Nursing Interns’ Stress Peaks Twice, Journey Map of 19 Students Reveals

Stress among undergraduate nursing interns does not begin when they first step onto a hospital ward. According to a new qualitative study published in Frontiers in Public Health, it emerges weeks earlier, during the anxious preparation phase before the internship even starts, and it rises to two distinct peaks: one in the first month of clinical placement, and another in the final months, when career decisions and professional identity come to a head. The finding comes from a longitudinal journey mapping study that tracked the same cohort of 19 nursing interns across four stages of a ten-month internship in Sichuan Province, China.

The research team, led by authors from Chengdu Medical College and collaborating institutions, recruited full-time undergraduate nursing students who were about to begin their compulsory clinical internship at one of five tertiary hospitals. Using purposive sampling, the study enrolled 19 interns, aged 20 to 23, and interviewed each of them four times at stage-aligned time points: one week before the internship began, four weeks after it started, at 20 weeks, and at 36 weeks. In total, 76 semi-structured interviews were completed, with every participant retained through all four waves. Each interview lasted roughly 20 to 40 minutes and was conducted in real time at the corresponding phase of the internship, a design choice the researchers say was intended to minimize recall bias.

Analysis followed reflexive thematic analysis, with two researchers coding the transcripts independently and resolving discrepancies through discussion. The team then applied journey mapping, a process-oriented approach that emphasizes the temporal sequence of experiences, to organize the findings along a timeline. The resulting map divides the internship into four stages: a Preparation Period covering the two to four weeks before the placement, a Shock Period spanning the first month, an Adaptation Period covering months two through seven, and a Differentiation Period covering months eight through ten. Across these stages, the analysis extracted 36 themes organized along three dimensions: tasks, emotional experiences, and pain points.

The Preparation Period revealed a pattern the authors describe as significant: stress originates before interns encounter any clinical reality. Participants described anxiety rooted in uncertainty about the hospital environment, fear of performing invasive procedures, and self-doubt about whether their theoretical knowledge and practical skills would meet clinical requirements. One intern reported being afraid of making mistakes in operations and worried that her ability would not suffice. A second pain point involved information asymmetry, a lack of concrete understanding of what real clinical work actually involves, which left interns unable to predict the difficulties ahead. Notably, many interns already carried competing pressures before day one, including postgraduate entrance examinations, thesis writing, and job searching, which some described as colliding directly with internship demands.

The Shock Period constituted the first stress peak. Interns entering wards for the first time reported panic and nervousness during their initial procedures, with trembling hands, fear of failure, and helplessness when patients refused their care. One participant described performing a first invasive procedure in a state of panic with shaking hands. The pain points identified in this stage were primarily task-related and skill-centered: insufficient operational proficiency despite theoretical knowledge, patients’ reluctance to let interns perform procedures, a perceived disconnection between textbook standards and clinical practice, and difficulty adapting to night shifts, which several participants linked to sleep deprivation and exhaustion. The authors interpret this stage through Meleis’ Transition Theory as an acute phase of role insufficiency, in which the gap between knowing and doing becomes the central mechanism of stress.

The Adaptation Period presented what the researchers call a paradoxical profile. On one hand, most interns progressed from assisted operations to independent completion of basic nursing procedures, reported emotional stabilization, and described growing senses of achievement, with some recounting moments of patient gratitude that bolstered their confidence. On the other hand, new stressors surfaced: early burnout driven by repetitive basic tasks, conflicts among multiple responsibilities as internship schedules overlapped with exam preparation and job seeking, and marked variability in workload and teaching styles across departments and supervisors. One intern described feeling as though she were paying to work, while another noted that motivation declined as the skills learned became repetitive. The authors suggest that when interns move from being unable to perform tasks to only performing basic tasks, a lack of new learning opportunities may reduce engagement, and they propose that multi-department rotation could serve as a resource against burnout if structured to expand competency rather than merely change setting.

The Differentiation Period formed the second stress peak, and here the character of stress shifted from task-related to development-related concerns. Interns faced dual anxiety about employment and further study, with one participant identifying January through March as the peak stress period due to uncertainty over exam and interview results. The study also documented a polarization of professional identity: positive internship experiences strengthened some interns’ commitment to nursing, while negative ones pushed others toward detachment, with one intern stating she had decided to change careers and never engage in clinical nursing again. Burnout, once established, appeared to solidify in some participants. A further pain point was the perceived failure of support systems, as several interns reported that family members could not truly understand or empathize with their clinical experiences, leaving them feeling isolated at the very stage when support mattered most.

To visualize the overall trajectory, the researchers constructed a relative stress curve using a structured rating approach. Each of the 76 interview transcripts was treated as a unit of analysis, with the frequency of stress-related statements normalized per 1,000 characters of transcript and two independent researchers rating perceived intensity on a three-point ordinal scale. The product of these metrics generated individual stage scores, and the median across participants defined the group-level value at each stage. The authors emphasize that the resulting curve reflects relative changes across stages rather than absolute quantitative values, and that the two branching lines shown for the Differentiation Period are a qualitative representation of diverging trajectories driven by professional identity polarization, not precise quantitative grouping.

The study’s implications, as framed by its authors, are directed at nursing educators and clinical managers rather than at clinical treatment. Because stress emerged before the internship began, the authors suggest that the intervention window should shift earlier, with strategies such as clinical simulation, experience-sharing from senior interns, and comprehensive introductions to departmental workflows potentially reducing information gaps. For the shock stage, they propose standardized onboarding and stepwise training models that gradually increase autonomy. For the adaptation stage, they discuss embedding psychological early-warning mechanisms into rotation processes, with regular touchpoint-based screening to track interns’ emotional status. For the differentiation stage, they suggest phase-specific career guidance and a tripartite collaborative model involving schools, clinical institutions, and families. The authors are careful to note that several of these proposals, including a graded night shift exposure strategy, are potential practice directions derived from the findings rather than empirically tested interventions.

The study carries important limitations. Participants were drawn exclusively from five tertiary hospitals in Sichuan Province, a setting that may differ substantially from secondary hospitals, community-based healthcare settings, and other regions in clinical workload and teaching resources, so the transferability of the findings requires further investigation. The authors also note that the journey map itself requires validation across diverse clinical settings, educational contexts, and nursing student populations. As a qualitative study of 19 interns in one Chinese province, the work does not establish causal relationships or quantify stress prevalence, but it offers a detailed, stage-by-stage account of how internship stress evolves, and it identifies the pre-internship period, often overlooked in research that captures stress at single time points, as the first critical window for supporting students through one of the most demanding transitions in nursing education.

Subject of Research: Stage-based trajectory of internship stress among undergraduate nursing interns

Article Title: A journey mapping study of internship stress among undergraduate nursing interns

Article References: Cheng, Y., Zeng, R., Li, Y., Huang, Y., Wang, H., Zhao, Y., Jiang, W., & Yang, Q. (2026). A journey mapping study of internship stress among undergraduate nursing interns. Frontiers in Public Health, 14, Article 1958747. https://doi.org/10.3389/fpubh.2026.1958747

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1958747

Keywords: nursing interns, internship stress, journey mapping, qualitative research, transition theory, nursing education, burnout, professional identity, clinical placement, Sichuan China, semi-structured interviews, stress trajectory