Concealing, Connecting, and Confronting: A Reflexive Inquiry into Mental Health and Wellbeing Among Undergraduate Nursing Students.

Abstract

Background: Undergraduate nursing students (UNSs) often enter clinical training just as they are still mastering the emotional labor of the profession. In Nepal, where teaching hierarchies discourage upward dialogue and hospitals routinely struggle with overcrowding, supply shortages, and outward nurse migration, these learners confront a distinct, under-documented burden of psychological distress. Objective: This study examines how UNSs interpret, negotiate, and cope with the mental health challenges that arise at the intersection of cultural deference, resource scarcity, and migration-fueled uncertainty. Methods: A qualitative design employing reflexive thematic analysis (RTA), guided by the Reflexive Thematic Analysis Reporting Guidelines (RTARG), was used. Fifteen second-, third-, and fourth-year Bachelor of Science in Nursing students at a major urban tertiary institution in Nepal were purposively recruited via on-campus digital flyers and brief in-class announcements that directed students (by QR code) to a secure sign-up form. Participants then completed semi-structured interviews; audio files were transcribed verbatim and iteratively analyzed through an inductive, reflexive coding process to ensure methodological rigor. Results: Four themes portray a continuum from silenced struggle to systemic constraint. First, Shrouded Voices, Quiet Connections captures how students confide only in trusted peers, fearing that formal disclosure could be perceived as weakness or incompetence. Second, Performing Resilience: Masking Authentic Struggles describes the institutional narratives of "strong nurses" that drive students to suppress anxiety, adopting scripted positivity to satisfy assessment expectations. Third, Power, Hierarchy, and the Weight of Tradition reveals that strict authority gradients inhibit questions in classrooms and clinical placements, leaving stress unvoiced and unaddressed. Finally, Overshadowed by Systemic Realities shows how chronic understaffing, equipment shortages, and patient poverty compel students to prioritize patients' hardships, normalizing self-neglect. Conclusions: Psychological distress among Nepalese UNSs is not an individual failing but a product of structural silence and resource poverty. Educators and policymakers must move beyond resilience-only rhetoric toward concrete reforms that dismantle punitive hierarchies, create confidential support avenues, and embed collaborative pedagogy. Institutional accountability-through regulated workloads, faculty-endorsed wellbeing forums, and systematic mentoring-can shift mental health care from a private struggle to a shared professional responsibility. Multi-site studies across low- and middle-income countries are now essential for testing such system-level interventions and building a globally resilient, compassionate nursing workforce.