amp; Al-Gamal, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). For example, Blomberg et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) explained that around 50% of nursing students had increased levels of anxiety and stress while undergoing clinical practice however, the precise causes of this stress and anxiety during internships is a question that remains unanswered. Moreover, although resilience is considered a protective element that reduces stress, the specific processes by which resilience functions in relation to nursing internship experiences require more exploration (Aryuwat et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Abdallah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This literature demonstrates an absence that shows the necessity of deep focus into nursing intern student\u0026rsquo;s experiences and pinpointing stressors and resilience aids to incorporate into nursing education.\u003c/p\u003e \u003cp\u003eMoreover, recognizing the experience of stress and resiliency among nursing intern students is more than just concern for their academic success. It relates a great deal with the future of nursing as a profession. With the advancements in nursing, students should be guided on how to effectively manage stress and build resiliency (Kim et al., 2021; Wheeler \u0026amp; Phillips, 2019). According to the literature, fostering resilience through planned interventions can positively impact the mental health status and professional efficacy of nursing students (Abbaszadeh et al., 2023); Khanmohammadi et al., 2020). When addressing the multidisciplinary complexities of internships, educational institutions can provide comprehensive support systems which promote the well-being of students and improve the quality of care provided to patients (Cheung et al., 2016). Hence, this study intends to address the information gap by studying the subtle experiences of nursing intern students which will result in more effective nursing education policy and planning.\u003c/p\u003e \u003cp\u003eNursing intern students' experiences of stress and their resiliency construction during internships remains largely unexplored. Reviewed literature did highlight on considerable sources of stress and the need for resiliency, however, the students\u0026rsquo; specific experiences in this critical transition phase remain inadequately studied. This study was designed to address these gaps and, in so doing, help to inform nursing education practices and improve nursing students\u0026rsquo; wellbeing, and thereby as well, the healthcare system. The training of future nurses has to incorporate professional self-care as coping skills and resilience building techniques for stress management will be paramount in the nursing field. This study meets this aspect by offering interventions that are grounded in evidence-based practice which can be used to develop programs meant to build resilience and cope with stress. Hence, this study aimed to explore the nursing intern students' experiences of stress and resilience during internship using photovoice.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Design\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study employed qualitative-phenomenological design using photovoice to encouraging the participants to reflect on their photos, discuss the meanings behind them, and create narratives that contextualize their experiences.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants/Sampling\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe participants were the 14 students (7 females and 7 males). Special focus was given to the participants who undertook nursing in the hospitals as interns for the last six months of their internship. This phase is specifically selected because these interns have a fair amount of experience with the profession and have started to build some coping strategies to deal with the associated stressors. Inclusion criteria combines enrollment into the second portion of the internship, effective communication skills in English, and the ability to provide informed consent. Exclusion criteria eliminates first-six months\u0026rsquo; interns, non-English speakers, subjects unable to give informed consent, individuals with cognitive or physical barriers that restrict their participation in the photovoice approach process such as moderate to severe sight impairment, and previously participated subjects in photovoice studies. The recruited participants were contacted through their nursing schools branch.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study was conducted at the King Khalid University, College of Nursing particularly at the Abha and Khamis Muhsayt branch. The data collection took place in a private room in the university. This ensured a comfortable and confidential environment for participants to share their experiences. Only the participants and the researchers were present during the interviews.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e The study commenced with an approved Institutional Review Board (IRB) at King Khalid University. Upon recruitment, participants received training on purposeful photography as a research tool, ethical photography of privacy and anonymization, and narrative building practice through images. Participants further engaged in photo journals where they took 5\u0026ndash;7 pictures depicting their experiences of stress and coping. These photos and narratives were discussed in individually so that participants can explain their photos and then group discussion was conducted to expand on the meaning of their photos.\u003c/p\u003e\u003cp\u003eThe interviews were conducted in a face-to face, recorded, transcribed verbatim, and anonymized. Data was collected from December 2024 to January 2025.\u003c/p\u003e\u003cp\u003eThe data was collected through semi-structured interviews conducted with the help of an interview guide detailing open-ended questions and prompts (See supplemental file 1). The main question was \u0026ldquo;How do nursing intern students experience and visually represent the interplay of stress and resilience during their internship experiences with sub questions. For instance, \u0026ldquo;What are the primary sources of stress identified by nursing intern students during their internships, as visually depicted through their photographs? What strategies and resources do nursing intern students utilize to foster resilience during their internships, and how are these reflected in their photographs?\u0026rdquo;. This guide was pilot-tested with four people with similar characteristics as the target population to ascertain clarity and relevance. No follow up interviews were held. Consent from the participants was obtained before undertaking any audio recording of the interview to ensure all transcripts and analyses would be accurate. All interviews were recorded. Researchers also took some brief field notes after each interview so that their observations contextualized and enhanced the interpretation of the data. Interview length varied between 50 and 60 minutes. Throughout the process of the study, the idea of data saturation was evident, and further interviews were not conducted after new insights diminished.\u003c/p\u003e\u003cp\u003eTwo researchers coded the interview transcripts on their own using a tree structure which evolved from their initial framework and dictated the subsequent analysis. As previously mentioned, in the derived data, a deeper level thematic analysis was done. Due to confidentiality, participants did not receive the opportunity to validate the final conclusions, however, they were shown their photo narratives to ensure they were accurately represented. Quotations from participants are included for every theme presented in the findings as evidence and reasoning, fully number coded to each participant. The consistency of the information and data collected clearly encapsulates the most critical and prominent aspects. Each major theme is discussed in detail, along with comprehensive context and supporting quotations. Some themes are lesser and very simple, as well as cases that are different from the general observation, depicting the softer side and changing dynamics of the interns to what they faced during internship are also put forward.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eNarrative Reflection\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study examining stress and coping strategies of nursing interns was conducted by a team of PhD prepared qualitative researchers. All of whom are faculty in a nursing program at a university and have extensive experience in photovoice methods. All of the researchers, while caring for the wellbeing of nursing students and all the issues that surround them, had a neutral stance towards the participants. The researchers and the interns who participated in the study had no contacts prior to the study.\u003c/p\u003e\u003cp\u003eThe participants were informed that the researchers were nursing faculty interested in the impact of the internship on the interns. It was clear to the participants that the researchers were after the interns\u0026rsquo; viewpoints on aspects of stress and coping during the internship. However, participants were not told any other personal intentions or objectives that may have existed beyond the stated purpose of the research.\u003c/p\u003e\u003cp\u003eThe researchers composed of three males and eight females had significant expertise in conducting qualitative interviews and narrative-driven data analysis. Every single researcher had received specific training in photovoice approaches so that they adhered to strict protocols of administering and analyzing the collected data. Although the nursing faculty colleagues\u0026rsquo; professional background certainly informed their context regarding the nursing internship, they made considerable attempts to alleviate bias. The research team understood that teaching nursing could potentially bias their analysis and thus practiced reflexivity. They deliberated on the assumptions they held with regards to intern\u0026rsquo;s stress and coping mechanisms, accepted those assumptions, and then systematically set them aside during data analysis. The researchers tended to be most concerned with the phenomenon of nursing internship because these interns encounter difficulties which, if not correctly managed, can adversely affect the student's success and well-being. While this impression may have shaped the theories and predictions of the phenomena, it was equally important and beneficial for the study as well as the research question have such interpretation. The intent of this study was to make it very clear that these individuals, their education and experience could affect the data, so trustworthiness and accuracy of the study could be achieved.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEnsuring Rigor\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIn this study, the following strategies were used to enhance the rigor of the study. Credibility is an important concept of trustworthiness in qualitative research and has to be dealt with first. Participants did not fully check their interview transcripts for all information because of confidentiality issues, but they were provided an opportunity to check their photo narratives to ensure that their visuals and written pieces captured what they intended. Such an effort ensured that participants had access to their contributions and made modifications where necessary. Moreover, researchers actively engaged in regular reflexivity exercises where they asked themselves what biases or stereotypes, they held during the research. This understanding mitigated the effects of the researchers\u0026rsquo; backgrounds as nursing faculty on the research interpretation.\u003c/p\u003e \u003cp\u003eTrustworthiness was approached differently with the use of an inquiry audit conducted by external qualitative researcher. Rather, this audit aimed at determining whether the available data confirmed the results, analyses, and conclusions drawn from it. The document offered traces of reasoning that raised the level of clarity and credibility concerning how data was collected, analyzed, and interpreted, known as the audit trail. This account of the research process, including the steps taken in collecting the data and coding it, developing themes, and other decisions made, provided an opportunity to verify the conclusions of the study. While the study investigated the phenomenological aspects of the interns\u0026rsquo; lived experiences, this audit trail showed that there was no possibility of making up such explanations, thus \u0026lsquo;defending\u0026rsquo; the outcome of the study. This mixture of reflexivity, participant photo narratives, and independent inquiry guarantees the trustworthiness of this research study.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThematic Analysis\u003c/h3\u003e\n\u003cp\u003eThis photovoice study utilized various methods for data analysis. At first, the photographs were assessed for common images and patterns within them with the aim of capturing the participants\u0026rsquo; representations of their experiences. At the same time, the participants\u0026rsquo; provided and transcribed speech narratives underwent content examination for recurring themes and meanings. Afterwards, an analysis was undertaken that focused on identifying comprehensive themes, fully capturing the participants\u0026rsquo; experiences by combining interpretation of the visual data and the narrative accounts. NVivo 14 was used for organization and coding of the merged visual and narrative data, thus improving the accuracy and speed of the thematic analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThere is an equal number of male and female (7 males and 7 females) nursing interns in this study. Their age ranges from 20\u0026ndash;23 years old. Most of them were decked in the medical and surgical wards. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the themes, subthemes and narratives of the 14 participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes, subthemes and narratives of the participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme and Definition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme and Definition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhoto and Narratives\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 1: The Weight of Responsibility\u003c/b\u003e: This theme captures an high level of stress of the interns that stems from the floor burdened responsibility often placed on them their self evaluated level of readiness surpasses their own expectations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSubtheme 1.1: Feeling Overwhelmed\u003c/b\u003e: The state of feeling as if the tasks and obligations one has to fulfill is unreasonable.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResponsibility Overload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipant 3: Photo: Medical-Surgical books piled on top of each other.\u003c/p\u003e \u003cp\u003eNarrative: \u0026ldquo;It felt as though there was no end to those books. Every single book is an intern\u0026rsquo;s life story that is important which made me feel utterly burden.\"\u003c/p\u003e \u003cp\u003eParticipant 7: Photo: Vulnerable hands injecting intramuscular on deltoid area.\u003c/p\u003e \u003cp\u003eNarrative: \u0026lsquo;I cannot believe that I am still shivering despite my six months of internship. My hands often trembled so hard and at times I am worrying I might injure the patient. Indeed, I was tensed\u0026rdquo;.\u003c/p\u003e \u003cp\u003eParticipant 12: Photo: Intern in break room, head in hand\u003c/p\u003e \u003cp\u003eNarrative \u0026ldquo;I felt that I simply needed a break. The demands along with anxiety of error consumed me with anxiety especially anticipating what is next procedure to be done in my area\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 2: The Emotional Rollercoaster\u003c/b\u003e: This theme clearly studies the emotional crises faced as a result of the internship experience, including suffering, death, and complex situations with patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSubtheme 2.1: Emotional Toll.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e-The adverse sympathy and feeling inflicted by the pain of the patient and having to deal with tough medical situations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmotional Burden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipant 1: Photo: Picture of a darkened corridor of a hospital.\u003c/p\u003e \u003cp\u003eNarrative: \u0026ldquo;This corridor depicts the environment where my experience as intern takes place. It is where my intense work shifts start. In my everyday going here, there was so much pain and suffering that it was difficult to leave it behind.\u0026rdquo;\u003c/p\u003e \u003cp\u003eParticipant 5: Photo: Intern crying.\u003c/p\u003e \u003cp\u003eNarrative: \u0026ldquo;You know, I was affected more than I thought by the passing of a patient, which made me doubt my perceived strength if I will be really good nurse. Inshallah, I will overcome this emotion\u0026rdquo;\u003c/p\u003e \u003cp\u003eParticipant 10: Photo: Reflection of an intern on a stainless-steel medicine cabinet.\u003c/p\u003e \u003cp\u003eNarrative: \u0026ldquo;What I saw in my reflection was seem so fatigue and feel very burden with the things in here [referring to the photo]. It made me emotionally down\u0026rdquo;.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 3: Finding Strength in Connection\u003c/b\u003e: This theme emphasizes the importance of social support and mentorship in building resilience.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSubtheme 3.1: The Power of Support\u003c/b\u003e: The role of peer support and mentorship in navigating the challenges of the internship.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSupportive Relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipant 2: Photo: Intern laughing with a fellow intern.\u003c/p\u003e \u003cp\u003eNarrative: \"My classmates were my lifeline and I feel very comfortable working and sharing with them ideas. We supported each other through everything.\"\u003c/p\u003e \u003cp\u003eParticipant 6: Photo: Intern talking with a nurse mentor.\u003c/p\u003e \u003cp\u003eNarrative: \"My mentor\u0026rsquo;s guidance especially my seniors as well as the nurses were invaluable. All of them shared their own experiences and helped me go through and overcome difficult situations.\"\u003c/p\u003e \u003cp\u003eParticipant 11: Photo: Group of interns celebrating together.\u003c/p\u003e \u003cp\u003eNarrative: \u0026ldquo;You know in our family, we celebrated the small victories, the same here in internship program. Or in my nursing career\u0026hellip; It helped us stay positive and motivated.\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 4: Self-Care and Reflection\u003c/b\u003e: This theme explores the strategies interns use to manage stress and maintain their well-being.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSubtheme 4.1: Coping Mechanisms\u003c/b\u003e: The various methods interns employ to manage stress and maintain their mental and emotional health.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-Preservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipant 4: Photo: Intern doing arm stretching.\u003c/p\u003e \u003cp\u003eNarrative: \"Stretching my arms up helped me de-stress and reconnect with myself. It is very relaxing especially when we have a lot of patients\u0026rdquo;.\u003c/p\u003e \u003cp\u003eParticipant 8: Photo: Intern reading a book in a quiet corner.\u003c/p\u003e \u003cp\u003eNarrative: \"Taking time for myself was essential. It helps me think more ideas afterwards. I needed to recharge and escape the hospital environment for a while.\"\u003c/p\u003e \u003cp\u003eParticipant 13: Photo: Intern journaling.\u003c/p\u003e \u003cp\u003eNarrative: \"I always do this\u0026hellip; I mean\u0026hellip;writing down my thoughts and feelings helped me process my experiences and gain perspective. You know, I use my journaling as part of my everyday life\u0026rdquo;.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 5: Gaining Perspective through the Lens\u003c/b\u003e: This theme reflects how the photovoice methodology prompted deeper reflection and self-awareness among participants.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSubtheme 5.1: Enhanced Self-Awareness\u003c/b\u003e: The impact of the photovoice process on interns' understanding of their own experiences and coping strategies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReflective Practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipant 14: Photo: A cluttered workspace vs. a clean, organized one:\u003c/p\u003e \u003cp\u003eNarrative: Taking the photos made me more aware of the things that were causing me stress, but also the resources I was using to cope.\"\u003c/p\u003e \u003cp\u003eParticipant 13: A photo of a support system (friends, family, mentors) vs. a photo of the intern alone.\u003c/p\u003e \u003cp\u003eNarrative: \"Sharing my photos and stories with the group helped me realize that I wasn't alone in my struggles than facing alone my struggles. That is why it hurts me a when friends are not helping us in times of our much needed time.\u003c/p\u003e \u003cp\u003eParticipant 9: A photo of the group sharing their photos and stories\u003c/p\u003e \u003cp\u003eNarrative: \u0026hellip;It gave me a voice to share my experiences and advocate for change. I wish we have more of this as an activity in the University.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 6: Bridging the Gap: Recommendations for Support: In this theme, the interns\u0026rsquo; comments as regards support systems and building resilience have been encapsulated.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSubtheme 6.1: Recommendations for Change\u003c/b\u003e: Suggestions that interns provided with regard to internships and support systems that are meant to build resilience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSupporting Internships. Systemic Change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipant 13: A photo of a supportive team environment, such as nurses and interns collaborating on a task.\u003c/p\u003e \u003cp\u003eNarrative: \u0026ldquo;I believe that these forms of assistance would be effective. Alhamdullilhah the hospitals should enhance other services for interns, including counseling or stress management workshops.\u0026rdquo;\u003c/p\u003e \u003cp\u003eParticipant 3: A photo of a group of interns and mentors participating in a workshop or training session.\u003c/p\u003e \u003cp\u003eNarrative: \u0026hellip;It would be beneficial to have more experienced nurses available for interns to de-brief after difficult shifts.\u0026rdquo;\u003c/p\u003e \u003cp\u003eParticipant 2: A photo of a nurse and an intern talking together:\u003c/p\u003e \u003cp\u003eNarrative: \u0026hellip;I have been so vocal about this that the nursing school and the hospital need to collaborate in order to provide a more positive and less challenging environment for the interns.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cb\u003eTheme 1: The weight of responsibility.\u003c/b\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis theme refers to the lived experience of intern stress and its complexity, which yields an overwhelming burden of responsibility. The photographs of interns alongside their narratives serve as important sources because they offer a glimpse, so to speak, of the essence of their reality. This enables one to go beyond mere description and understand their experience.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubtheme 1.1\u003c/b\u003e Feeling overwhelmed as a subtheme concerns the phenomenon of \"Responsibility Overload,\" which explains the felt burden and how it is expressed.\u003c/p\u003e\u003cp\u003eParticipant 3, for instance, presents a photograph of enormous medical books, citing\u0026hellip; \u0026ldquo;It felt as though\u0026hellip;\u0026rdquo; utterly burdened.\u0026rdquo; As Participant 3 claims, \u0026ldquo;I was tensed\u0026rdquo; [when doing injection]. This narrative goes hand in hand with the image and serves to showcase how the participant imagines their encounter undermined their knowledge. Such exemplification gives life to abstract notions of pressure. In the case of photovoice of participant 7 trembling hands during the injection alongside, \"I was tensed\" serves to metaphorically express her fear but also anxiety and vulnerability during a very practical task. Finally, Participant 12 reveals the image of an intern lying in a breakroom while claiming, \u0026ldquo;I simply needed a break.\u0026rdquo; This photovoice shows the feeling of exhaustion that elevation anxiety gives. The image and narrative serve to illustrate the lack of motivation.\u003c/p\u003e\u003cp\u003eOverall, it captures assignments that seem to surpass one\u0026rsquo;s ability using a photovoice-phenomenology technique describing \u0026ldquo;Responsibility Overload.\u0026rdquo; The combination of narratives and images showing piled books, shaking hands, and a hunched attitude highlight overwhelming feeling of burden, tension, and fatigue. All these elements are meant to put the towering weight of the pressure interns experience into perspective.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: The emotional rollercoaster\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis theme offers insights into the emotional lives of the interns during their internship period, highlighting the pain of suffering, death, and the nuanced situations of patients. Using photovoice-phenomenology approaches, we examine the emotional crises they undergo, studying not simply what is observable but rather the very essence of their emotional reality.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtheme 2.1: Emotional toll\u003c/b\u003e further elicit some aspects of \u0026ldquo;Emotional Burden\u0026rdquo; which occurs on the interns and their adverse sympathy and feeling harm caused due to pain inflicted upon the patients and the other various medical predicaments.\u003c/p\u003e \u003cp\u003eThe photograph of Participant 1, a darkened hospital corridor serves as a metaphor for the interns\u0026rsquo; emotional journey. The interns\u0026rsquo; starting statement, \u0026ldquo;This corridor depicts the environment where my experience as an intern takes place. It is where my intense work shifts start. In my everyday going here, there was so much pain and suffering that it was difficult to leave it behind\u0026rdquo;, explains immersion into an all-encompassing environment filled with pain. The photovoice component bears witness to this burdening environment and makes it more tangible than suffering. The corridor is not simply a place; it is now a lived space of burden.\u003c/p\u003e \u003cp\u003eParticipant 5\u0026rsquo;s photograph depicting an intern in tears brings out the emotional facets involved in patient death. The quote, \u0026ldquo;You know, I was affected more than I thought by the passing of a patient, which made me doubt my perceived strength if I will be really good nurse. Inshallah, I will overcome this emotion,\u0026rdquo; speaks to the lived uncertainty and vulnerability of the intern. Such an unaltered grief and make the impact of patient loss tangible. The photograph speaks to a captured lived emotional crisis.\u003c/p\u003e \u003cp\u003eParticipant 10\u0026rsquo;s photograph, reflection of an intern on a stainless-steel medicine cabinet, reminds us of extreme fatigue and accumulated emotional burden. Their quote, \u0026ldquo;What I saw in my reflection was seem so fatigue and feel very burden with the things in here [referring to the photo]. It made me emotionally down,\u0026rdquo; illustrates the intern\u0026rsquo;s struggle and exhaustion internally. The photovoice approach allows us to see the intern the way the intern sees herself and her emotional state through her own reflection. The reflection qualitatively captures a live emotional experience.\u003c/p\u003e \u003cp\u003eThese photovoice showcase the emotional vulnerabilities of the interns. Participant 1\u0026rsquo;s darkened corridor embodies the almost omnipresent agony within. The tears of a participant 5 and her self-reflection after a patient died is suggestive of the heavy burden loss can bring. In the case of participant 10, her reflective image and the accompanying narrative reveals a state of inner fatigue and overall self-exhaustion which can be felt.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Finding Strength in Connection\u003c/h2\u003e \u003cp\u003eThis theme focuses on an intern\u0026rsquo;s finding of social support and mentorship, which facilitated their resilience as they navigated through their internship.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtheme 3.1: The Power of Support\u003c/b\u003e focuses on the supportive relationships that help interns manage which helps highlight peer support and mentorship.\u003c/p\u003e \u003cp\u003eParticipant 2\u0026rsquo;s photograph, interns laughing together, shows the face of peer support, its lifeline. Their narrative goes,\" My classmates were my lifeline and I feel very comfortable working and sharing with them ideas. We supported each other through everything\". The photo voice element depicts the joy of and the connection that these relationships provide. The photo marks a phrase of shared joy, which offers support.\u003c/p\u003e \u003cp\u003eParticipant 6\u0026rsquo;s photograph shows an intern in conversation with a nurse mentor speaking to the significance and value of mentorship. \u0026ldquo;My mentor\u0026rsquo;s guidance especially my seniors as well as the nurses were invaluable. All of them shared their own experiences and helped me go through and overcome difficult situations,\u0026rdquo; as stated in their narrative, means the reality of mentorship and wisdom is richer than assumed. The nature of photovoice provides the evidential impact of mentorship in the intern\u0026rsquo;s journey. The photograph represents a captured moment of the lived experience of guidance and learning.\u003c/p\u003e \u003cp\u003eParticipant 11\u0026rsquo;s photograph depicts a group of interns rejoicing which captures the importance of celebrating milestones, however small they may be. \u0026ldquo;You know, in our family we celebrated the small victories\u0026hellip;he same here in internship program. Or in my nursing career\u0026hellip;\u0026rdquo; It helped us stay positive and motivated, \u0026ldquo;as highlighted in their narrative,\u0026rdquo; states the experienced phenomenon of motivation and joy. The intern's enhanced motivation is one of the consequences of phenomena photovoice. The photograph represents a celebrated moment of encouragement.\u003c/p\u003e \u003cp\u003eOverall, \u0026ldquo;Finding Strength in Connections\u0026rdquo; no longer is an abstract idea but a lived experience which they have deeply pondered upon in relation to their coping mechanisms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Self-Care and Reflection\u003c/h2\u003e \u003cp\u003e This theme analyzes the interns\u0026rsquo; active strategies utilized towards achieving their wellbeing using self-care and reflection which showcases the techniques they use to navigate the stress of their internship.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtheme 4.1: Coping Mechanisms\u003c/b\u003e as a subtheme explains the preservation methods that the interns employed during the internship that aided their emotional and mental health coping strategy.\u003c/p\u003e \u003cp\u003eInterns underscore coping mechanisms which help in preserving health and sanity while completing the exceedingly demanding tasks characterizing the internship. For participant 4, the photograph of an intern stretching serves as an image that directly correlates to their visual narrative, \u0026ldquo;Stretching my arms up helped me de-stress and reconnect with myself. It is very relaxing especially when we have a lot of patients.\u0026rdquo; Here, the experience of relief and peace of mind through enhanced movement in the arms and upper body speaks volumes when describing what seasoned interns have to go through flawlessly executing the tasks assigned to them. The intern is witnessing first hand the myriad of benefits that derive from simply stretching. Stretching improves their well-being in more ways than one, both physically and psychologically, and this photograph demonstrates this synthesis.\u003c/p\u003e \u003cp\u003eThe participant 8 photovoice \u0026lsquo;An intern reading in a quiet corner\u0026rsquo; illustrates an intern\u0026rsquo;s solitude and mental escape. As Participant 8 explains, \u0026ldquo;Taking time for myself was essential. It helps me think more ideas afterwards. I needed to recharge and escape the hospital for the environment for a while,\u0026rdquo; the account portrays the necessity for emotional and mental space. The methodology gives us insight into how the intern purposefully attempted to create a personal retreat. The photograph depicts a moment when it was possible to mentally recharge.\u003c/p\u003e \u003cp\u003eParticipant 13 draws another aspect of intern personal experience as \u0026lsquo;an intern journaling\u0026rsquo; for reflecting the strong process of emotions. Their narrative, \u0026ldquo;I always do this, writing down my thoughts and feeling helped me process my experiences and gain perspective. You know I use my journaling as a part of my everyday life,\u0026rdquo; illuminates the side of journaling where it serves as emotional regulation and self reflection. With photovoice the viewer is able see to the Self of the intern \u0026ndash; the inner world that matters. The photovoice captures a reflecting moment of self through contemplation.\u003c/p\u003e \u003cp\u003eUsing the photovoice-phenomenological approach, it is clear that \u0026lsquo;Self-Care and Reflection\u0026rsquo; is not simply a concept but an active practice for these interns. The images and stories self-reported show how they practice self-care in their drastically different and personally unique ways during an internship that is markedly demanding. Overall, the theme examines self-reflection and self-awareness located within the photovoice process. Interns were able to crystallize their coping and emotional experiences through the narration and capturing of their experiences. We apply a photovoice-phenomenological lens to broaden the scope of self-awareness into the lived experience.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 5: Gaining Perspective through the Lens\u003c/b\u003e: This theme reflects how the photovoice methodology prompted deeper reflection and self-awareness among participants.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtheme 5.1 Enhanced Self-Awareness\u003c/b\u003e the \u0026ldquo;reflective practice\u0026rdquo; in photovoice is understood as a practice that enables a person to reflect on what they captured.\u003c/p\u003e \u003cp\u003eParticipant 14\u0026rsquo;s narration, \u0026ldquo;Taking the photos made me aware of the things that were causing me stress, but also the resources I was using to cope,\u0026rdquo; as well as the cluttered workspace photo alongside the organized workspace photo built a narrative that reveal astoundingly transforming experience. These clips demonstrate the process of attaining clarity though the utilization of conscious reflection. The intern was able to make visible what had previously only existed internally, in relation to stress and coping. In summary these photographs together with the narrative constitute an attained moment of self realization.\u003c/p\u003e \u003cp\u003eParticipant 13\u0026rsquo;s pictures on a support system against isolation, in addition to the quote, \u0026ldquo;Sharing my pictures as well as experiences with the group made me understand that I was not alone in my struggles... This is why it hurts me when my friends are not helping us during times we need that help most,\u0026rdquo; emphasizing the experience of bridging social isolation through shared experiences. The images along with the quote support the understanding of the significance that social support means for the person\u0026rsquo;s lived experience. The photos and quote spotlight an event in life when support is required and how important it is. The picture of photovoice participants sharing their work, Participant 12 complemented with:\u0026rdquo; It was empowering just to be a participant of the photovoice. It gave me an opportunity to articulate my experiences and look for change. We need more of this in the University,\u0026rdquo; show the phenomenon of collectively lived experience of participant empowerment and narrative advocacy. The participants were able to share their narratives and seek for change which the internship provided, thus portraying the power of shared experiences. The photo and quote expose us to the event in life that contextualizes and depicts power.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 6: Bridging the Gap\u003c/b\u003e,\u0026rdquo; is not just a set of recommendations, rather it is the meaning that the intern\u0026rsquo;s selection of photographs expresses: a wish for a more holistic supportive and proactive approach to their internship. The photographs without understanding context of their accompanying stories give rise to urgency for change within the systemic setup. The interns were able to contemplate on their experiences, reflect on their self-perception, and mobilize for action through the methodology of photovoice.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSubtheme 6.1: Recommendations for Change\u003c/b\u003e integrates Interns' Systemic Change thoughts focusing on Support for Internships Systemic Change.\u0026rdquo; This portion finalizes Interns\u0026rsquo; recommendations for Interns Resilience Building Persistence within Structural Constraints supporting system for advanced advocacy through allowing for advanced restructuring of supporting institutions.\u003c/p\u003e \u003cp\u003eThe interns\u0026rsquo; suggestions were elucidated drawing directly from Participant 14\u0026rsquo;s narrative: \u0026ldquo;I personally believe these forms of support would work. Alhamdulillah Interns within our hospitals should be offered other forms of assistance such as counseling and stress management workshops.\u0026rdquo; This suggestion, alongside Participant 13\u0026rsquo;s photograph depicting a positive team environment, suggest greater desire of supportive institutional settings. The photograph and statement depicts a lived moment of advocating change at the institutional level, capturing their voice. Participant 2's photograph depicting a nurse talking with an intern and the internally experienced need of voice Participants 11's quote, \u0026ldquo;I have been so vocal about this that the nursing school and the hospital needs to find a more positive and less challenging way for the interns,\u0026rdquo; exposes participants' developed and collaborative case. The photograph and the narrative present a moment of active advocacy for the changes needed to work, and those required to frame an integrated approach. The evidence presented speaks to what is achievable through the doing of photo-voice as with this skeletal account of photo-voice in the preceding chapters. What is of concern is whether, devoid of context to assist in fostering the changes that are required, interns\u0026rsquo; trainees remain mere respondents. The photo and the quote highlight advocates have not the skeletal support necessary for collaborative institutional change.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore the nursing intern students' experiences of stress and resilience during internship using photovoice. The theme of \"The Weight of Responsibility\" in nursing internships encapsulates the significant stress experienced by nursing intern students, primarily due to the heavy responsibilities placed upon them. This stress is exacerbated by their self-evaluated readiness, which often exceeds their actual preparedness for the demands of clinical practice. Interns frequently report feeling overwhelmed by the multitude of tasks and obligations they must fulfill, leading to heightened anxiety and emotional strain. Intern nursing students face a myriad of stressors during their internships, with employment-related stress being identified as a primary concern. Zheng et al. highlight that the increasing number of nursing graduates contributes to this stress, as students feel pressured to perform at levels that may not align with their training or experience (Zheng et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This sentiment is echoed by earlier scholars who found that the mental strain experienced by nursing interns, particularly during the COVID-19 pandemic, was profound, necessitating immediate psychological support (Eweida et al., 2020). The pandemic has intensified feelings of inadequacy and anxiety among nursing students, as they grapple with the dual challenges of learning and providing care in a high-stakes environment (Zhao et al., 2021).\u003c/p\u003e \u003cp\u003eThe subtheme on \u0026lsquo;Feeling Overwhelmed\u0026rsquo; is especially important, as numerous nursing students report that their workload is unreasonable in both volume and complexity. This overwhelming feeling is not just an individual impression but something that is backed up by evidence. For example, it was point out that nursing students are often stressed because of their assignments and workload which can produce a state of feeling overwhelmed (Noureen et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In the same fashion, it was discussed how the online learning that came with the pandemic has been an additional burden as students try to learn new ways of doing things while ensuring clinical competencies (Chang et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The accumulation of these factors can cause a great deal of psychological damage, and goes on to detail how nurses during the pandemic have mental health issues (Galehdar, 2020). Moreover, the concept of being overwhelmed is examined more closely by researchers stating that the emotional weight of nursing can contribute to the feeling of being overwhelmed as general well-being and professional self-image (Kabigting, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The changeover between student and intern is not easy because many interns undergo severe stress in their first year due to the possibility of making mistakes and being unable to cope with the responsibilities placed on them (Gaundan \u0026amp; Mohammadnezhad, 2018). As noted, the professional experiences of nursing intern students during the internship period is accompanied by lifting a huge load of responsibility that often leads to being overwhelmed. This is one of the most important phenomenon which needs further detailed investigation and is clearly justified by existing literature, the sources of psychological stress nursing students endure in education and clinical practice. The nursing education system must adapt to such changes and provide clinical nursing students with the necessary support to increase resiliency to psychological stressors.\u003c/p\u003e \u003cp\u003eThrough the lens of \u0026lsquo;The Emotional Rollercoaster\u0026rsquo;, nursing internships outline the detrimental emotional turmoil that nursing students undergo during their clinical practice. This theme is particularly important in understanding the suffering which is caused by witnessing patient suffering, demise, and intricacies in medical management The subtheme \u0026ldquo;Emotional Toll\u0026rdquo; captures specifically sympathy induced negative emotions, and emotional distress that nurse interns are faced with as they experience the hardships of caring for patients. There are nursing students who are required to cope with emotionally sensitive situations that involve managing patient pain and death. As noted nurses have to comprehend the complex suffering of the patients which is very engaging (Younas \u0026amp; Inayat, 2023). This can cause emotional anguish as interns deal with their own patients\u0026rsquo; pain and suffering. Added to this is the fact that nurses have to act professional while they deal with feelings of empathy and sadness, an issue that is referred to as \u0026lsquo;compassion in nursing practice\u0026rsquo; (Younas \u0026amp; Maddigan, 2019). The emotional burden of caring for patients with complex needs can lead to what is termed compassion fatigue where the nurse\u0026rsquo;s emotional reserve is summarily used up, making it difficult to provide compassionate care (Mok et al., 2020).\u003c/p\u003e \u003cp\u003eIn addition, the emotional aspects that nursing students have to deal with are not exclusively linked to patient interactions alone. Performing in a high-stakes situation can lead to overwhelming psychological stress. Accordingly, nursing students frequently report feeling inadequate, especially in dealing with the emotional aspects of caring for seriously ill patients. These students often become overwhelmed with feelings of powerlessness and emotional exhaustion (Hedenstrom et al., 2021). Even interns suffer from the emotional burden of being fearful to make mistakes in important situations, a form of anxiety which, as discussed in the context of resilience in nursing education, often accompanies self-doubt (Tur-Porcar et al., 2020). Such feelings must be dealt with in a resilient manner to be able to cope with the emotions, enabling nursing students to focus on the intricacies of patient care without risking their mental health (Venkatesan, 2020). The consequences left behind by the COVID-19 pandemic has exacerbated the psychical crises suffered by nursing students. An atmosphere full of anxiety and stress presents itself, caused by the previously unseen challenges nursing interns experience during patient care (Zhongxiang et al., 2020). Internally, students are suffering more than ever because of life threatening feeling and heat, increasing their feelings of helplessness (Lin et al, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Clinical environments need support systems where students can receive adequate guidance to mentor them through their experiences to help them cope (Mikkonen et al., 2021). To this end, nursing interns have to deal with significant emotional challenges due to their interpersonal responsibilities in caring for patients. Nursing students have to deal with the mix of empathy, compassion, and clinical practice - the most difficult phase.\u003c/p\u003e \u003cp\u003eThe theme \u0026ldquo;Finding Strength in Connection\u0026rdquo; emphasizes the aspect of social support and mentorship during the internship period, that immensely enhances the resilience of nursing interns. This theme stands out in particular because nursing students face immense emotional and professional development challenges during their internship period, and supportive networks have the potential to greatly help. The subtheme \u0026ldquo;The Power of Support\u0026rdquo; illustrates these connections and networks as important aides in the stressors of practicing with patients. Social support has been cited as one of the most critical components in building resilience among nursing students, more so during adverse conditions like the COVID-19 pandemic. Scholars have highlighted the ecological model of resilience, which suggests that maintaining resilience in times of crisis necessitates social support and resource exchanges (Drach-Zahavy et al. \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These findings highlight the strong social support nursing students receive from their peers, and how this impacts stress and demonstrates the need for supportive networks as well as mentorship in the clinical setting. Furthermore, it was indicated that nursing students, who had help from co-workers while interning, had higher rates of personal resilience\u0026rdquo; (Garderen \u0026amp; Leeuwen, 2021). This system of support reduces feelings of detachment while simultaneously creating an increased sense of community between students, which is important for their emotional health. Supportive teachers and peers can offer a compassionate atmosphere in which students feel encouraged to voice their worries, seek help, and increase their learning and skill development during the study. It suffices to say that mentorship bears critical import in nursing education. Althaqafi et al (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) identifies that at the onset of the internship phase, mentorship paradigms should be instituted for ease of clinical practice and the advancement of students in nursing scope. These programs grant interns from nursing schools access to veteran nurses who can facilitate their understanding of intricacies involved in patient care. Such mentoring drives learning and skill development but also increases the levels of self confidence and self-efficacy among nursing students. In addition, students of nursing need to have ample time to think and talk about the emotional issues that confront them. It was enunciated that students require spaces to talk about their experiences, whether through formal reflection seminars or informal conversations with peers and supervisors (Weurlander et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). To sum up, the sub theme of \u0026ldquo;Finding Strength in Connection\u0026rdquo; captures the essence of social support and mentorship as critical factors that help nursing interns to cultivate resilience. Nursing students are able to tackle the emotional and professional difficulties of their internships through peer support, mentorship programs, and positive interactions with their educator. Such linkages improve not only their learning but their overall health and most importantly, their capacity to adapt in the future nursing profession, which is a tenacious one.\u003c/p\u003e \u003cp\u003eThe subtheme \u0026lsquo;coping mechanisms\u0026rsquo; scrutinizes the techniques interns employ in dealing with the emotional and psychological aspects of their role. This is concerns nursing interns as it highlights the stressors emerging from patient responsibilities, the burdening emotions that come with suffering, and the high pressure to consistently perform. Accordingly, maintaining reflective journals as a form of reflective practice, greatly augments the decision making and problem solving skills of nursing students (S\u0026uuml;r\u0026uuml;c\u0026uuml;, 2021). Interns are enabled to analyze their experiences, which enhances their comprehension of their emotional triggers, enabling them to control their stress in the future. Emphasis is placed on the nursing student\u0026rsquo;s strategies to effectively balance stressors and challenges for mental and emotional well being during internships. This is important because it addresses the coping strategies that are necessary to maintain resilience for the multitude of challenges faced in clinical environments. The theme \u0026ldquo;Self-care and reflection\u0026rdquo; narrows down to focus on the subtheme coping mechanisms. Besides, the inequivocable necessity for these support systems to be integrated within the coping strategies is notable. It has been argued that all educational and training programs must go beyond the self-care and mental health issue and formulate plans for teaching nursing student\u0026rsquo;s self-care and crisis management skills (de Bot \u0026amp; de Vos, 2022). This is especially important considering the emotional strain that nursing students face which has intensified during the pandemic. Students can more readily handle the challenges of clinical practice if the educational institutions prepare them with appropriate coping mechanisms. Apart from peer assistance, self-care also plays an important role in supporting the mental health of nursing interns. The workplace stress can be mitigated through protective mechanisms such as support networks or other positive forms of communication that can be built (Silva et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These mechanisms serve to promote more than just coping; they also build identity and community among nursing students and significantly safeguard their emotional health. Supporting nursing program interns assists them in coping with the emotional aspects of patient care, thereby improving their self-efficacy. In essence, \u0026ldquo;Self-Care and Reflection\u0026rdquo; highlights the coping strategies that nursing interns utilize to mitigate stress and promote their health and well-being. Reflective practice, positive coping strategies, and structured supportive process aid nursing students in handling the emotional and psychological realities of their internship. in adapting to a self-caring approach while attending to nursing education, interns' resiliency would be improved which in turn leads to appropriate patient care and greater job satisfaction.\u003c/p\u003e \u003cp\u003eThe theme of \u0026ldquo;Gaining Perspective through the Lens\u0026rdquo; describes how the photovoice methodology affects the circling nursing interns, especially on self-reflection and self-interpretation of their experiences. This aspect of the theme is important because it demonstrates how the photovoice process allows interns to reflect more deeply on the coping strategies that they used during their clinical training. The subtheme \u0026ldquo;Enhanced Self-Awareness\u0026rdquo; addresses how the photovoice process impacts interns self-emotion as well as self-psychology to the challenges they encounter. Photovoice has been shown to be a strong means of increasing self-awareness among respondents by allowing them to document their experiences visually and recall their emotions. Researchers like Rania et al (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) explain that the photovoice methodology constructively enables critical reflection to be reframed and for the participants to interact with their experiences meaningfully. This approach promotes coping at the individual level while nurturing group benevolence and discussion. In doing so nursing interns, through photography, self-expression captures what they feel and the problems they face and as a result, gain an understanding of their emotions and self-regulatory strategies. Similarly, a research aimed at analyzing photovoice as a stigma alleviating measure among healthcare students validates the implications of self-awareness and self-claimed schema as relief generated from photovoice (Tippin \u0026amp; Maranzan, 2022). Looking at the studies, the participants are able to tell their experiences by framing stories which address problems that are confronted and coping strategies which improve self awareness.\u003c/p\u003e \u003cp\u003eThe theme \u0026ldquo;Gaining Perspective through the Lens\u0026rdquo; shows how the photovoice method helps nursing interns to reflect on themselves more deeply. As nurses, interns need to focus on critical reflection, and narrative construction in a \u0026ldquo;story\u0026rdquo; format further supports their understanding of their emotions and how they cope. This helps further personal resilience but just as importantly, building a community of practice that promotes the wellbeing of nursing students while they prepare for practice. The subtheme \u0026ldquo;recommendations for Support\" summarizes the perspectives shared by nursing interns regarding the support systems that could help them build endurance during their internships. This theme appears particularly important, because it captures how interns perceive existing systems, and how those systems can be made more responsive to their needs and overall wellness. The subtheme \"Recommendations for Change\" captures the specific, actionable comments made by interns regarding the structure and support them during their internship. Interns have noted the necessity of holistic support systems which consider the emotional and mental burdens trainees are likely to endure during their clinical practice sessions. Alodhialah et al. (2024) brought light to the fact that nurses have emotional issues which need urgent attention especially during periods of high stress, for example, in palliative care. Their research results indicate that there is a need for health care organizations to take the initiative in formulating emotional resilience support systems, the same could also apply for nursing internships. This involves the provision of mental health care, counseling, and mentorship to assist interns to cope with the emotional intricacies acquired while dealing with patients. Moreover, it was emphasizing the relevance of community resilience for supporting people experiencing mental health difficulties (Lestari \u0026amp; Yusuf, 2018). Together with other insights, these approaches can be integrated into nursing internship programs where supportive community building among interns is useful for resiliency enhancement. Nursing programs can make interns feel more connected and less lonely in their experiential learning by fostering environments that promote collaboration and mutual assistance. Such communities can be established through organized peer-facilitated mentorship schemes and forums where interns discuss their challenges and ways of coping with them.\u003c/p\u003e \u003cp\u003eInterns have further suggested that the curriculum of the internship should include structured reflection and debriefing sessions. These sessions allow the interns to reflect on their experiences and share how these experiences affected them, as well as learn ways to cope with them. This is in agreement with earlier research highlighting the role of social support in building resilience in people who experience great hardship (Wu et al., 2024). Contemplative nursing practices that aim at discussing the effects of clinical practice on the intern\u0026rsquo;s psyche make it simpler for the intern to cope with the stressful realities of nursing. Moreover, faculty and mentors play an equally important role in providing direction and support. The effectiveness of support systems is determined by mentorship which gives and receives feedback openly (Carrad et al., 2022). Interns have already pointed out the lack of such mentorship programs, via which seasoned nurses may help, provide advice, share coping methods, and give them emotional aid. Such mentors are very important in helping interns accept the challenges of patient care and aid in their changes in professional self-concepts. It is important to carry out the wellness programs directed towards self-care and stress management. Interns have stated how they require workshops and trainings that help them practice stress management and overall well being. This resonates with what earlier research stating that the need for internal support systems to be more focused upon in order to improve performance and resilience (Kurniawan et al., 2024). If such wellness initiatives are incorporated into nursing internships, the interns are bound to be more appreciative of their mental health and learn positive coping methods. To sum up, the \u0026ldquo;Bridging the Gap and Recommendations for Support underscored the special aspects raised by nursing interns regarding what type of support is needed to build resilience during the internship. Community resilience building through comprehensive supportive structures, guided reflection, mentoring, and wellness interventions, is what makes nursing education improve the students\u0026rsquo; internship experience. These changes, which stem from the interns, also positively impact the quality of healthcare services provided as well as the nursing profession's future.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStudy implications\u003c/h2\u003e \u003cp\u003eThis study has considerable consequences for nursing education, practice, and future inquiries. Nursing education focuses more on integrating resilience training, enhancing clinical preparedness, and incorporating reflection and debriefing sessions. Mentorship programs should be established together with emotional intelligence training to help interns cope with their stressful experiences. Stress management and self-care instruction as part of wellness initiatives are also important. As the method photovoice has been recognized for reflection, self awareness, and other areas, it should be accepted for a greater focus. Healthcare organizations also need to work towards building and maintaining supportive structures, increasing access to mental health services, and controlling intern workloads. Community fostering, as well as fighting compassion fatigue, is largely essential in a supportive clinical environment. Future research should concentrate on the longitudinal effects, comparative best practice studies, and quantitative studies of the interventions' effectiveness. Due consideration also needs to be given to the culture and sustainability of photovoice changes. Supporting nursing interns and helping them develop resilience, alongside addressing these implications, we improve the quality of health care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eAlthough this analysis sheds light onto the lived experiences of nursing intern students using a qualitative-phenomenological photovoice design, certain issues stand out. The study has very limited general scope due to its sample size consisting of only 14 individuals, and the interns placed at a selected university branch during the later part of their internship. Moreover, participants were not able to corroborate the final coded interview transcripts due to confidentiality issues and therefore may have inconsistencies with the way the narratives are interpreted, although the photo narratives were corroborated. In addition, although the researchers reflexively participated and performed an external inquiry audit, they brought with them as nursing faculty a certain set of unconscious assumptions. Moreover, the requirements set out for participation which included proficiency in English may have prevented attendance from several non-English speaking interns aiding in the study. Although photovoice is a participatory approach that has its merits, participants\u0026rsquo; ability to represent their experiences using visuals could be highly nuanced and subjective, the nature of photos interprets even the most complex emotions having a limitation. Lastly, ensuring confidentiality is key, but complete anonymity becomes difficult in small qualitative studies. Overall, the absence of follow-up interviews could have restricted the scope of opinion gathered, even though data saturation was attained. Future researchers will need to try and overcome these challenges using larger, heterogeneous samples, multi-method approaches, and considering longitudinal designs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis photovoice study revealed the surprising nuances of nursing internships, uncovering that interns endure significant amounts of stress because of their hefty responsibilities and emotional burden of patient care. Also, the study brought to light the importance of social support, peer and mentorship relationships proved to be central spokes to the wheels in overcoming these problems. Interns utilized self-care treatment techniques and reflective practices, made possible through photovoice technology which heightened their self-awareness. Finally, the study provided actionable recommendations to systemic mentorship structures and stress management initiatives, as well as for better coordinated joint activities between schools and hospitals in order to promote a more favorable environment for emerging nursing professionals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eERC\u003c/strong\u003e- Ethic Review Committee\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIRB-\u003c/strong\u003e Institutional Review Board\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKKU\u003c/strong\u003e- King Khalid University\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhD\u003c/strong\u003e- Philosophical Doctor\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Ethics Research Committee (ERC) Institutional Review Board (IRB) of King Khalid University (KKU). The research team confirmed that all methods were performed in accordance with relevant guidelines and regulations under the Helsinki Declaration. Further, informed consent was obtained from all subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants provided informed consent for participation in the study, and explicit consent for the publication of anonymized data was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to participant confidentiality. Data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they do not have a competing interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Princess Nourah bint Abdulrahman University Researchers supporting project (No. PNURSP2025R875), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEP, SRS, RHA, MSA, Conceptualization, Methodology, Data collection, Formal analysis, writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing. NAA, AG, JG, BAJ, FG, AJD Data collection, Formal analysis, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the support of the Princess Nourah bint Abdulrahman University Researchers supporting project (No. PNURSP2025R875), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u0026zwnj;Abbaszadeh, M., Tavakkol Aghayari Hir, Mahnaz Jabraeili, \u0026amp; Ebrahim Mohammadpour. (2023). The impact of organizational education on nurses\u0026rsquo; career resilience during the COVID-19 pandemic. \u003cem\u003eResearch and Development in Medical Education\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e, 2\u0026ndash;2. https://doi.org/10.34172/rdme.2023.33107\u003c/li\u003e\n\u003cli\u003eAbdallah, B., Ali, R., \u0026amp; Ali, A. (2023). Nursing Students\u0026rsquo; Perception of Stress and Resilience during Their Clinical Training. \u003cem\u003eMinia Scientific Nursing Journal\u003c/em\u003e, \u003cem\u003e014\u003c/em\u003e(1), 59\u0026ndash;66. https://doi.org/10.21608/msnj.2023.238647.1082\u003c/li\u003e\n\u003cli\u003eAlanazi, F. J., Alenezi, M. H. M., Alanazi, A. A. N., \u0026amp; Alanazi, T. S. R. (2023). Do internship students do well in a clinical environment? A qualitative naturistic study. Belitung nursing journal, 9(6), 539\u0026ndash;546. https://doi.org/10.33546/bnj.2938\u003c/li\u003e\n\u003cli\u003eAlemi M, Rezanejad A, Marefat B. Exploring the reasons behind Iranian TEFL graduate students\u0026rsquo; academic failure. Profile: Issues in Teachers\u0026rsquo; Professional Development. 2021; 23:151\u0026ndash;66\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Alodhialah, A. M., Almutairi, A. A., \u0026amp; Almutairi, M. (2024). Exploring Nurses\u0026rsquo; Emotional Resilience and Coping Strategies in Palliative and End-of-Life Care Settings in Saudi Arabia: A Qualitative Study. \u003cem\u003eHealthcare\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(16), 1647. https://doi.org/10.3390/healthcare12161647\u003c/li\u003e\n\u003cli\u003eAlthaqafi, S., Alhatimi, H., Almalki, A., Alyamani, O., \u0026amp; Banakhar, M. (2019). Nursing students\u0026rsquo; clinical practice experience during the internship year at different hospitals: a qualitative study. American Journal of Nursing Science, 8(5), 255. https://doi.org/10.11648/j.ajns.20190805.18\u003c/li\u003e\n\u003cli\u003eAlzayyat, A., \u0026amp; Al-Gamal, E. (2014). A review of the literature regarding stress among nursing students during their clinical education. \u003cem\u003eInternational Nursing Review\u003c/em\u003e, \u003cem\u003e61\u003c/em\u003e(3), 406\u0026ndash;415. https://doi.org/10.1111/inr.12114\u003c/li\u003e\n\u003cli\u003eARDA S\u0026Uuml;R\u0026Uuml;C\u0026Uuml;, H. (2021). Clinical Decision Making, Problem Solvig and Autonomy for Nursing Students Attending an Internship Training Program: A Comparative Study. \u003cem\u003eMAS Journal of Applied Sciences\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(7). https://doi.org/10.52520/masjaps.91\u003c/li\u003e\n\u003cli\u003eAryuwat, P., Asp, M., L\u0026ouml;venmark, A., Radabutr, M., \u0026amp; Holmgren, J. (2022). An integrative review of resilience among nursing students in the context of nursing education. Nursing Open, 10(5), 2793-2818. https://doi.org/10.1002/nop2.1559\u003c/li\u003e\n\u003cli\u003eBlomberg, K., Bisholt, B., Engstr\u0026ouml;m, A., Ohlsson, U., Sundler, A., \u0026amp; Gustafsson, M. (2014). Swedish nursing students\u0026apos; experience of stress during clinical practice in relation to clinical setting characteristics and the organisation of the clinical education. Journal of Clinical Nursing, 23(15-16), 2264-2271. https://doi.org/10.1111/jocn.12506\u003c/li\u003e\n\u003cli\u003eCai, Z., Cui, Q., Liu, Z., Li, J., Gong, X., Liu, J., \u0026hellip; \u0026amp; Wang, G. (2020). Nurses endured high risks of psychological problems under the epidemic of covid-19 in a longitudinal study in wuhan china. Journal of Psychiatric Research, 131, 132-137. https://doi.org/10.1016/j.jpsychires.2020.09.007\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Carrad, A., Aguirre‐Bielschowsky, I., Rose, N., Charlton, K., \u0026amp; Reeve, B. (2022). Food system policy making and innovation at the local level: Exploring the response of Australian local governments to critical food systems issues. \u003cem\u003eHealth Promotion Journal of Australia\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(2). https://doi.org/10.1002/hpja.626\u003c/li\u003e\n\u003cli\u003eChang, C., Chung, M., \u0026amp; Yang, J. (2022). Facilitating nursing students\u0026apos; skill training in distance education via online game-based learning with the watch-summarize-question approach during the covid-19 pandemic: a quasi-experimental study. Nurse Education Today, 109, 105256. https://doi.org/10.1016/j.nedt.2021.105256\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Cheung, T., Wong, S., Wong, K., Law, L., Ng, K., Tong, M., Wong, K., Ng, M., \u0026amp; Yip, P. (2016). Depression, Anxiety and Symptoms of Stress among Baccalaureate Nursing Students in Hong Kong: A Cross-Sectional Study. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(8), 779. https://doi.org/10.3390/ijerph13080779\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;de Bot, C. M. A., \u0026amp; de Vos, A. J. B. M. (2022). Three-Questions-Method for Coping with the Emotional Burden of Nurses and Nursing Students during COVID-19. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(11), 6538. https://doi.org/10.3390/ijerph19116538\u003c/li\u003e\n\u003cli\u003eDrach‐Zahavy, A., Goldblatt, H., Admi, H., Blau, A., Ohana, I., \u0026amp; Itzhaki, M. (2021). A multi‐level examination of nursing students\u0026apos; resilience in the face of the covid‐19 outbreak: a cross‐sectional design. Journal of Advanced Nursing, 78(1), 109-120. https://doi.org/10.1111/jan.14951\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Eweida, R. S., Rashwan, Z. I., Desoky, G. M., \u0026amp; Khonji, L. M. (2020). Mental strain and changes in psychological health hub among intern-nursing students at pediatric and medical-surgical units amid ambience of COVID-19 pandemic: A comprehensive survey. \u003cem\u003eNurse Education in Practice\u003c/em\u003e, \u003cem\u003e49\u003c/em\u003e, 102915. https://doi.org/10.1016/j.nepr.2020.102915\u003c/li\u003e\n\u003cli\u003eGalehdar, N., Toulabi, T., Kamran, A., \u0026amp; Heydari, H. (2020). Exploring nurses\u0026apos; perception of taking care of patients with coronavirus disease (covid‐19): a qualitative study. Nursing Open, 8(1), 171-179. https://doi.org/10.1002/nop2.616\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Gaundan, D., \u0026amp; Mohammadnezhad, M. (2018). Intern-Nurses\u0026rsquo; Perception on Transition at Labasa Hospital, Fiji: A Qualitative Study. \u003cem\u003eJournal of Nursing and Health Studies\u003c/em\u003e, \u003cem\u003e03\u003c/em\u003e(01). https://doi.org/10.21767/2574-2825.100031\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Hedenstrom, M. L., Sneha, S., Nalla, A., \u0026amp; Wilson, B. (2021). Nursing Student Perceptions and Attitudes Toward Patients With Cancer After Education and Mentoring: Integrative Review. \u003cem\u003eJMIR Cancer\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(3), e27854. https://doi.org/10.2196/27854\u003c/li\u003e\n\u003cli\u003eKabigting, E.-N. R. (2019). The Humanbecoming Concept Inventing Model: Feeling Overwhelmed. \u003cem\u003eNursing Science Quarterly\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(3), 214\u0026ndash;218. https://doi.org/10.1177/0894318419845401\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Khanmohammadi, S., Hajibeglo, A., Rashidan, M., \u0026amp; Bekmaz, K. (2020). Relationship of resilience with occupational stress among nurses in coronavirus ward of Khatam Al-Anbia Hospital, Gonbad Kavous, 2020. \u003cem\u003eNeuropsychiatria I Neuropsychologia\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(1-2), 1\u0026ndash;6. https://doi.org/10.5114/nan.2020.97397\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Kim, S. C., Sloan, C., Montejano, A., \u0026amp; Quiban, C. (2021). Impacts of Coping Mechanisms on Nursing Students\u0026rsquo; Mental Health during COVID-19 Lockdown: A Cross-Sectional Survey. \u003cem\u003eNursing Reports\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(1), 36\u0026ndash;44. https://doi.org/10.3390/nursrep11010004\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Kurniawan, A., Haliah Haliah, \u0026amp; Andi Kusumawati. (2024). Internal Control Analysis and Fraud Prevention Efforts in Public Sector Accounting. \u003cem\u003eEast Asian Journal of Multidisciplinary Research\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(11). https://doi.org/10.55927/eajmr.v3i11.11809\u003c/li\u003e\n\u003cli\u003eLin, Y., Hu, Z., Danaee, M., Alias, H., \u0026amp; Wong, L. P. (2021). The Impact of the COVID-19 Pandemic on Future Nursing Career Turnover Intention Among Nursing Students. \u003cem\u003eRisk Management and Healthcare Policy\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e, 3605\u0026ndash;3615. https://doi.org/10.2147/RMHP.S322764\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Mikkonen, K., Tomietto, M., Tuomikoski, A., Miha Kaučič, B., Riklikiene, O., Vizcaya‐Moreno, F., P\u0026eacute;rez‐Ca\u0026ntilde;averas, R. M., Filej, B., Baltinaite, G., Cicolini, G., \u0026amp; K\u0026auml;\u0026auml;ri\u0026auml;inen, M. (2021). Mentors\u0026rsquo; competence in mentoring nursing students in clinical practice: Detecting profiles to enhance mentoring practices. \u003cem\u003eNursing Open\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(1). https://doi.org/10.1002/nop2.1103\u003c/li\u003e\n\u003cli\u003eNoureen, S., Hussain, M., Afzal, M., \u0026amp; Gilani, S. (2019). Relationship of nursing students stress and their personal response to stress in learning environment. JHMN. https://doi.org/10.7176/jhmn/62-01\u003c/li\u003e\n\u003cli\u003eRania, N., Coppola, I., Brucci, M., \u0026amp; Pinna, L. (2022). Enhancing empowerment in young adults during the COVID-19 era in Italy through the Photovoice technique. \u003cem\u003eCurrent Psychology\u003c/em\u003e. https://doi.org/10.1007/s12144-022-03635-5\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Retno Lestari, \u0026amp; Yusuf, A. (2018). Developing community resilience as a supporting system in the care of people with mental health problems in Indonesia. \u003cem\u003eIndian Journal of Public Health Research \u0026amp; Development\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(11), 1687\u0026ndash;1687. https://doi.org/10.5958/0976-5506.2018.01685.6\u003c/li\u003e\n\u003cli\u003eSilva, S., Baptista, P., Silva, F., Almeida, M., \u0026amp; Soares, R. (2020). Resilience factors in nursing workers in the hospital context. Revista Da Escola De Enfermagem Da Usp, 54. https://doi.org/10.1590/s1980-220x2018041003550\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Tippin, G. K., \u0026amp; Maranzan, K. A. (2022). Photovoice as a Method to Reduce the Stigma of Mental Illness Among Health Care Students. \u003cem\u003eHealth Promotion Practice\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(2), 331\u0026ndash;337. https://doi.org/10.1177/15248399211057152\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Tur Porcar, A. M., Cuartero Monteagudo, N., Gea-Caballero, V., \u0026amp; Ju\u0026aacute;rez-Vela, R. (2020). Resilience Scale Psychometric Study. Adaptation to the Spanish Population in Nursing Students. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(12), 4602. https://doi.org/10.3390/ijerph17124602\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Venkatesan, L. (2020). Effectiveness of Integrated Teaching Involving Patients as Teachers (PAT) Vs Traditional Teaching (TT) upon Cognitive Behaviour of Nursing Students at TamilNadu, India. \u003cem\u003eInternational Egyptian Journal of Nursing Sciences and Research\u003c/em\u003e, \u003cem\u003e0\u003c/em\u003e(0), 6\u0026ndash;9. https://doi.org/10.21608/ejnsr.2020.30805.1003\u003c/li\u003e\n\u003cli\u003eWeurlander, M., L\u0026ouml;nn, A., Seeberger, A., Broberger, E., Hult, H., \u0026amp; Wernerson, A. (2018). How do medical and nursing students experience emotional challenges during clinical placements?. International Journal of Medical Education, 9, 74-82. https://doi.org/10.5116/ijme.5a88.1f80\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Wheeler, K., \u0026amp; Phillips, K. E. (2019). The Development of Trauma and Resilience Competencies for Nursing Education. \u003cem\u003eJournal of the American Psychiatric Nurses Association\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(4), 107839031987877. https://doi.org/10.1177/1078390319878779\u003c/li\u003e\n\u003cli\u003eWilliams, K. (2014). An exploratory study: reducing nursing students stress levels facilitate perceived quality of patient care. Open Journal of Nursing, 04(07), 512-519. https://doi.org/10.4236/ojn.2014.47054\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Wu, Y., Guo, Z., Zhang, D., Wang, Y., \u0026amp; Wang, S. (2024). Sleep Quality and Suicidal Ideation in Adolescent Depression: A Chain Mediation Effect of Perceived Social Support and Resilience. \u003cem\u003eClinical Psychology \u0026amp; Psychotherapy/Clinical Psychology and Psychotherapy\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(2). https://doi.org/10.1002/cpp.2990\u003c/li\u003e\n\u003cli\u003eYaseen Fathi K, Ibrahim RH. Factors influencing integration of theory into practice in clinical skills acquisition among nursing students. Inform Med Unlocked. 2023; 37:101181\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Younas, A., \u0026amp; Maddigan, J. (2019). Proposing a policy framework for nursing education for fostering compassion in nursing students: A critical review. \u003cem\u003eJournal of Advanced Nursing\u003c/em\u003e, \u003cem\u003e75\u003c/em\u003e(8), 1621\u0026ndash;1636. https://doi.org/10.1111/jan.13946\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Younas, A., \u0026amp; Shahzad Inayat. (2023). Alleviating suffering of individuals with multimorbidity and complex needs: A descriptive qualitative study. \u003cem\u003eNursing Ethics\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(2-3). https://doi.org/10.1177/09697330231191280\u003c/li\u003e\n\u003cli\u003e\u0026zwnj;Zhao, Y., Zhou, Q., Li, J., Luan, J., Wang, B., Zhao, Y., Mu, X., \u0026amp; Chen, H. (2021). Influence of psychological stress and coping styles in the professional identity of undergraduate nursing students after the outbreak of COVID‐19: A cross‐sectional study in China. \u003cem\u003eNursing Open\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(6), 3527\u0026ndash;3537. https://doi.org/10.1002/nop2.902\u003c/li\u003e\n\u003cli\u003eZheng, Y., Jiao, J.-R., \u0026amp; Hao, W.-N. (2022). Stress levels of nursing students: A systematic review and meta-analysis. \u003cem\u003eMedicine\u003c/em\u003e, \u003cem\u003e101\u003c/em\u003e(36), e30547. https://doi.org/10.1097/md.0000000000030547\u003c/li\u003e\n\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"Nursing Interns, Stress, Resilience, Photovoice, Phenomenology","lastPublishedDoi":"10.21203/rs.3.rs-6188343/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6188343/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNursing intern students' experiences of stress and their resiliency construction during internships remains largely unexplored. This study aimed to explore the nursing intern students' experiences of stress and resilience during internship using photovoice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a phenomenological investigation using photovoice, focusing on the stressors and coping mechanisms of 14 nursing interns from the King Khalid University, Abha and Khamis Muhsayt branches during the last three months of their internship. The nursing interns, comprising 14 individuals with an equal male to female ratio, took between 5 to 7 photographs that they felt best represented their experience during the internship. After taking these photographs, the participants engaged in individual and group semi-structured interviews discussing the photos and narratives. The interviews were recorded and then transcribed word for word. Thematic analysis was conducted by two researchers. Rigor was maintained by researchers’ reflexivity, participant photo narrative review, and an independent inquiry audit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study revealed six key themes: interns experienced significant stress from the Weight of Responsibility and the Emotional Rollercoaster of patient care. However, they found Strength in Connection through peer and mentor support, engaged in Self-Care and Reflection, and gained Perspective through the Lens of photovoice. Interns also provided Recommendations for Support, advocating for systemic changes to improve the internship experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis photovoice study revealed that nursing interns face significant stress from heavy responsibility and emotional challenges, but find crucial support through connections with peers and mentors. They actively use self-care and reflect on their experiences, leading to calls for systemic changes like enhanced mentorship and stress management resources to create a more supportive internship environment.\u003c/p\u003e","manuscriptTitle":"Exploring nursing intern students' experiences of stress and resilience during internship using photovoice","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-14 09:24:53","doi":"10.21203/rs.3.rs-6188343/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-30T08:15:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-18T11:01:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122322256065720700461976602355388811755","date":"2025-06-06T06:07:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-18T22:30:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99052925883237352971209838880697504038","date":"2025-04-08T16:47:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-27T09:08:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-27T09:00:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-24T17:27:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-23T04:06:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-03-23T04:05:02+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":"b8a9b4f5-1e09-401e-be85-6d802ae68b18","owner":[],"postedDate":"April 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T15:58:24+00:00","versionOfRecord":{"articleIdentity":"rs-6188343","link":"https://doi.org/10.1186/s12912-025-03701-w","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-08-07 15:56:53","publishedOnDateReadable":"August 7th, 2025"},"versionCreatedAt":"2025-04-14 09:24:53","video":"","vorDoi":"10.1186/s12912-025-03701-w","vorDoiUrl":"https://doi.org/10.1186/s12912-025-03701-w","workflowStages":[]},"version":"v1","identity":"rs-6188343","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6188343","identity":"rs-6188343","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}