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

Clinical placement is the cornerstone of nursing education. In Low- and 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.

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.

Data were analysed using Braun and Clarke's reflexive thematic analysis, and Patricia Benner's Novice to Expert Model was applied as a guiding theoretical lens across the analysis; the integrated interpretation is presented in Fig. 1. The analysis revealed a profound disconnect between academic preparation and clinical reality, encapsulated in five major themes: (1) Systemic and Environmental Deficiencies, 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 for Systemic Reform, outlining student-driven recommendations for accountability and improved supervision.

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 required to bridge the theory-practice gap and ensure safe clinical learning environments.