Survival over competence: a qualitative study of senior nursing students’ clinical experiences in Karachi, Pakistan

BMC Nursing https://doi.org/10.1186/s12912-026-04800-y Article in Press Survival over competence: a qualitative study of senior nursing students’ clinical experiences in Karachi, Pakistan Sheheryar Shahid, Salma Rattani, Saima Sachwani & Saira Lalani Received: 23 December 2025 Accepted: 18 May 2026 Cite this article as: Shahid S., Rattani S., Sachwani S. et al. Survival over competence: a qualitative study of senior nursing students’ clinical experiences in Karachi, Pakistan. BMC Nurs (2026). https://doi.org/10.1186/ s12912-026-04800-y A We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply. E R P S S If this paper is publishing under a Transparent Peer Review model then Peer Review reports will publish with the final article. I T R E L C IN © The Author(s) 2026. 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To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. ACCEPTED ARTICLEMANUSCRIPT IN PRESS Title: Survival over Competence: A Qualitative Study of Senior Nursing Students' Clinical Experiences in Karachi, Pakistan. Authors: Sheheryar Shahid, Salma Rattani, Saima Sachwani, and Saira Lalani. Affiliations: School of Nursing and Midwifery, Aga Khan University (AKU-SONAM), Karachi, Pakistan. Corresponding Author: Sheheryar Shahid S S E R P School of Nursing and Midwifery, Aga Khan University Stadium Road, P.O. Box 3500 E L C I T R A Karachi 74800, Pakistan IN Email: [] Abstract Background Clinical placement is the cornerstone of nursing education. In Lowand Middle-Income Countries (LMICs) like Pakistan, the lack of affiliated teaching hospitals in private nursing colleges requires students to undertake clinical rotations in resource-constrained public facilities, shaping challenging learning environments. This study explores the clinical experiences, challenges, and coping strategies of senior undergraduate nursing students. ACCEPTED ARTICLEMANUSCRIPT IN PRESS Methods An exploratory descriptive qualitative design was employed, underpinned by Benner’s from Novice to Expert theoretical framework. Data were collected through eight semi-structured focus group discussions (FGDs) with 59 Bachelor of Science in Nursing (BSN) students from three private nursing colleges in Karachi, Pakistan, using purposive maximum variation sampling. Data was analyzed using Braun and Clarke’s reflexive thematic analysis. Results S S E R P Data were analysed using Braun and Clarke’s reflexive thematic analysis, and Patricia Benner’s Novice to Expert Model was applied as a IN guiding theoretical lens across the analysis; the integrated interpretation is E L C I TEnvironmental Deficiencies Systemic and R A presented in Figure 1. The analysis revealed a profound disconnect between academic preparation and clinical reality, encapsulated in five major themes: (1) , characterized by institutional neglect and severe resource scarcity leading to unsafe practices; (2) A Culture of Supervisory Neglect and Hostility, where students felt abandoned by instructors and devalued by hospital staff; (3) The Pervasive Theory–Practice Chasm, marked by the cognitive dissonance of witnessing normalized unsafe protocols; (4) The Crucible of Confidence, detailing the psychological toll on students and their development of resilience and "digital mentorship" as survival mechanisms; and (5) A Call ACCEPTED ARTICLEMANUSCRIPT IN PRESS for Systemic Reform, outlining student-driven recommendations for accountability and improved supervision. Conclusions The current model of clinical education for private college students in public hospitals in Karachi is fraught with systemic failures that compromise patient safety and student well-being. Students’ progress toward competence is not through structured mentorship, but through resilience developed in a harsh, unsupported environment. Urgent reforms in regulatory oversight, preceptor training, and resource allocation are S S E R P required to bridge the theory-practice gap and ensure safe clinical learning environments. Keywords E L C I T R A IN Clinical learning environment, Undergraduate nursing students, Qualitative research, Theory-practice gap, Benner’s Novice to Expert Model Introduction Clinical education is central to nursing preparation because it integrates theoretical knowledge with hands-on patient care in real healthcare settings. The Clinical Learning Environment (CLE) is more than a venue for skills practice; it is a complex social and organizational space where students develop clinical competence, exercise critical judgment, and begin professional socialization (1, 2). Across contexts, the quality of supervision, psychosocial interactions, and institutional support within the CLE strongly shapes students’ confidence and readiness for practice (3). In ACCEPTED ARTICLEMANUSCRIPT IN PRESS well-resourced systems, formal preceptorship models and adequate infrastructure partially buffer students from clinical pressures. However, in low- and middle-income countries (LMICs), persistent shortages of staff, space, and materials fundamentally alter how students experience and learn in clinical settings (4, 5). These structural constraints are especially visible in Pakistan, where rapid expansion of nursing education has been driven largely by private colleges. Many of these institutions lack affiliated teaching hospitals and therefore depend on formal affiliations with publicly funded tertiary care S S E R P hospitals to meet mandatory clinical hour requirements (6, 7). While this model exposes students to diverse pathologies and high patient volumes, it IN places them in overcrowded wards characterized by understaffing and E L C I T R A limited resources (8). Students often report a stark contrast between the controlled academic environment of their colleges and the chaotic realities of public hospital wards (...truncated)