Understanding undergraduate nursing students' clinical experience: An integrative review

Clinical education is a required component of undergraduate nursing education and a prerequisite for program completion and licensure.^[1,6] Clinical education encompasses hands-on experiences with face-to-face patient contact in healthcare environments, such as hospitals, clinics, or community settings.^[4,7,8] During clinical experiences, students complete a specified number of direct patient care hours, during which they are exposed to practical nursing skills and acquire the knowledge, professional behaviors, and attitudes necessary for success as practicing nurses.

There are several traditional clinical education models used by nursing programs.^[1,4,9] In the faculty supervision model, clinical faculty accompany small groups of students to clinical units.^[10] The assigned clinical faculty or clinical instructor is responsible for all learning activities and provides expert supervision and guidance of patient care activities.^[6] Clinical faculty must balance the educational needs of students with the operational demands of the clinical unit, often while supervising up to ten students simultaneously.^[10,11] A key strength of this model is the presence of an academic nurse educator who can intentionally link classroom content with clinical learning.^[12] However, limited faculty availability may result in task-focused supervision rather than deeper integration of knowledge, skills, and professional judgment.^[4]

Another model, the preceptorship model, assigns students to a nurse preceptor employed by the facility on the student’s assigned unit.^[1,6,13] The preceptorship model provides one-on-one supervision, where the preceptor is responsible for all learning activities for the student. The preceptor provides oversight of patient care decisions and assessments, as well as expert supervision of patient care. A strength of this model is the student’s opportunity to practice and learn alongside an experienced nurse with one-on-one supervision.^[12] A significant weakness of this model is that preceptors are often not trained as educators and may struggle to bridge the gap between classroom and clinical learning.^[7,12] Additionally, preceptors may experience workload burden, limited time for teaching, and lack of compensation, all of which can reduce their availability to students and contribute to variability in clinical learning experiences.

Alternative clinical education models include Dedicated Education Units (DEUs) and hub-and-spoke models, both of which rely on structured academic–practice partnerships.^[1,14] DEUs are intentionally designed clinical units in which staff nurses are prepared and supported to serve as clinical educators while academic faculty assume a coaching and oversight role. This model emphasizes consistency, shared educational responsibility, and intentional integration of learning objectives within the clinical environment. DEUs have been described as a strategy to enhance student engagement, increase instructor availability, and strengthen the integration of classroom learning with clinical practice.^[1,12]

Hub-and-spoke models organize clinical education around a central “hub” facility, typically a large healthcare organization or academic medical center.^[1,14] From the “hub” facility, there are affiliated “spoke” sites such as community hospitals, outpatient clinics, or specialty units. This model allows nursing programs to expand clinical placement capacity while maintaining curricular consistency and standardized learning outcomes across diverse settings. Both DEU and hub-and-spoke models require strong institutional collaboration, coordinated faculty involvement, and resource investment, which may limit feasibility for some nursing programs despite their potential to address clinical placement shortages and variability in student experiences.^[1,8,12,14]

Simulation-based learning is also widely used in undergraduate nursing education as a component of clinical preparation.^[4] Simulation supports the development of psychomotor skills, clinical judgment, and confidence by providing structured, low-risk opportunities for deliberate practice and feedback prior to and alongside in-person clinical experiences. When integrated intentionally, simulation can help students prepare for real-world clinical encounters. Although simulation plays an important adjunctive role in clinical education, it is designed to complement rather than fully replace direct patient care experiences required for licensure and professional practice.

Although clinical education is a long-standing requirement in nursing curricula, significant gaps remain in understanding its impact on student readiness and competence. Leighton et al. recently conducted a systematic review to examine traditional clinical outcomes.^[4] The Leighton et al. review was empty, as the researchers found no current evidence to support conventional clinical education models. The primary purpose of clinical education is to prepare students for independent clinical practice by application of classroom knowledge to real-life patients.^[15] The clinical experience fosters the advancement of student skills and confidence in the clinical setting.^[2,16] Clinical education also promotes student socialization and integration into the nursing profession, influencing future career decisions.^[1]

Understanding the current state of nursing clinical education is timely and relevant, given the persistent challenges facing the nursing workforce and the increasing demands for practice-ready graduates. The ongoing global nursing shortage, exacerbated by the COVID-19 pandemic and an aging population, has underscored the urgent need for effective clinical training models that can foster student competence, confidence, and professional identity.^[5] Clinical education is a foundational rite of passage for nursing students.^[16] There are several benefits to providing clinical education, including enhanced communication, increased student confidence, and improved student self-efficacy.^[2,16] To address the current gap in clinical education in undergraduate nursing programs, the purpose of this study was to conduct a comprehensive review of the existing literature. This integrative review aimed to explore and critically review the experiences of undergraduate nursing students learning in generalist nurse clinical rotations in the United States.

This literature review followed the framework of Whittemore and Knafl for integrative reviews.^[14] This method provided a detailed approach to conducting an integrated review, which included problem identification, a clearly defined literature search, critical evaluation of the literature, analysis and data extraction, and synthesis of the findings. The integrative review method allows for the review of both qualitative and quantitative research.^[17]

Articles were included if they were primary peer-reviewed research studies, written in the English language, and peer reviewed. Additional inclusion criteria included studies that focused on generalist nurse clinical experiences in undergraduate nursing programs in the United States. Studies were included from traditional baccalaureate nursing programs, associate degree registered nursing programs, and accelerated registered nursing programs. The review included qualitative and quantitative research, mixed-methods, and retrospective research designs.

Articles were excluded if they included graduate programs, nursing programs, or clinical rotations outside of the United States, were written in languages other than English, or were articles older than ten years. Additionally, articles were excluded if they included virtual clinical experiences, didactic teaching, or simulation-based experiences, as these modalities cannot fully replace in-person clinical education required by state boards of nursing for licensure and to allow focused examination of traditional, in-person clinical experiences. Studies focused on gender-specific or patient-population–specific clinical experiences were excluded to maintain focus on generalist undergraduate clinical education, as specialized contexts involve distinct emotional, ethical, and instructional factors that limit comparability across studies. Literature reviews, opinion papers, and editorials were also excluded.

The overall search yielded 257 published research studies. Figure 1 showed the PRISMA flow diagram for this study.^[18] These were exported to EndNote,^[19] where duplicates were excluded. A total of 79 published research studies remained. Examination of abstracts excluded 59 studies for failure to meet inclusion criteria, with 20 studies remaining for further review. Full texts of the remaining 20 studies were reviewed for inclusion. The author reviewed the reference lists of these studies, which yielded two additional research studies. Thirteen of the remaining studies were excluded following the in-depth review due to failure to meet the inclusion criteria.

Figure 1.

PRISMA screening diagram

A critical review of the remaining studies was completed using the Scoring System for Mixed Methods Research by Pluye et al.^[20] This tool was used to screen studies for relevance, reliability, and applicability to the review. Following this final review, the definitive sample for this integrative review consisted of nine studies, which underwent critical appraisal: five mixed-method studies, two qualitative studies, one retrospective research study, and one cross-sectional study. Details of each included article were included in Table 1.

Themes and outcomes were depicted in Figure 2. A total of nine studies were used in this review. All studies were published between 2014 and 2024. All studies (n = 9) explored experiences of undergraduate nursing students in the clinical environment. Additionally, all studies involved nursing students pursuing a degree that would result in a career as a registered nurse. Nearly all studies (n = 8) specifically explored student clinical experiences in acute care settings. One study did not specify the location of the student’s clinical experiences. Seven studies included qualitative questions, with two being entirely qualitative studies. Only one study (n = 1) focused specifically on the influence of clinical instructors on the clinical experience of the student. All studies (n = 9) provided recommendations for nurse educators to enhance or improve students’ clinical experiences. Very few studies (n = 1) discussed student skill development in clinical experiences. Table 2 illustrates the thematic analysis of the studies in this review.

Figure 2.

Diagram of thematic analysis

Six research studies explored the theme of students’ emotional responses to clinical experiences. The American Psychological Association (n.d.) defines emotional response as “an emotional reaction, such as happiness, fear, or sadness, to a given stimulus.” Studies that met this definition were included in this thematic analysis. The assessment of student emotional responses included excitement,^[13,21] anxiety,^[2,16] fear,^[11,15,16] concern,^[2,15] psychological distress or trauma,^[14,21] stress,^[11] nervousness,^[16,21] and insecurities.^[15,21] As clinical experiences increased, some students reported reduced fear,^[16] and greater confidence.^[8,15,16,22]

Most studies in the emotional response theme revealed adverse reactions such as stress, fear, anxiety, psychological distress, and nervousness associated with clinical experiences of undergraduate nursing students. These negative emotions may interfere with student development and learning.^[15] Repeated negative feelings associated with the clinical learning environment were also reported to leave students questioning their decision to pursue a career in nursing.^[21]

Seventy-seven percent (n = 7) of the research studies included the theme of the influence of a clinical instructor or nurse preceptor on the clinical experience of the student. The research by Donovan et al. focused centrally on the impact of clinical faculty and nursing staff on the student experience in the clinical environment.^[9] Researchers identified key behaviors that positively and negatively impacted student learning in the clinical environment. Key positive behaviors included communication, encouragement, and availability of clinical instructors. The key positive behaviors identified in this study align with findings in other studies reviewed, including George et al., Hood & Copeland, and Singer et al.^[8,21,22]

In contrast, the study by Wallace et al. explored negative behaviors exhibited by clinical instructors and nurse preceptors.^[11] These behaviors were more frequently reported as contributing to the student’s negative experiences. Nurse incivility, inconsistent instructor/preceptor expectations, and waiting for the clinical instructor/preceptor all created stress and anxiety in students. Payne reported similar findings regarding negative behaviors by clinical instructors and nurse preceptors, including a lack of interest in teaching, inadequate instructor organization, and bullying-type behaviors that impacted the students’ overall clinical learning experience.^[16]

Both Payne and Singer et al. stressed the importance of a positive relationship between the clinical instructor and the clinical partner (hospital, clinic, or community health providers).^[8,16] This relationship affected the learning environment and influenced the student experience.

Four studies contributed to the theme of student confidence and belonging in the clinical learning environment, each employing quantitative methods to assess variables such as confidence, self-efficacy, and sense of belonging. These traits are essential components of the overall student experience, influencing engagement and development in clinical settings.^[8] Cowen et al. measured student confidence in physical assessment skills at two points during an academic semester, finding that initial confidence was low but improved with clinical exposure.^[15] Similarly, George et al. examined self-efficacy, using a Likert scale to assess student confidence across 10 items at the beginning and end of a semester.^[2] While students reported increased confidence in seven areas following the clinical experience, a significant decrease in response rate between data collection points raised concerns about the validity of the findings. Singer et al. explored students’ perceived sense of belonging in the clinical environment, reporting that a sense of belonging significantly influenced confidence and willingness to participate in learning activities.^[8] This large-scale study (n = 759) highlighted that inclusion and belonging have a positive impact on students’ confidence and professional development. Finally, Leighton et al., in a literature review on student outcomes, noted that much of the existing research relies on student self-reports of clinical confidence and skill proficiency.^[4] They cautioned that confidence and competence are not synonymous, as students often overestimate their abilities.

This review included a single study that explored skill development. Quantitative data were collected on the number of psychomotor skills and physical assessments performed by students on each clinical day through self-report by students.^[6] Data was also obtained about supervision and feedback. Researchers found that students had minimal experience in the clinical environment, particularly in psychomotor skills and physical assessment skills. Additionally, Schroers et al. indicated that the lack of hands-on opportunities contributes to the trend of graduates who are unprepared for clinical practice.^[6] These findings were consistent with the results of the systematic review conducted by Leighton et al., which found no evidence to support our current clinical education model for teaching clinical skills.^[4] Information regarding students’ prior laboratory or simulation-based learning experiences was inconsistently reported across included studies and therefore could not be systematically analyzed, though such experiences may influence students’ competence and confidence in clinical settings.^[6]

Findings from this integrative review suggest that future clinical education in undergraduate nursing programs must move beyond traditional, loosely structured clinical placements toward more intentional and evidence-informed learning designs. Nursing educators and academic leaders should prioritize the development of clinical experiences that explicitly align learning objectives, supervision models, and expected student outcomes.

First, greater emphasis should be placed on preparation and support of clinical educators, including both academic faculty and nurse preceptors. Structured orientation, ongoing development in teaching strategies, and clear expectations for student supervision may enhance consistency in clinical instruction and improve student learning experiences. Investment in faculty development and academic–practice partnerships is particularly critical as programs increasingly rely on adjunct faculty and preceptor-based models.

Second, nursing programs should adopt a deliberate approach to clinical skill development by intentionally integrating skills laboratories, simulation-based learning, and in-person clinical experiences. Rather than viewing these components as separate or interchangeable, educators should design clinical curricula that support progressive skill acquisition, repeated practice, and timely feedback across learning environments. Structured clinical models, such as Dedicated Education Units, may offer opportunities to strengthen supervision, clarify expectations, and support hands-on skill development in authentic clinical settings.

Third, findings highlight the importance of relational and psychosocial aspects of the clinical learning environment, including student–instructor relationships, communication, feedback, and a sense of belonging. Clinical experiences should be designed to promote psychological safety and inclusion, as these factors influence student confidence, engagement, and willingness to participate in learning activities. Intentional strategies to foster supportive clinical environments may mitigate student anxiety and enhance professional identity formation.

Finally, nursing education leaders should critically examine clinical hour requirements and learning expectations, recognizing that the quantity of clinical hours alone does not ensure competence. Greater attention should be given to the quality, structure, and supervision of clinical experiences, as well as to how students demonstrate competence and readiness for practice. Collectively, these implications underscore the need for coordinated, evidence-based approaches to clinical education that better prepare undergraduate nursing students for professional practice.