Nursing remains central to healthcare delivery, yet in countries like Pakistan, systemic barriers such as underinvestment, stigma, and limited clinical exposure hinder workforce development. This multi-themed compilation explores critical areas in nursing education and practice, highlighting challenges and solutions to building a resilient, patient-centered nursing workforce. A study on electroconvulsive therapy (ECT) among 107 nursing students in Lahore revealed prevalent misconceptions, stressing the need for enhanced mental health education. Similarly, cardiopulmonary resuscitation (CPR) training at S.V. Memorial College, Amritsar, demonstrated significant knowledge gains post-intervention, reinforcing the value of early emergency preparedness education. A systematic review on burnout found high stress levels among nursing students due to academic overload and clinical fatigue, exacerbated by personal and environmental stressors. Patient satisfaction studies at Saidu group of teaching hospital (SGTH) and Children’s hospital Lahore emphasized the importance of communication, empathy, and privacy, while another study exposed underreporting of needlestick injuries, highlighting occupational safety gaps. A survey in Swat identified intrinsic motivation and role models as key factors influencing nursing career choices. Qualitative findings on leadership barriers, resource scarcity, gender bias, and political interference further revealed structural issues affecting nursing effectiveness. Modern approaches, including simulation-based training for workplace violence and digital engagement through nursefluencers, showed promise in shaping professional identity. Additionally, wildfire smoke exposure studies underlined the urgent need for adaptable, environment-informed nursing strategies. Strategically enhancing nursing leadership, addressing stigma, improving training, and aligning curricula with modern realities will help shape a resilient and empowered nursing workforce, ready to meet the healthcare demands of tomorrow.

Electroconvulsive therapy, Cardiopulmonary resuscitation, Burnout, Patient satisfaction, Parent satisfaction, Needlestick injuries, Infection control, Nursefluencers, Asthma.

Nursing, a profession central to healthcare delivery, continues to evolve in response to societal needs, clinical advancements, and global challenges. From mental health care and emergency response to infection control and environmental health, nurses play a pivotal role. However, the field faces persistent obstacles, particularly in countries like Pakistan, where systemic limitations hinder the development of a robust and well-prepared nursing workforce. Addressing these challenges requires a comprehensive understanding of key issues such as education, patient care, leadership, safety, and professional identity formation.

ECT: Demystifying mental health interventions
ECT remains a valuable non-pharmacological intervention for severe psychiatric conditions like major depression, particularly when medications fail. Although ECT has historically been controversial due to earlier misuse and public misconceptions, modern ECT is safe, regulated, and administered under general anesthesia with muscle relaxants. Technological advances in electrode placement and monitoring have significantly reduced cognitive side effects. Despite these improvements, negative perceptions persist, especially among nurses and nursing students. This resistance often stems from limited exposure and inadequate understanding of ECT. As nursing students frequently interact with psychiatric patients, their informed perspectives are critical to demystifying the procedure and improving mental health care. Educational strategies such as lectures, video demonstrations, and supervised clinical exposure can enhance both attitudes and knowledge, contributing to better patient outcomes.[1-5]

Amjad A et al. conducted a cross-sectional study from September to December 2021 at Lahore School of Nursing (University of Lahore) and Bahria Town School of Nursing to assess knowledge and attitudes regarding ECT. The total population included 146 nursing students: 123 from Lahore School (3rd year, 4th year, and 2nd year Post-RN) and 23 from Bahria Town School (3rd year BSN). A total of 107 students participated. Results revealed significant gaps in knowledge, particularly regarding ECT’s effectiveness, indications, and side effects. While over 70% correctly answered “What is ECT?” and “Where is it applied?”, knowledge of treatment duration and clinical use remained poor.[6]

Attitudes toward ECT were mixed. Nearly half (49.5%) strongly agreed that ECT is dangerous, and the same percentage found it cruel. Additionally, 32.7% believed it should be outlawed. However, 72% of participants stated they would recommend ECT to a relative if advised by a healthcare provider. Many students remained neutral on whether ECT is inhumane or overused. These findings highlight the urgent need for improved education on ECT within nursing curricula to address misconceptions and prepare students for informed patient care. Lack of knowledge may lead to perpetuating stigma and misinformation among patients.[6]

CPR training: Building emergency awareness
CPR is a lifesaving skill vital for responding to sudden cardiac arrest (SCA). Early intervention through chest compressions and defibrillation significantly improves survival chances. While once reserved for healthcare providers, CPR training has now become a universal requirement, especially in community settings. Nurses, as front-line responders, must maintain up-to-date CPR skills through regular training. Integrating CPR into early nursing education boosts students’ confidence and competence, ensuring they are prepared to manage emergencies in diverse clinical environments.[7,8]

CPR knowledge before and after a structured teaching cum demonstration programme (STP) was evaluated in a quasi-experimental study. This study was conducted at S.V. Memorial College of Nursing, Amritsar, using convenient sampling. Sixty nursing students participated. A structured questionnaire (KR-20 = 0.87) was used in this study. The questionnaire included demographic details and multiple-choice questions on CPR. Data were collected in three stages: pre-test, STP implementation with CPR demonstration, and post-test conducted after 7 days.[9]

Before the intervention, only 10% of students had good CPR knowledge, with 45% scoring poorly. After the STP, 50% had good knowledge and 35% scored very good, showing significant improvement. Demographic analysis showed most students were female (60%), rural (60%), and had biology in their 12th-grade stream (60%). Chi-square analysis revealed a significant association between prior CPR knowledge and source of information with post-test scores (p < 0.05), while variables like age, gender, education, and residence showed no significant correlation.[9]

Burnout: A hidden threat in nursing education
Burnout is a growing concern in nursing education and practice. It is characterized by emotional exhaustion, depersonalization, and a sense of reduced accomplishment due to prolonged academic or occupational stress. Nursing students often encounter high expectations, emotional strain from clinical exposure, and intense academic workload factors that contribute to burnout. Left unaddressed, burnout compromises academic performance, clinical judgment, and long-term career sustainability. Globally, burnout among nurses has been linked to increased rates of depression, attrition, and even suicide. Institutions must adopt proactive strategies such as mental health support, workload adjustments, and fostering positive clinical learning environments to mitigate burnout and ensure student well-being.[10]

A systematic review revealed high burnout levels among undergraduate nursing students. Across multiple studies, 60–94% of students experienced moderate to high burnout, with emotional exhaustion, depersonalization, and reduced professional efficacy being the most affected dimensions. Factors contributing to burnout include academic overload, poor sleep quality, internet overuse, lack of clinical preparedness, regret over career choice, and emotional stress from patient care. Clinical placements intensify stress due to unfamiliar environments, time pressure, and emotionally demanding situations. Students with less clinical experience reported higher burnout levels.[11]

Burnout also showed demographic associations: younger and female students often reported higher rates. Personal circumstances such as financial strain, living conditions, and lack of work experience further aggravated stress. Consequences of burnout included poor academic performance, absenteeism, diminished patient care, and increased dropout rates. Students frequently resorted to unhealthy coping mechanisms like alcohol use and sleep avoidance. Ultimately, burnout weakens professional identity, emotional resilience, and the ability to transition from student to competent nurse.[11]

Patient satisfaction: The heart of quality care
Patient satisfaction is a critical indicator of care quality, especially in high-stakes settings like surgical units. Postoperative nursing care must encompass not just medical management, but also empathy, clear communication, and responsiveness. When nurses fail to meet this expectation, such as through delayed care or poor communication, patient satisfaction and recovery can be adversely affected. Improving satisfaction involves a multidimensional approach: strengthening patient-centered care, refining nurse communication skills, ensuring adequate staffing, and training nurses to deliver compassionate care. Hospitals that prioritize these areas witness better clinical outcomes and higher patient trust.[12]

Shah Hussain et al. performed a quantitative cross-sectional study in SGTH, Northwest Pakistan, from June to August 2024 to assess patient satisfaction with nursing care. Using convenience sampling, 350 postoperative surgical patients aged 18–60 years who had been admitted for at least 48 hours participated. Data were collected through a structured, author-developed questionnaire covering aspects like communication, responsiveness, empathy, pain management, professionalism, and privacy, rated on a 5-point Likert scale. Analysis via the Statistical Package for the Social Sciences (SPSS) v27 revealed that overall nursing care satisfaction was high (mean = 3.94 ± 0.83), with the highest ratings in cleanliness (mean = 4.10) and respect for privacy (mean = 4.12). [13]

Occupational safety: The needlestick injury crisis
Needlestick injuries (NSIs) remain a major occupational hazard for nursing interns and students. These incidents expose individuals to bloodborne infections such as hepatitis B, hepatitis C, and HIV. A 2023 study in Pakistan revealed that approximately 66.4% of NSIs go unreported, pointing to serious underreporting and systemic gaps in safety culture. Educational programs must prioritize practical safety skills, proper handling of sharps, and a non-punitive environment that encourages incident reporting. Bridging institutional disparities and standardizing safety protocols can greatly reduce NSI risk, enhancing the overall safety of clinical education.[14]

Aqsa et al. assessed the knowledge, attitudes, and practices (KAP) of 184 nursing interns regarding NSIs at SGTH, Swat, Pakistan, through a cross-sectional descriptive study. Participants were selected via convenience sampling, and data were collected over one month using a self-administered, paper-based questionnaire consisting of demographic details, knowledge, and attitude items. Ethical clearance was obtained, and all participants provided informed consent, ensuring confidentiality and anonymity. Data were analyzed using SPSS v26.0, with descriptive and inferential statistics applied. Most participants were aged 29–30 years (59.2%) and male (90%). Knowledge levels were moderate among 51.6% of interns, while 21.7% displayed negative attitudes toward NSIs. The study highlights the need for targeted educational interventions to improve safety practices.[15]

Professional commitment and career motivation
Nursing students’ professional choices and commitment are shaped by intrinsic motivation, societal views, educational quality, and perceived career stability. While some are drawn by a sense of purpose, others are influenced by job availability or family expectations. Unfortunately, in some cultures, nursing is undervalued or stereotyped as a female-only occupation, which can discourage potential candidates. Positive interactions with faculty, inspiring mentors, and enriching clinical placements foster greater professional engagement. Creating an educational environment that respects nursing’s societal value is essential for nurturing a committed and motivated nursing workforce.[16,17]

Sohail R et al. conducted a cross-sectional quantitative study in Swat, Pakistan (June–August 2024), to identify factors influencing nursing students’ career choices. Three hundred undergraduate students from public and private nursing colleges were selected via convenience sampling. Participants were mostly male (70%) and aged 18–22 (40%), with first-year students forming 33.3% of the sample. Key motivating factors included the desire to help others (75%) and perceived job security (78.4%). Role models, family influence, and earning potential were also significant. Mean scores showed strong agreement for intrinsic motivations (desire to help others: 3.92) and moderate for extrinsic ones (income security: 3.62). Chi-square tests revealed significant associations between age, gender, academic year, and influencing factors like passion for helping others and role model impact. Overall, students reported a high level of satisfaction with their career choice, shaped by personal values, social perceptions, and supportive environments. Findings suggest that tailored educational strategies and mentorship can further guide and reinforce informed nursing career decisions.[18]

Leadership in nursing: Systemic challenges and opportunities
Nursing leadership in Pakistan is plagued by systemic issues, political instability, economic hardship, gender disparities, and inadequate infrastructure. Leaders often face high-pressure environments with limited emotional support, contributing to burnout and reduced effectiveness. These problems are magnified by chronic staff shortages, poor resource distribution, and bureaucratic inertia. Effective leadership is key to healthcare delivery and workforce retention. Developing strong nursing leaders requires targeted investment in leadership training, policy advocacy, and integrating evidence-based practice. Institutions must prioritize leadership development as a national health strategy to ensure better clinical governance.[19]

A qualitative study explored challenges in nursing leadership within public tertiary hospitals in Swat, Pakistan, using semi-structured interviews with 15 nurse leaders in various roles. Data were collected through one-on-one interviews and analyzed using Braun and Clarke’s thematic method. Key themes included resource limitations, staffing shortages, lack of leadership training, gender barriers, bureaucratic delays, and political interference. Participants highlighted the difficulty of managing care without essential supplies or adequate staff. Many leaders lacked formal training and leadership skills on the job. Female leaders faced gender-based resistance, and bureaucratic hurdles limited timely decision-making. Political involvement often disrupts institutional plans. These systemic issues undermined leadership effectiveness, resulting in staff burnout, poor morale, and reduced care quality.[20]

Parent satisfaction in pediatric care
In pediatric settings, parent satisfaction serves as a crucial measure of nursing care quality. Effective communication, empathy, and emotional support from nurses significantly influence parental trust and engagement in their child’s treatment. When parents are well-informed and actively involved, they report higher satisfaction, which correlates with improved pediatric outcomes. Hospital experiences vary based on disease severity, cultural background, and socioeconomic status. Understanding these factors enables nurses to deliver more tailored care. Enhancing pediatric nursing practices through training, communication skills development, and family-centered models ensures better healthcare experiences and outcomes for both children and families.[21]

Hina M et al. carried out a descriptive cross-sectional study in the Children’s Hospital Lahore to measure parent satisfaction with nursing care in pediatric units. Using convenience sampling, 306 parents of children were hospitalized for at least 24 hours in general pediatric wards; the pediatric ICU and HDU were included. Data were collected via a structured questionnaire covering communication, professionalism, responsiveness, emotional support, and overall care. Results showed high satisfaction, especially in professionalism (88%) and communication (85%). Higher satisfaction was linked to older age, higher education, and socioeconomic status. Gender had no significant effect. Satisfaction was highest in the pediatric ICU (mean = 4.2). Ethical approval was obtained, and informed consent was secured from all participants.[22]

Infection control: Foundational nursing practice
Infection control remains central to healthcare, safety, and quality. Healthcare-associated infections (HAIs) lead to increased patient morbidity, longer hospital stays, and higher costs. Rooted in Florence Nightingale’s pioneering sanitary reforms, modern infection control practices focus on hand hygiene, use of PPE, and proper disinfection protocols. Despite established guidelines, compliance challenges often remain due to long hours, limited staffing, and a lack of adequate facilities. Continuous education, supportive infrastructure, and organizational commitment are vital to improving infection prevention, which in turn enhances patient outcomes and healthcare system efficiency.[23]

Nurses’ infection control practices and their perceived impact on patient health outcomes were determined using a quantitative cross-sectional study at SGTH, Peshawar. Using purposive sampling, 200 registered nurses with at least one year of clinical experience from various departments were selected. Findings showed high adherence to infection control practices, with hand hygiene scoring highest (mean: 4.5). Nurses strongly believed effective practices reduced hospital-acquired infections (mean: 4.6) and improved outcomes. However, the barriers included heavy workloads (42.5%) and insufficient staffing (30%). Ethical approval was secured, and informed consent was obtained from all participants. The study highlights the positive impact of infection control efforts and the systemic challenges that limit full compliance.[24]

Promoting self-directed learning (SDL)
To navigate the dynamic demands of modern healthcare, nursing students must become independent, lifelong learners. Self-directed learning (SDL) cultivates critical thinking, adaptability, and clinical competence. Its success relies on intrinsic motivation, faculty support, access to resources, and flexible curricula. Research confirms that students practicing SDL perform better academically and clinically. However, rigid educational models, insufficient mentorship, and time constraints often hinder its implementation. Embedding SDL within nursing education not only improves student outcomes but also ensures a more agile, resilient nursing workforce prepared for future healthcare challenges.[25]

Asaf S et al. demonstrated SDL abilities and academic performance among nursing students at Pak Swiss Nursing College and Swat College of Nursing using a descriptive cross-sectional correlational study. This study was conducted over six months (April-September 2024). Using a random sampling method, 180 second to fourth-year students participated. Most students were male (88.9%) and aged 23–25 years (49.4%). The majority were unmarried (83.3%) and lived off-campus (72.2%). Most had completed their intermediate education in private institutions (68.3%). Academic performance showed most students had grade point average (GPA) scores in the B (3.1) and B+ (3.45) ranges. SDL scores revealed that 51.6% had a high SDL aptitude, while 46.6% were in the average range. The mean SDL score was 147.74. Statistical analysis showed a significant relationship between SDL and academic performance (p < 0.001). Students from government institutions and younger age groups performed better. However, gender, marital status, and living conditions had no significant impact on cumulative grade point average (CGPA).[26]

The workforce crisis: Shortages and workplace violence
Pakistan faces a dire nursing workforce shortage, with one of the lowest nurse-to-patient ratios globally. This deficiency results in overburdened staff, substandard patient care, and burnout, especially in rural areas. Decades of underinvestment and a lack of strategic workforce planning have compounded the crisis. Immediate national reforms in recruitment, retention, and professional development are urgently needed. Simultaneously, workplace violence (WPV) against nurses, ranging from verbal abuse to physical assault, further threatens safety and retention. Globally, nearly 40% of healthcare workers report physical abuse, with even higher rates of verbal harassment. In Pakistan, the absence of safety protocols and training exacerbates the issue, particularly for nursing students who are often unprepared for hostile environments. Simulation-based education offers a promising solution. Through immersive, realistic scenarios, students can develop de-escalation skills, communication strategies, and emotional resilience. Though widely adopted in developed countries, such approaches remain underutilized in Pakistan. Expanding access to simulation training is crucial for building safe, effective nursing professionals.[27]

A cross-sectional descriptive correlational study was conducted among 320 nursing students from public and private colleges in Swat, Pakistan, to assess their perceptions of simulation-based training for WPV. Using stratified random sampling and a validated, pilot-tested questionnaire, the researchers gathered demographic data and views on simulation realism, emotional preparedness, and skill development. Students were eligible if they had attended at least one WPV simulation session. Data were collected over two weeks and analyzed using SPSS v27.

Results showed that 82.5% found simulations realistic, 77.8% felt more emotionally prepared, and 86.9% believed the training reflected real hospital settings. Most (80.6%) felt better prepared to handle WPV, and 92% recommended simulations for all nursing students. Correlation analysis showed a strong positive link between simulation exposure and both perceived readiness (r = 0.614) and emotional confidence (r = 0.538), confirming the training’s effectiveness in preparing students for real-world WPV situations.[28]

The rise of nursefluencers and digital identity formation
In today’s digital age, nursefluencers, registered nurses who share health content on social media platforms like TikTok and Instagram, are shaping public and student perceptions of the profession. These influencers share unfiltered insights into clinical life, advocacy, and personal experiences, often reaching audiences far beyond traditional classrooms. For new nursing students, such content plays a role in professional identity formation (PIF). While online narratives can inspire and foster community, they also risk spreading misinformation or glamorizing nursing. Educators must acknowledge these influences and integrate digital media literacy into curricula to ensure students develop an informed, ethical, and grounded sense of professional identity.[29]

Sabha NU et al. examined how nursefluencer content on social media impacts professional identity formation among first-year nursing students in Swat, Pakistan. In this quantitative cross-sectional study, using stratified random sampling, 320 students from public and private institutions were surveyed. Participants were selected based on social media access and excluded if they had prior healthcare experience. Most students were male (69.4%), aged 20–21 (48.1%), and enrolled in private colleges (89.1%). All social media are used, with TikTok being the most popular (85.9%), followed by Instagram and YouTube.

Nursefluencer content, especially clinical tutorials and day-in-the-life videos, was frequently viewed by 44.4% of students. Professional identity scores were highest among students with greater content exposure (M = 4.18), showing a strong positive correlation (r = 0.612, p < 0.001). Time spent on social media also moderately correlated with professional identity formation (r = 0.398, p < 0.01). Findings suggest digital engagement with nursefluencers positively shapes students’ early professional development.[30]

Environmental health: Nurses and wildfire-related asthma
With climate change driving more frequent wildfires, exposure to fine particulate matter (PM2.5) poses serious health risks, particularly for individuals with asthma. Wildfire smoke exacerbates respiratory conditions, leading to increased hospitalizations and emergency visits. Despite this, research on the role of nursing interventions in such crises remains limited. Nurses are often first responders during environmental emergencies. Their roles in patient education, medication management, and early symptom identification are essential in mitigating asthma severity. Developing evidence-based nursing strategies for wildfire-related asthma can inform public health planning and improve patient outcomes amid environmental threats.[31]

How exposure to wildfire smoke affects the effectiveness of nursing interventions in asthma management was assessed using a cross-sectional correlational study. This study was conducted at SGTH on a total of 80 adult asthmatic patients from wildfire-affected regions who were selected using convenience sampling. Inclusion criteria require patients aged 18 or older who have a confirmed asthma diagnosis and who reside in wildfire-exposed areas for at least one year. The average overall effectiveness score of nursing interventions was 7.9 ± 1.4 out of 10, with inhaler technique reinforcement scoring highest (8.1 ± 1.1). However, statistical analysis using Pearson correlation showed a significant negative relationship between wildfire smoke exposure frequency and intervention outcomes. Increased exposure correlated with reduced effectiveness in asthma education (r = -0.41, p = 0.002), inhaler support (r = -0.38, p = 0.004), trigger counseling (r = -0.35, p = 0.007), and overall intervention success (r = -0.44, p = 0.001). These findings indicate that frequent wildfire smoke exposure can diminish the impact of standard nurse-led asthma interventions, underscoring the need for tailored care approaches during wildfire seasons.[32]

Table 1: Key nursing issues and research findings

Recommendations
To address the multifaceted challenges facing nursing in Pakistan, several key recommendations are proposed. First, nursing education must be strengthened through the integration of simulation-based learning, which enhances students’ clinical preparedness and equips them to manage workplace violence effectively. Encouraging SDL within academic curricula, supported by faculty mentorship and access to appropriate resources, will help foster critical thinking and lifelong learning. Additionally, specialized content such as Electroconvulsive Therapy and climate-related respiratory care should be included to expand clinical competencies.

To alleviate workforce shortages, national recruitment and retention strategies must be developed, particularly targeting rural and underserved regions. Financial incentives and scholarship programs can encourage more students to pursue and remain in the nursing profession. Enhancing workplace safety and well-being is also essential. Mandatory training on needlestick injury prevention, effective reporting protocols, and stress reduction programs should be established to support nurses’ physical and mental health.

Given the increasing influence of social media, media literacy should be incorporated into nursing education to help students critically evaluate content from nurse influencers and avoid misinformation. Furthermore, leadership development initiatives focusing on communication, decision-making, and policy advocacy will empower nurses to take on stronger roles in healthcare governance. Finally, ongoing infection control education and adequate staffing must be prioritized to ensure high standards of patient safety.

Nursing in Pakistan faces mounting challenges due to workforce shortages, underinvestment, and a low nurse-to-patient ratio, especially in rural areas. These factors contribute to burnout, care delays, and diminished health outcomes. Nursing students endure academic stress, emotional fatigue, and exposure to patient deaths, while nearly 40% of healthcare workers face WPV, for which students are often unprepared.

Simulation-based learning and SDL offer promising solutions by improving conflict management, clinical readiness, and adaptability. However, rigid curricula and limited institutional support hinder their full implementation. Social media “nursefluencers” also shape students’ professional identity, offering both insight and potential misinformation.

Essential clinical skills such as CPR training and infection control remain foundational, yet safety gaps like NSIs persist. Specialized domains, including ECT and climate-related asthma care, are underemphasized. Addressing these challenges through targeted educational reforms, leadership development, and mental health support is crucial to building a competent, resilient, and future-ready nursing workforce.

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Corresponding Author:
Samatha Ampeti, PhD
Department of Pharmacology
Kakatiya University, University College of Pharmaceutical Sciences, Warangal, TS, India
Email: ampetisamatha9@gmail.com

Co-Authors:
Raziya Begum Sheikh, Mansi Srivastava, Patel Nirali Kirankumar, Shubham Ravindra Sali
Independent Researcher, Department of Content
medtigo India Pvt Ltd, Pune, India

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

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https://doi.org/10.63096/medtigo3061233

Raziya BS, Samatha A, Mansi S, Patel NK, Shubham RS. Contemporary Challenges and Evolving Roles in Nursing Education and Practice. medtigo J Pharmacol. 2025;2(3):e3061233. doi:10.63096/medtigo3061233 Crossref