This study employed a qualitative descriptive design[13, 14], situated within a constructivist paradigm. Qualitative description is the methodology of choice when the goal is to provide a comprehensive, low-inference summary of events in the everyday terms of those events, staying close to the data while allowing for interpretative depth[15]. This approach aligns with our objective to capture the straightforward yet nuanced lived experiences of male nursing students without imposing a restrictive theoretical framework. Reflexive Thematic Analysis (RTA)[16] was utilized as the method for data analysis. The reporting of this study adheres to the Reflexive Thematic Analysis Reporting Guidelines (RTARG)[17].

Data were analyzed following the six phases of Reflexive Thematic Analysis[16, 19]:

(1) Familiarization: Immersion in the data through repeated reading of transcripts;(2) Coding: Systematic, inductive coding of the entire dataset, focusing on both semantic (explicit) and latent (conceptual) meanings regarding professional identity and gender; (3) Constructing Themes: Collating codes to identify patterns of shared meaning, moving beyond topic summaries to conceptual stories (e.g., "The Double-Edged Sword"); (4) Reviewing Themes: Checking candidate themes against the dataset for coherence and distinctiveness; (5) Defining and Naming Themes: Refining the essence of each theme; (6) Producing the Report: Weaving data extracts with analytic narrative.

NVivo 14 software facilitated data management, but the interpretative work was driven by the researchers.

The study was approved by the Ethics Committee of Shandong First Medical University (Approval No. R202410160298). Written informed consent was obtained from all participants. Confidentiality was ensured by anonymizing transcripts and using pseudonyms in all reports.

Thirteen male nursing students participated in the study. All were undergraduate students from a medical university in China, aged 22 to 23 years. To maintain anonymity, participants are identified by codes P1 through P13 based on the interview sequence. Detailed demographic information is provided in Table 1.

Through reflexive thematic analysis, we constructed three overarching themes that capture the trajectory of male nursing students' professional identity formation: (1) The Crucible of Practice, (2) The Double-Edged Sword of Gender, and (3) From Adversity to Pragmatism. These themes do not represent a linear progression but rather intersecting dimensions of their lived experience, illustrating how they navigate the complex terrain of clinical reality. A visual representation of the thematic structure is presented in Fig. 1.

This theme encapsulates the profound cognitive and emotional restructuring students undergo upon entering the clinical environment. The internship acts as a "crucible" where idealized textbook knowledge clashes with the chaotic reality of hospital work, forcing a rapid adaptation to high-stakes responsibility.

Participants described a jarring disconnect between the linear, standardized procedures taught in classrooms and the dynamic, multitasking nature of clinical practice. The transition required them to shift from a "single-threaded" learning mode to simultaneously managing documentation, technical procedures, and patient interaction. This gap was often experienced as a sense of unpreparedness.

As male interns, participants faced a "trust deficit" from patients and families. Unlike the idealized "humanistic care" models, real-world communication often involved managing skepticism, non-cooperation, or even hostility. Students described the emotional labor required to proactively "earn" trust, moving beyond their technical competence to prove their reliability.

The internship exposed students to the raw vulnerability of human life. Participants recounted vivid memories of trauma, death, and occupational hazards (e.g., needlestick injuries). These experiences triggered intense ethical reflection and emotional turmoil, ranging from helplessness to panic, which became pivotal moments in their maturation.

This theme highlights the paradoxical nature of being a male in a female-dominated profession. Gender acted as both a barrier and a resource—restricting learning opportunities in some contexts while providing distinct advantages in others.

Gender bias manifested as operational restrictions, particularly in obstetrics and gynecology, where male students were often excluded from procedures to protect female patient privacy. Additionally, participants felt they had to work harder to overcome the stereotype that men are inherently "careless" or less suited for delicate nursing tasks.

Participants noted that their physical strength was often "instrumentalized" by the clinical team. While they accepted this role, they recognized that it sometimes reinforced a gendered division of labor where they were valued more for their "muscle" (e.g., lifting patients, moving equipment) than for their clinical acumen.

Conversely, participants perceived their gender as a distinct asset in high-pressure environments like the Emergency Department. They described themselves as being viewed as the "anchor" or backbone of the team—offering emotional stability, stress resilience, and rapid execution. This perception directly boosted their confidence in the job market, where they felt "sought after."

The final theme illustrates the dynamic evolution of the students' professional identity. It describes a shift from passive anxiety to proactive adaptation, culminating in a pragmatic, calculated approach to their future careers.

Over time, participants developed strategies to overcome initial barriers. They shifted from being passive observers to active agents who sought out learning opportunities, asked questions, and demonstrated their competence to win over skeptical mentors and patients.

Professional identity was not static but fluctuated between moments of profound pride and disillusionment. While successful patient interactions reinforced their sense of mission, low salary expectations and high workloads often reduced nursing to merely "a means of making a living." This duality reflects a pragmatic reconciliation with the profession's reality.

Our first theme, "The Crucible of Practice," underscores that the internship is not merely a venue for skill acquisition but a profound "liminal space" for professional socialization[5]. While the "theory-practice gap" is a universal phenomenon in nursing education[21], our analysis reveals that for male students, this gap is compounded by a specific "trust deficit." Unlike their female counterparts who are often culturally assumed to be "natural caregivers," male students must perform extra emotional labor to legitimate their presence and "earn" patient trust [22]. This aligns with Benner’s[23] framework but adds a gendered dimension: male novices must not only learn how to nurse but also learn how to be accepted as a nurse. The emotional shocks reported—trauma, helplessness, and ethical dilemmas—further catalyze this maturation, serving as critical incidents that force a shift from idealized student thinking to the resilience required of a practitioner.

The "Double-Edged Sword" theme offers a nuanced understanding of how gender operates in nursing. Participants faced structural barriers (e.g., exclusion from obstetrics) consistent with the concept of "role strain" in cross-gender professions[1]. However, crucially, they did not reject their masculinity to fit in; rather, they instrumentalized it. By accepting roles as the "muscle" or the "anchor", they engaged in what Butler[24] might describe as a "performative" negotiation of gender. They strategically aligned their professional identity with traditional masculine traits—strength, emotional stability, and technical competence (especially in ER/ICU settings)—to carve out a legitimate niche within the feminized hierarchy. This strategy allows them to resolve the "double bind" of their identity: remaining "men" while becoming "nurses"[24, 25].

The final theme, "From Adversity to Pragmatism," reveals a distinct form of professional commitment. Unlike the vocational "calling" often associated with nursing history, these male students exhibited what we term "calculated pragmatism." Their decision to stay in nursing was often driven less by intrinsic passion than by extrinsic stability and employability in a volatile economic climate[26]. This finding offers a critical counter-narrative to studies linking low professional identity solely to turnover[27]. Our participants demonstrated that one can have a "wavering" identity yet a "stable" career plan. This pragmatic stance serves as a protective mechanism, allowing them to detach from the emotional exhaustion of the job while valuing its socioeconomic benefits. It suggests that retention strategies for men should perhaps focus less on "inspiring passion" and more on clear career pathways and stability[3].

Consistent with the qualitative descriptive tradition, these findings offer a rich, context-specific account of a particular cohort in China and do not claim statistical generalizability. The sample was drawn from a single university system, potentially limiting the transferability to other regions with different cultural norms. Additionally, as a cross-sectional study, it captures a "snapshot" of identity formation. Future research should employ longitudinal designs to track how this "pragmatic" identity evolves as these men transition from students to registered nurses.

To support this "anchor" of the future workforce, nursing educators should acknowledge the specific "trust deficit" male students face and provide communication training tailored to overcoming gender bias. Clinical managers should be wary of "instrumentalizing" male students solely for physical labor, ensuring instead that they receive equitable opportunities for holistic skill development. Finally, recognizing their pragmatic career motivations, retention policies should emphasize clear career progression pathways and the stability of the profession.