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How do nursing students experience the
clinical learning environment and
respond to their experiences? A
qualitative study
Majid Najafi Kalyani, Nahid Jamshidi, Zahra Molazem, Camellia Torabizadeh,
Farkhondeh Sharif

To cite: Najafi Kalyani M, Abstract

Jamshidi N, Molazem Z, et al. Strengths and limitations of this study
Introduction On entry into the clinical environment,
How do nursing students
nursing students are confronted with many challenges. ►► The study, by performing a grounded theory re-
experience the clinical learning
environment and respond
It is a common problem throughout the world, including search, provided increased, indepth understanding
to their experiences? A Iran. Although many studies have been conducted on the of how nursing students experience the clinical
qualitative study. BMJ Open problems of nursing students in the clinical environment, learning environment and the way they respond to
2019;9:e028052. doi:10.1136/ limited information is available on nursing students’ this experience.
bmjopen-2018-028052 experiences of the clinical learning environment and the ►► Combining resources and using the experiences
►► Prepublication history for way they respond to these experiences. Identifying nursing of educators, clinical nurses and students provid-
this paper is available online. students’ experiences is essential to develop interventions ed multiplied validity to this study and helped iden-
To view these files, please visit to reduce challenges. tify a more comprehensive image of the process
the journal online ([Link] Objective This study aimed to explore nursing students’ under investigation.
org/​10.​1136/​bmjopen-​2018-​ experiences in a clinical learning environment and the way ►► The information gained from this study may be use-
028052). ful in improving clinical environments and educa-
they responded to these experiences.
Received 21 November 2018 Design The present study was conducted based on tional contexts.
Revised 28 May 2019 the qualitative research design of the grounded theory ►► Due to the sociocultural uniqueness and the con-
Accepted 3 July 2019 methodology. construct theory from data, text-bound relevance of the qualitative findings of
Setting This study was conducted at schools of nursing in this study, repetition of the study is required in other
academic settings in Iran. countries and cultures.
Participants The participants included 19 nursing
students, 4 nursing instructors and 3 clinical nurses.
Introduction
Methods The data were collected using semistructured
Nursing students should employ their knowl-
interviews, field notes and observation, and were analysed
using Strauss and Corbin’s approach. edge and skills in clinical environments to
Results Students, as a result of the inadequacy of the acquire the required qualifications for taking
educational environment, were faced with ‘confusion care of patients, and their success depends to
of identity’, stating this as their main concern. When a great extent on efficient clinical training.1
confronted with this concern, they employed specific Clinical training is regarded as the heart
strategies, some of which prevented them from getting and essence of learning and education in
into unpleasant conditions. These strategies did not help nursing.2 3 Furthermore, clinical learning
students solve their problems and also prevented them environment plays an important role in
from accepting their professional roles and responsibilities. turning nursing students into professionals
© Author(s) (or their Conversely, some other strategies led them to advanced and preparing them to function as nurses.4
employer(s)) 2019. Re-use professional development and enabled them to accept A clinical learning environment is a
permitted under CC BY-NC. No their role and the clinical environment. combination of several physical, psycholog-
commercial re-use. See rights Conclusion According to the results of this study,
and permissions. Published by
ical, emotional and organisational factors
educational policymakers should focus on improving the affecting the students’ learning and how they
BMJ.
clinical environment. Identifying professional models and confront the environment.5 6 This environ-
Nursing, School of Nursing and
increasing their influence on management, education ment has considerable effects on students’
Midwifery, Shiraz University of
Medical Sciences, Shiraz, The and clinical education, as well as teaching positive and positive learning and emotional well-being.7 8
Islamic Republic of Iran constructive strategies, will promote positive strategies
Furthermore, students get acquainted with the
in coping with inadequate educational contexts. This is
Correspondence to realities of their profession and functions
necessary for the professional development of nursing
Dr Zahra Molazem; of nursing in this environment.9 However,
students.
​molazem@​sums.a​ c.​ir the clinical learning environment has been

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referred to as a reason for either quitting or continuing
Table 1 Characteristics of the students participating in the
the nursing profession.10 The complexity of this environ- study
ment and the events involved causing tension make it
Identifier Age (years) Sex
hard to be controlled.11 On entry into the clinical environ-
ment, nursing students are confronted with many chal- S1 22 Male
lenges and problems which affect their learning in that S2 20 Female
environment.10 Quitting the profession, fear, anxiety and S3 20 Female
confusion have been mentioned as the main reasons for
S4 23 Female
nursing students’ unpreparedness and concern in clinical
learning environments.12 13 Bachelor nursing studies last S5 23 Female
for 4 years in Iran, during which students enter clinical S6 25 Female
education and clinical learning environments. The major S7 20 Female
part of nursing education in clinical environments in Iran S8 22 Female
begins in the second term and continues until the end of
S9 20 Female
the eighth term.10
The results of the study by Papathanasiou et al14 indi- S10 23 Female
cated a considerable gap between students’ expectations S11 23 Male
and clinical learning environments, which confronted S12 21 Male
them with problems in the clinical learning environ- S13 21 Female
ment. Identification and elimination of the problems in
S14 21 Female
clinical learning environments reduce nursing students’
emotional and behavioural problems in these environ- S15 21 Female
ments.15 16 Despite the severe shortage of nurses and the S16 20 Female
need for nurse training in Iran, there is not enough incen- S17 21 Female
tives to enter this profession, and many cases of leaving S18 20 Female
the profession,17 lack of motivation18 and psychological S19 19 Female
problems occur after entry into the clinical environment.2
The quality of clinical practice in Iran is determined
by two main factors, namely the nursing care delivery
for profound understanding of how students experience
method and the nurse to patient ratio. Within the clinical
things (behaviours, events and interactions) on entering
field, nursing students and nurses take care of patients
clinical environments and attending clinical depart-
from various ethnic groups and different cultures
ments. This would pave the way for improvements in clin-
based on the case method.19 Several studies have been
ical training and reduction of probable problems in the
conducted on nursing students’ clinical training in Iran.
clinical environment.
One study conducted by Peyrovi et al19 demonstrated that
nursing students were afraid of providing care in clinical
learning environments. Also in the research by Joolaee Methods
et al10, nursing students reported fear and anxiety in Study design
clinical environments. Similarly, the students partici- Qualitative research with the grounded theory approach
pating in the study carried out by Hanifi et al18 stated that was used as the appropriate method to answer the
becoming a nurse was one of their major concerns in clin- research question. Grounded theory approach is a deep
ical environments. Long-term experience (20–30 years) study of clinical practices, behaviours, and attitudes of
of researchers in clinical education of nursing students individuals and groups. Since grounded theory focuses
also shows that nursing students undergo a lot of changes on social processes and is related to the context, it is a
after entering clinical setting, causing mental and psycho- suitable method to answer the research question and
logical problems, lack of motivation, and the decision to to describe the social processes lying in the data.20
leave the profession.
Although the above-mentioned studies have addressed Participants
nursing students’ problems and challenges in clin- In this research, 19 nursing students as key informants
ical environments, none of these has investigated how were first selected based on purposive sampling (table 1).
students experience the learning environment and the Then, to complete the connections between the cate-
way they respond to this experience. Considering the gories that emerged and to extract the process in the
problems of Iranian nursing students after entering the data, four instructors (table 2) and three clinical nurses
clinical environment, the effects of this environment (table 3) were interviewed based on theoretical sampling
on students’ professional learning and future, and the until data saturation was achieved. The selection criteria
existing gap in the literature, and given that no compre- for nursing students included internship experience
hensive research has been conducted in this regard, this in clinical learning environments and willingness to
study was performed using a grounded theory approach participate in the research and to express their personal

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After this, similar codes were placed in one category by
Table 2 Characteristics of the instructors participating in
the study constant comparison. In axial coding, the initial cate-
gories formed in the open coding were compared, and
Educational
those that were similar to each other were rooted in a
experience
Identifier Age (years) (years) common axis. At this stage, the categories were related
to their axial categories in order to provide more precise
I1 38 5 and complete explanations of the phenomenon. In the
I2 32 10 third step or the selective coding, constant comparison
I3 40 4 was used to determine the relationships among the cate-
I4 35 9 gories and to search for the process involved in the data.
The researchers also looked for the core variable and the
existing process in the data.21 Memoing and diagram-
experiences. It should be noted that the instructors and ming were used as well.
nurses had at least 5 years of work experience.
Rigour
Data collection Regarding the trustworthiness of the data, credibility
Semistructured personal interviews were used to collect was established through member check, data collection
data from the students, instructors and nurses from triangulation and prolonged engagement. In this regard,
October 2014 to May 2017. The interviews were decided the texts of the interviews and the derived codes were
to be conducted at Shiraz Faculty of Nursing and to last returned to the participants (n=10) and they were asked
between 40 and 70 min, as agreed by the participants. It to comment on the researchers’ perceptions of their state-
should be noted that five nursing students were inter- ments and to correct any variations. Indeed, peer check
viewed twice. was performed by five expert supervisors of nursing and
The interviews began with the following questions: experts in qualitative research. They also supervised the
‘What did you experience after entering the clinical process of interviewing, coding and categorisation. More-
leaning environment’, ‘What happened during your clin- over, maximum variation of sampling (in terms of sex and
ical practice’, ‘How did you feel at that time’, and ‘What academic term) enhanced the confirmability and credi-
did you do’. The instructors and nurses were also asked bility of the data.21
to share their experiences about exposing students to
the clinical learning environment. The interviews were Patient and public involvement
recorded and transcribed. Field notes and observations Patients were not involved in this study. The study partic-
were employed as well. ipants included nursing students, instructors and clinical
nurses.
Data analysis
Data collection and analysis were performed simultane-
ously using Strauss and Corbin’s approach. In this method,
the data were examined several times and analysed (as in Results
the example in table 4) using the three steps of open, The findings of the present study (figure 1) showed
axial and selective coding until theoretical saturation was that, due to the inadequacy of the clinical environment,
achieved. The data were collected by the authors (ZM, NJ nursing students were faced with confusion of identity and
and MNK). All authors participated in the data analysis; stated this as their main concern. Students in confronta-
they talked about the codes and categories and reached tion with this concern used two sets of strategies according
an agreement. Data analysis was conducted during the to the condition. Some of these strategies prevented them
data collection process as follows. At the beginning, the from getting into unpleasant situations. These strategies
audio files of the recorded interviews and observations did not help students solve their problems and prevented
were transcribed. In the analysis for open coding, the them from accepting their professional roles and respon-
texts of the interviews and observations were read several sibilities. On the other hand, some other strategies
times and the main concepts were extracted and coded. promoted the students’ professional development and
helped them better embrace their clinical environment
and professional responsibilities. Supportive systems in
Table 3 Characteristics of the nurses participating in the this process would also facilitate students’ professional
study development.
Clinical
experience Inefficient educational context
Identifier Age (years) (years) When in clinical training environment, nursing students
N1 33 4 realised that it lacked the required efficiency. Inefficient
N2 36 10 educators, unfavourable educational plans and inappro-
priate clinical environment were the components of this
N3 35 7
inefficient educational context.

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Table 4 An example of data analysis
Text of the interview Code Subcategory Category
“There were lots of dressings and lots of things connected to Fear from the unknowns Fear Emotional
them (the patients). I had never seen these; it’s scary…I have no Fear from negative feedback flares
idea how to operate them; it’s so bad.” (S16)
Fear from harming patients
“It has happened to me a lot…They shiver…I asked some
and they replied ‘we’re afraid of being told that we are making
mistakes.’” (N2)

Inefficient educators Furthermore, some nurses in clinical environments

According to students’ experiences, some instructors were not able to respond to students’ questions properly.
and nurses did not have adequate efficiency to educate
students and transfer knowledge to them. Some instruc- Unfavourable educational planning
tors’ failure to provide sufficient details on medications, Lack of correspondence between the length of internship
procedures and required care was among the items courses and the specified objectives, as well as between
mentioned by the students. the times of theoretical and practical courses, resulted
…In one of the internships, the teacher provided us in students encountering challenges when in the clinical
with no explanations on what the medication was, environment.
how it was to be dissolved, and what complications it In the same term that we have orthopedics, we have
had… (S13) to attend internship at that department. Before learn-
Some instructors’ improper assessment of students, ing about the diseases and care, we are encountered
inflexibility, lack of experience, lack of clinical skills and with patients at the ward, which causes us not to learn
failure to respond to students’ questions were other items well… (S18)
stated by the students.
Based on the students’ experiences, educational focus
…Master students are now set as instructors. They on performing routine tasks and repetitive departments
neither have sufficient knowledge, nor do they know in different internships restricted the opportunity to
how to communicate and teach… (S5) learn more.

Figure 1 Nursing students’ experiences and strategies in the clinical learning environment.

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…We haven’t seen many cases at all; we go to the de- nurses’ different expectations also increased the confu-
partment and everything is repeated… (S4) sion and conflicting roles.
From the students’ perspective, limitations in the …We instructed a student how to communicate with
curricula deprived them of the requirements for entering the patient and go through the nursing process. The
the clinic in terms of knowledge and clinical and commu- student was explaining to the patient, but the nurse
nication skills. Furthermore, admission in nursing profes- said there was no need for too much explanation…
sion with no regard to the correspondence between the (I2)
students’ characteristics and the field, or its mandatory or
blind selection by some students, made them spiritually Nurses with negative attitudes towards their career
unprepared to attend clinics and receive the required brought this attitude to the students and doubted them
instructions. in accepting their role as a nurse.

… Nurses themselves keep telling me ‘what a pity you

Inappropriate clinical environment
selected this field’. They speak ill of it…They are by
Some nurses’ negative attitudes towards the students’ pres-
no means motivated, they keep groaning at depart-
ence in the department, lack of support, and nurses’ and
ments. Then, how can I have a positive attitude to-
patients’ mistrust caused an unsupportive atmosphere in
wards nursing… (S17)
clinics, which was very unpleasant to the students.
…I feel that nurses are treated like servants, which is
…Well, they (nurses) are biased, saying ‘oh, students not at all the case. A nurse also studies, as in all other
are there again!’…Then, they always seek for prob- fields, and what she does is scientific… (S10)
lems with our work… (S10)
These factors caused nursing students in clinical envi-
Students observed unpleasant interactions in clin- ronments to change their attitudes towards nursing and
ical departments that challenged them. They kept be confused in accepting their professional identities.
complaining about the nurses’ neglect or indifference
towards them, as well as the staff’s non-cooperation.
Emotional flares
…Department nurses behave so badly, just as if you’re When confronted with the problems and challenges in
saying something bad to them. They don’t cooperate educational opportunities and clinics, students were
at all. (S16) faced with psychological problems, fear and stress. Their
fear and stress in clinical learning environments could
Furthermore, educational injustice and discrimination be rooted in the unknowns, equipment and fear from
between nursing and medical students were major prob- harming the patients.
lems in clinical learning environments.
…There were lots of dressings and lots of things con-
…I was reviewing a patient’s record when the nurse nected to them (the patients). I had never seen these;
took it away from me very roughly. She would say it’s scary…I have no idea how to operate them; it’s so
nothing to a medical student though… (S5) bad… (S16)
Moreover, lack of facilities and unavailability of the Another source of students’ fear in clinical learning
needed equipment led to waste of time and delay in environments was receiving negative feedback from
patient care; such an educational environment was instructors, patients’ companions or nurses.
unpleasant to the students. Nurses also found the phys-
ical space inappropriate to the number of students in the …It has happened to me a lot…They shiver…I asked
department. some and they replied ‘we’re afraid of being told that
we are making mistakes’… (N2)
Confusion of identity
There was no clear description of tasks for nurses and Hopelessness was another psychological reaction
students, which was why they did not know what they created under the influence of nurses’ attitudes. Discrim-
were responsible for. Non-professional tasks performed inatory behaviours and an unsupportive atmosphere in
by nurses, for instance, caused a negative attitude towards clinical environments, as well as the negative attitude
nursing and confusion about its functions. towards nursing students and nursery in clinical depart-
ments and the society, caused an inferiority complex, a
…We do things at the department that attendants are sense of humiliation or deficiency in self-confidence
responsible for; for example, when patients want us in students. Furthermore, some nurse instructors’
to clean their beds…. (S4) unfriendly behaviours intensified these feelings.
Furthermore, the mismatch between expectations and …When instructors don’t talk to us and don’t treat
reality and the difference between what they have been us properly, we have no self-confidence to be able to
taught in classrooms and what they observe in clinical serve patients; we are upset to the extent that we have
environments intensified the confusion. Instructors’ and no incentive to work… (S14)

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The unsupportive, unfriendly atmosphere sometimes Efforts for promotion
caused the students to cry or jitter. Some students used a strategy to grow and promote due
to a sense of internal commitment as well as the need for
Fluctuation of escape and promotion understanding and improving their practical skills. In this
Nursing students used two sets of strategies based on their way, support from nearby people, including peers and
conditions in the clinical environment as an inadequate instructors, was helpful. They tried to find themselves in
educational context. Some of these strategies made it the environment and to understand who they are, what
possible for them to escape from unpleasant situations. their duties are, and how they can establish a relation-
These strategies did not help students solve their prob- ship and gain the trust of patients and nurses. In this way,
lems and prevented them from accepting their profes- the students tried to better understand their roles and
sional roles and responsibilities. On the contrary, some responsibilities and to increase their practical knowledge
other strategies promoted students’ professional devel- and skills. Therefore, they identified some nurses and
opment and helped them embrace their clinical envi- educators with high care and skill levels and good rela-
ronment and professional responsibilities and reduce tionships as their models to improve their performance
negative emotional responses. In this study, fluctuation and reduce the stress caused by their lack of knowledge
of escape and promotion was recognised as the core and skills.
variable. …I definitely choose the instructor with proper be-
havior as my role model, and try to learn from her…
Escape (S16)
Sometimes, the students tried to deal with unpleasant
behaviours by neglecting or staying silent in order to Furthermore, some students tried to be responsible
reduce tension and stress and to avoid the increase of towards the patients due to their intrinsic sense of
such behaviours. commitment and made efforts to gain patients’ trust and
satisfaction and provide better care. Thus, they overcame
…Whenever we enter the department, nurses say ‘the their lack of interest and incentive, and they satisfied
clumsy are there again,’…We said nothing, kept si- themselves and promoted their own performance.
lent, and just stopped and looked… (S8)
…even if I’m not interested in nursing, I try to do my
Some students tried to avoid the nurses’ unpleasant, job properly to satisfy the patients since I feel respon-
destructive behaviours. They also tried not to get stuck in sible now; this makes me interested at least… (S1)
situations that required knowledge and skills to prevent
stress and irritation. Search for information was another important measure
taken by the students to manage the stress that resulted
…I can’t perform electrocardiography and get from unpreparedness and fear.
stressed when I need to do it…I don’t select a patient The students stated that they used support from their
for whom I have to do so; I avoid these opportunities friends, peers and some instructors to reduce their psycho-
in order not to get stressed… (S18) logical problems and overcome their fear and negative
feelings towards clinical environments, so that they could
However, the students sometimes chose a different appear with confidence and perform the assigned tasks.
method; they denied the reality, that is, lack of knowledge
and skills, and tried to pretend that they held high skills
or the required knowledge for caretaking.
Discussion
…I never admit that I don’t know something…either The findings of this study expanded nursing students’
to a teacher or to a patient…never…I don’t know, in main concern in the clinical education environment and
fact, and I’m also stressed… (S1) the overall strategies used to deal with it.
It is one of the instructors’ and nurses’ important obli-
Escaping from responsibility was another strategy,
gations to provide nursing students with training and
which was sometimes adopted by the students. Lack of
support on entry in clinical environments and help them
correspondence between the students’ personalities
accept their roles as nurses. However, the findings of the
and the field also resulted in escape from responsibil-
present research, as well as those of some other studies,
ities. This was manifested as a waste of time or failure
have indicated that nurse instructors and nurses lacked
to do the assignments through which the students tried
the required efficiency, knowledge and skills for training
to encounter the unpleasant conditions in the clinical
students.22 23 Furthermore, the results of the present
environments.
study demonstrated that defects in educational planning
…Students really come to the department and don’t reduced the students’ preparedness to enter the field.
work willingly; they always seek for a way to escape… The wide gap between theoretical and clinical education
They attend the department conference, but they ar- results from educational planning methods in the field.24
en’t prepared; they make excuses… (I1) The results of the research by Pourghane23 indicated that

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repetitive topics in clinics resulted in negative clinical problem-solving were other solutions to reduce students’
experiences, and this had to be taken into consideration. stress.34 Gaining support from friends has also been one
Students enter clinics with insufficient preparedness of the most important strategies employed by students.37
and with their own conceptions of clinics and nursing. According to the results of the study by Vaghee et al38,
They discover conflict between their expectations and training in communication skills reduced the employ-
learnt subjects and the reality in clinics once they are ment of the ‘escape from troublesome situations’ and
encountered with an unsupportive atmosphere, nurses’ avoidance strategies, and could enforce the ‘seeking for
negative behaviours and attitudes, and so on. This finding social support’ strategy, increase efforts to obtain infor-
is in line with those of other studies.14 25 Abazary et al26 mation and emotional support from others, and increase
stated that nursing students’ entry into clinical environ- the employment of ‘responsibility’ and ‘problem solu-
ments caused interference between their and nurses’ tion’ strategies, as well as analytical efforts to solve prob-
responsibilities and the resultant problems. Factors lems in stressful situations.
causing problems between students and the department It is essential that health and education policymakers
staff include lack of correspondence between education have a special focus on improving clinical environments
and treatment, rejection of criticism, insufficient equip- and educational contexts. Identifying professional models
ment provided to students and failure to consider the and increasing their influence on management, educa-
students’ list of responsibilities. tion and clinical education, as well as teaching positive
Improper clinical work environments and lack of corre- and constructive strategies, help strengthen and promote
spondence between reality and the students’ preconcep- positive strategies in coping with inadequate educational
tions resulted in nursing students’ negative view of their contexts.
career and the decision to quit.17 This is a major reason
for quitting the career and withdrawing from the field Limitations of the study
after entering clinical environments.27 Nonetheless, most This study only focused on discovering the experiences
students enter nursing profession with positive attitudes of Iranian nursing students, clinical nurses and instruc-
towards the values of caretaking and expect to learn it as a tors. Thus, further studies in other cultures are needed to
caretaking career.28 Of course, students’ personality traits make the results more generalisable.
are of great importance with regard to their prepared-
ness to work in clinical environments and their role as
nurses. Iranian university entrance exam only assesses Conclusion
participants’ theoretical knowledge and educational The present study showed that continued attention
talent. A study conducted in Iran demonstrated that 44% is required to minimise unsupportive atmosphere in
of students did not hold personality traits appropriate the clinical environment, as well as negative attitudes
to the nursing career, and about 77% of them had little towards nursing students and nursing profession in clin-
knowledge of the field when selecting it.29 Therefore, an ical departments and the society. In this context, educa-
important point for admitting students to this field is to tors and nurses should be aware that they, as proper role
assess its correspondence with their personality traits. models, can motivate students and enhance their clinical
Another important factor in the students’ achievement of knowledge and skills. In addition, educators and nurses
nursing purposes and proper professional performance can be effective in helping nursing students properly
is to establish good relationships with the treatment confront the challenges of the clinical environment. Use
team. However, students hardly have such experiences of constructive strategies that lead to professional devel-
and consequently encounter conflicts in accepting their opment of nursing students should be enforced with the
profession.30 necessary instructions, and at the same time faculties
The interpersonal relationship between the instructors and clinical environments are coordinated. In this way,
and clinical nurses and the students plays an important clinical authorities are informed about students’ expec-
role in the development of students’ personal and profes- tations and clinical environments are improved, eventu-
sional identities.31 Furthermore, instructors’ and clinical ally enhancing students’ preparedness and capabilities
nurses’ negative relationships with and behavioural and before entering the clinics.
verbal aggression towards students are a major factor in
the development of stress in students, creating a sense of Acknowledgements This article was extracted from the PhD dissertation written
inefficiency and disqualification.32 Establishing proper by NJ. The authors would like to thank Ms A Keivanshekouh at the Research
Improvement Center of Shiraz University of Medical Sciences for improving the use
relationships with students and supporting them in clin- of English in the manuscript.
ical environments both facilitate the learning process and
Contributors Study design and conception: MNK, NJ, ZM, FS, CT. Data collection:
result in professional socialisation.33 MNK, NJ, ZM. Data analysis and interpretation: MNK, NJ, ZM, FS, CT. Manuscript
When confronted with stressful, unpleasant factors in writing: MNK, NJ, ZM. Critical revision of the manuscript: MNK, NJ, ZM, FS, CT. Final
clinical environments, students try to use coping strat- approval of the manuscript: MNK, NJ, ZM, FS, CT.
egies.34 Some studies have demonstrated that students Funding This article was financially supported by the Shiraz University of Medical
tended to use positive35 or avoidance strategies.36 37 Coping Sciences (grant no 93-7126).
strategies including transference, staying optimistic and Competing interests None declared.

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Ethics approval This study was approved by the Research Ethics Committee of 16. Melincavage SM. Student nurses' experiences of anxiety in the
Shiraz University of Medical Sciences (EC-93-7126). After the purpose was stated clinical setting. Nurse Educ Today 2011;31:785–9.
and the methodology was described, written informed consent was obtained from 17. Joolaee S, Mehrdad N, Bohrani N. A survey on nursing student's
all participants. In all research steps, confidentiality was observed and codes were opinions toward nursing and reasons for giving it up. Iranian Journal
of Nursing Research 2006;1:21–8.
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8 Najafi Kalyani M, et al. BMJ Open 2019;9:e028052. doi:10.1136/bmjopen-2018-028052