Public knowledge of ultra-processed foods: Insights from a national survey of Australian adults.

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 [, ]. Across contexts, the quality of supervision, psychosocial interactions, and institutional support within the CLE strongly shapes students’ confidence and readiness for practice []. In 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 [, ]. 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 hospitals to meet mandatory clinical hour requirements [, ]. While this model exposes students to diverse pathologies and high patient volumes, it places them in overcrowded wards characterized by understaffing and limited resources []. Students often report a stark contrast between the controlled academic environment of their colleges and the chaotic realities of public hospital wards, intensifying the theory–practice gap and limiting opportunities for safe, supervised learning [, ]. Evidence from comparable LMIC contexts further suggests that, under such pressures, staff may perceive students as an additional burden rather than learners, weakening the supervisory relationships essential for effective clinical education [, ]. However, beyond resource limitations and supervisory strain, an important structural dimension remains insufficiently explored: the ‘pedagogical outsider’ status of private-sector nursing students who train in public-sector hospitals. Within this affiliation model, students pay for private education but enter clinical spaces where they lack institutional standing, formal preceptors, and access to protected learning opportunities. Quantitative evidence from Karachi indicates dissatisfaction with clinical experiences [], yet little is known about how this ‘guest status’ reshapes students’ learning processes, professional identity formation, and ability to progress clinically. Understanding this dynamic is essential because it may shift students from a pedagogical mode of learning to a survivalist mode, where coping with the environment takes precedence over structured skill development.