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Keywords:

  • Clinical Experience;
  • Occupational Stress;
  • Nurse Education;
  • Quantitative Research

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Method
  6. Results
  7. Discussion
  8. Author contributions
  9. References

PULIDO-MARTOS M., AUGUSTO-LANDA J.M. & LOPEZ-ZAFRA E. (2011) Sources of stress in nursing students: a systematic review of quantitative studies. International Nursing Review59, 15–25

Aim:  This study aimed to identify the main sources of stress for students of nursing and the evolution of the stressors when training in nursing competences.

Background:  Levels of stress are higher for health professionals than for other workers. A higher number of stressors with negative health consequences are present, especially among nursing professionals. Stress is a psychosocial factor that influences the academic performance and well-being of this group. The interest in analysing sources of stress in nursing students is due to the influence that their training period may have on their perceptions of stress on their future work.

Methods:  We conducted a systematic review of the scientific literature on stressors in nursing students. The search comprised all the articles published at the end of 2010.

Results:  The most common sources of stress relate to academics (reviews, workload and problems associated with studying, among others). Other sources of stress include clinical sources (such as fear of unknown situations, mistakes with patients or handling of technical equipment). In general, no changes occur at the different years of the student's education.

Conclusion:  Comparing studies is difficult because of the differences among them (designs, instruments, number of stressors, etc.). However, our revision gives a current state-of-the-art and includes descriptive information that might be very useful for future research. Furthermore, we offer some recommendations for improving the design of curricula taking into account sources of stress.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Method
  6. Results
  7. Discussion
  8. Author contributions
  9. References

Stress refers to a dynamic interaction between the individual and the environment. In this interaction, demands, limitations and opportunities related to work may be perceived as threatening to surpass the individual's resources and skills (Kohler et al. 2006). In case of disarrangement, this interaction may lead to cognitive, emotional and behavioural alterations.

Nursing students face not only academic stress but stress at work during their training period. One focus of interest in research on stress at work is the sources of stress, or stressors, which interact and contribute to the onset of stress in organizational settings (Spielberger & Reheiser 2005). Some of the most common stressors are time pressures, workload, making decisions, continuous changes and economic mistakes at work.

In recent decades, research on health in work environments has evolved from a focus on the prevention of physical risks to a global approach. In this context, emergent psychosocial risks, such as job stress, are of particular interest. Among the negative effects of stress on the individual are physical, psychological and behavioural disorders (Shirom 2003). In turn, stress is associated with organizational-level issues, such as increased absenteeism, decreased quality of work and decreased productivity (Elkin & Rosch 1990).

According to various reports by occupational health institutions, stress affects almost every profession. However, levels of stress are higher, and there are a greater number of sources of stress among health professionals, especially nurses, with negative consequences for their health (Demeuroti et al. 2000; Humpel & Caputi 2001; Lim et al. 2010). However, the focus should be at a stage prior to nurses' incorporation into their workplaces: their training period. Stress is a psychological factor that influences the academic performance and welfare of nursing students (Sawatzky 1998). This has led to the development of a large body of research aimed at determining the levels and sources of stress in the training of future nurses (see Burnard et al. 2008; Pryjmachuk & Richards 2007b; or Timmins & Kaliszer 2002, for a review).

Three main groups of stressors have been identified: (i) academic stressors (testing and evaluation, fear of failure in training, problems with workload, etc.), (ii) clinical stressors (work, fear of making mistakes, negative responses to the death or suffering of patients, relationships with other members of the organization, etc.), and (iii) personal/social stressors (economic problems, imbalance between housework/schoolwork, etc.) (Pryjmachuk & Richards 2007b).

In this paper, we present a systematic review of the studies that quantitatively analyse the sources of stress in nursing students. More specifically, we choose only those studies that use standardized instruments for assessing the situations that cause stress in students. Compared with other reviews, this systematic review considers a greater number of studies.

Objectives

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Method
  6. Results
  7. Discussion
  8. Author contributions
  9. References

The aim of this paper is to identify sources of stress among nursing students. Beyond this general objective, we analyse the specific objective of each study. Moreover, we analyse the situation and stressors, taking into account the academic year the students are in. The review includes cross-sectional studies with students from a single academic course, cross-sectional studies comparing various academic courses and longitudinal studies that include the evolution of the sources of stress for the same group across different academic courses. Another specific objective is to analyse situations and stressors directly related to the conduct of clinical practice as part of the training of students. Finally, given that some of the studies reviewed compare levels and sources of stress in samples of students from different educational systems, we identify characteristically sources of stress of the educational system.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Method
  6. Results
  7. Discussion
  8. Author contributions
  9. References

This review includes quantitative studies of the factors that nursing students perceive as stressful at the end of 2010.

Data sources and searches

MEDLINE and PsycInfo were the databases for the search. MEDLINE is one of the most complete bibliographic databases and includes nursing journals. We also used PsycInfo because the stress has a psychological nature, and PsycInfo is the American Psychology Association's database that includes information from different disciplines, including nursing.

The terms for the search were ‘stress’ (terms such as environmental stress, occupational stress, psychological stress, social stress, stress management, stress reaction, financial strain, physiological stress, anxiety, distress, chronic stress, burnout, job stress, work stress, etc.) and ‘nursing students’ (terms such as nursing students, nursing education, nursery school students, nursery school, college students, educational programs, clinical practice, school nurses, etc.) in different combinations. The search included articles as recent as the last week of 2010. We established the following search limits: English-language articles published in scientific journals with anonymous processes of peer review that exclusively sampled humans. We conducted an additional search based on the references included in selected papers from the database search.

Selection criterion of the study and data extraction

The authors conducted a reading of titles and abstracts and made the decision to include articles in the review based on the following criteria: (i) the study included one or more instruments to collect information on stress factors among nursing students, (ii) the study included only nursing students or, if other samples were considered, the study provided information on nursing students separately, and (iii) the work included quantitative information on sources of stress, excluding those studies that only reported a global measure of stress. Articles were included in the review if they met these three criteria. In case of discrepancies between the researchers, discussion meetings helped to unify the decision. Finally, papers that based their analysis on a qualitative interpretation of the information collected (e.g. discourse analysis, conversation analysis) were rejected.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Method
  6. Results
  7. Discussion
  8. Author contributions
  9. References

General results

Eighty-six articles (out of 784) seemed to meet the objectives and criteria of this systematic revision on the basis of titles and abstracts. After the complete reading, 63 articles were discarded for one of the following reasons: (i) samples were not exclusively nursing students, and their results were not separated from other students, (ii) the results only reported global scores and not factor scores, or (iii) although the abstract did not report a qualitative study, it became clear upon reading the study that a qualitative method was used. Consequently, the final sample was reduced to 23 studies. Table 1 summarizes the characteristics of the selected studies.

Table 1. Characteristics of the Studies analyzing sources of stress in Nursing students
Author/s and location of researchnTemporal momentDesignInstrumentSources of stress assessed
Birch (1979), England207First and second yearsLongitudinalDesigned ad hoc (56 items)Behavioural
Administrative
Procedural
Lindop (1991), England413All yearsCross-sectionalDesigned ad hoc (144 items) α = 0.99Stress experience in the educational environment
Stress experience in the clinical environment
Clarke & Ruffin (1992), Australia306First yearLongitudinalDesigned ad hoc (28 items) α = 0.58 to 0.93Interpersonal interaction
Emotional demands
Study demands
Family/personal
Technology
Williams (1993), USA245First yearCross-sectional, descriptive correlationalNursing Students' Concern Survey (Designed ad hoc; 38 items) α = 0.93Support and guidance
Learning
Language and communication
Clinical
Financial
Loneliness
Family
Miscellaneous concerns
Thyer & Bazeley (1993), Australia79First yearCross-sectionalModification of Students' Workplace Stressors Schedule (Silins & Cooper 1989) (38 items)Anxiety experienced on general matters
Anxiety experienced when submitting an assignment
Anxiety experienced during study
Anxiety related to lecturer's time available for student consultation
Anxiety related to assessment of course work
Anxiety regarding the course program
Basson & van der Merwe (1994), South Africa81Second and third yearsCross-sectionalSources of Stress Questionnaire (Designed ad hoc; 60 items) α = 0.83 to 0.89Factors intrinsic to the job
Role in the organization
Relationships at work
Career development
Organizational structure and climate
Home–work interface
Rhead (1995), England106Cross-sectionalModification to Nurse Stress Scale questionnaire (Gray-Toft & Anderson 1981) (32 items)Practical elements
Academic elements
Issues of death and suffering within nursing
Admi (1997), Israel46Exploratory longitudinalNursing Student's Stress Scale (Designed ad hoc; 25 items) α = 0.61 to 0.93Inadequate knowledge and training
Adverse and embarrassing sights
Instructor's close supervision
Insufficient hospital resources
Causing pain and suffering
Education-reality conflict
Lindop (1999), England292All yearsCross-sectional, comparative studyQuestionnaire used by Lindop (1991) α = 0.86Stress experiences in the educational environment
Stress experiences in the clinical environment
Brown & Edelmann (2000), England88LongitudinalDesigned ad hocMaintaining a balance between clinical work and studying
Feeling competent to demonstrate theoretical knowledge
Feeling part of a peer group
Meeting personal expectations of role
Making ends meet financially
Feeling competent in clinical skills
Sheu et al. (2002), China561Cross-sectionalPerceived Stress Scale (Sheu et al. 1997) (29 items) α = 0.89Stress from taking care of patients
Stress from teachers and nursing personnel
Stress from assignments and workload
Stress from peers and daily life
Stress from lack of professional knowledge and skills
Stress from the clinical environment
Timmins & Kaliszer (2002), Ireland110Third yearCross-sectionalDesigned ad hoc (12 items), Pearson correlation test–retest, 14 of 19 items r > 0.50Theory, exams, assignments, workload, contact hours
Relationships with tutors, relationships with clinical placement coordinators
Clinical placements, relationships with staff on wards
Finance
Death of a patient
Kim (2003), USA61Final yearCross-sectional, correlationalClinical experience assessment form (Kleehammer et al. 1990) (16 items) α = 0.88Communication and procedural aspects of client care
Interpersonal relationships with healthcare providers
Interactions with faculty
Evans & Kelly (2004), Ireland51Third yearCross-sectionalLindop's (1991, 1999) questionnaire α = 0.94Clinical stress
Academic stress
Jones & Johnston (2006), Scotland853First yearLongitudinal, comparative survey studyStudent Nurse Stress Index (SNSI) (Jones & Johnston 1999) (22 items) α = 0.63 to 0.85Academic load
Clinical concerns
Personal problems
Interface worries
Zupiria et al. (2007), Spain69All yearsLongitudinal, prospective cohort studyKEZKAZ (Zupiria et al. 2003) (41 items)Lack of competence
Uncertainty and impotence
Being harmed by the relationship with patients
Emotional involvement
Lack of control in relationships with patients
Contact with suffering
Relationships with tutors, workmates and classmates
Overload
Patients seeking a close relationship
Seyedfatemi et al. (2007), Iran366All yearsDescriptive cross-sectional studyThe Student Stress Survey based on the Student Stress Scale (Insel & Roth 1985) (40 items) α = 0.78Interpersonal sources of stress
Intrapersonal sources of stress
Academic Sources of stress
Environmental sources of stress
Pryjmachuk & Richards (2007b), England1005All yearsCross-sectional survey designSNSI (Jones & Johnston 1999) (22 items) α > 0.70Academic load
Clinical concerns
Personal problems
Interface worries
Basso et al. (2008), Chile129Second and third yearsCross-sectional, quantitative, correlative with descriptive analysisAdaptation of the KEZKAZ (Zupiria et al. 2003) (26 items) α = 0.84Competences
Teaching
Burnard et al. (2008) Albania, Brunéi, Czech Republic, Malta, Wales1707All yearsCross-sectional surveyStress in Nurse Education questionnaire (SINE) (Rhead 1995) (32 items)Clinical situations
Academic situations
Chan et al. (2009), China205First, second and third yearsCross-sectional descriptivePerceived Stress Scale (Sheu et al. 1997) (29 items) α = 0.89Stress from taking care of patients
Stress from teachers and nursing personnel
Stress from assignments and workload
Stress from peers and daily life
Stress from lack of professional knowledge and skills
Stress from the clinical environment
Edwards et al. (2010), UK169All yearsLongitudinal, prospective cohort studySINE (Rhead 1995) (32 items) α = 0.88Clinical situations
Academic situations
Jimenez et al. (2010), Spain357All yearsCross-sectional designAdaptation of the Perceived Stress Scale (Sheu et al. 1997) (30 items) α = 0.92Stress from lack of professional knowledge and skills
Stress from practical assignments and workload
Stress from taking care of patients
Stress from examinations of personal competence
Stress from the clinical environment and the teaching and nursing staff
Stress from interference with daily life

As Table 1 reflects, in some cases, there is a discrepancy between the size of the sample reported in the abstract and the size reported in the sample section (sample column). Other studies only include part of the original sample, those who completed the instrument to measure stress; in other studies, the authors dismiss subjects in the data analysis. Although the original sample may be larger and instruments used may measure additional variables, we only included the sample that referred to stress and only the sources related to stress (sources of stress column), respectively.

In the results, terms associated with occupational settings, such as occupational stress, job stress or workloads, among others, are used. Obviously, these terms are placed in the context of students' clinical practice, understanding that in any case students maintain any employment relationship with the centre.

Specific results

There are many difficulties in comparing studies. The composition of the sample, the instrument used and the coding of responses are among the factors that may impede comparison of the results obtained in different studies. Moreover, in some cases, the results refer to the dimensions or factors of the sources of stress, and in other cases, the results refer to the content or specific items of these dimensions. Thus, we report the specific results of this systematic review on the base of the following criteria: (i) the research objectives, (ii) the analysis of stress segregated by academic courses, (iii) sources of stress associated with clinical practice and (iv) sources of stress in terms of curriculum.

Research objectives
Transformation of nursing curricula

A large number of the studies analyse the effects of the transformation of nursing curricula. This transformation often consists of changing from training based on practice developed in hospitals and schools to training based on university classes with a significant increase in academic workload and a professional curriculum. Under the Bologna process in Europe, nursing studies have transformed to address students' acquisition of competencies, such as managing stressful situations.

In some of the reviewed studies, the majority of the samples were students enrolled under the new qualifications that have a greater academic load (Brown & Edelmann 2000; Clarke & Ruffin 1992; Evans & Kelly 2004; Pryjmachuk & Richards 2007a,b; Thyer & Bazeley 1993). In other cases (Lindop 1999; Rhead 1995), studies compare sources of stress perceived by students in the traditional system with those in the new system; Jones & Johnston (2006) in the northeast of Scotland made this comparison. Zupiria et al. (2007) in Spain examined the innovations of the new educational programmes.

In four studies, the research objective was to analyse the levels of stress in students when the study introduced partial changes in the form of strategies, programmes or actions to improve training. For example, the research hypothesis that guided Birch's (1979) study involved a lack of adequate preparation for nursing students to address the psychological needs of patients. The author presented the necessary restructuring of training plans to include content specific to psychology, thus improving patient care. Another example is Lindop's (1991) study, which aimed to develop a support system for the nursing staff. Both Williams (1993) and Sheu et al. (2002) studied how nursing students effectively manage stress. Specifically, Williams' study analysed the main concerns of nursing students on five campuses of one of the most prestigious universities of the Western USA. Williams proposed improving the cultural competence of the campuses to develop support and orientation programmes for current students and to encourage future students to contact the campus. Sheu et al. (2002) assessed the types and levels of stress, including physiological, psychological, and social responses, coping behaviours for stressful situations and the effect of coping behaviour on physical, psychological, and social health during the initial period of practice.

Relations of stress with other constructs

Four of the studies explored the relationship between stress and other constructs (Basson & van der Merwe 1994; Chan et al. 2009; Edwards et al. 2010; Seyedfatemi et al. 2007). Both Seyedfatemi et al. (2007) at the Faculty of Nursing and Midwifery of the Medical Sciences University of Iran and Chan et al. (2009) at the University of Hong Kong aimed to determine the stressors and the coping strategies nursing students employed to cope with stressful situations. Basson & van der Merwe (1994) examined the moderating role of major life events, coping strategies and sources of perceived stress on the effects of burnout. Edwards et al. (2010) focused on the evolution of stress and levels of self-esteem during the training of students. Although the samples of some of these studies were students who were undertaking clinical practices. Other studies analysed the relationship between the experience of clinical practices and students' perceived levels of stress (Admi 1997; Basso et al. 2008; Kim 2003; and Jimenez et al. 2010).

Cross-cultural comparisons

Another group of studies has focused on cross-cultural comparisons. Timmins & Kaliszer (2002) conducted a review of studies that examined the sources of stress among nursing students from different countries and compared Ireland with those results. They found that the most common sources are clinical environment concerning learning, academic stress, degree of stress among nursing students and stress because of interpersonal relationships. Burnard et al. (2008) compared data from five countries (Albania, Brunei, Czech Republic, Malta and Wales) with similar results.

General stress sources segregated by academic years

This section analyses the sources of stress reported in the studies for the entire degree programme and for different courses.

Studies with samples from all academic years

Among the studies with representative samples of the entire nursing degree programme are those of Burnard et al. (2008), Pryjmachuk & Richards (2007a,b) and Seyedfatemi et al. (2007). Pryjmachuk & Richards (2007a,b) report the situations that are perceived as stressful: examinations/assessments, fear of failing the course and managing financial aid. Seyedfatemi et al. (2007) show that the most stressful situations are new friends and working with people they did not know. Regarding intrapersonal sources of stress, the most frequently selected were new responsibilities and starting college. With regard to academic stress, increased class workload was most frequently selected and as for the most stressful environment stressors, being placed in unfamiliar situations and waiting in long lines were the most selected in this order.

In a longitudinal and cross-cultural study, Burnard et al.'s (2008) study yielded heterogeneous results depending on the country. Specifically, academic aspects stressed students in Brunei and Malta whereas clinical aspects stressed students in the Czech Republic and Albania (Tirana). Finally, there were no differences between academic and clinical aspects in Wales.

Clarke & Ruffin's (1992), Thyer & Bazeley's (1993) and Williams' (1993) analyses focused on new students in nursing. Williams (1993), used only descriptive statistics to analyse the items in a disaggregated way. The students showed the highest concern for keeping their grades up, fear of making a mistake with a patient and learning clinical procedures. Thyer & Bazeley (1993) studied first semester Australian students and the areas in which students experienced higher levels of anxiety corresponded with the assessment of work throughout the course and the return of assignments.

Also in Australia, Clarke & Ruffin (1992) collected data on students enrolled in the first year of nursing at three different centres (university, advanced education and hospital). The most stressful situations were the total amount of work to be completed, coping with exams and handling emergencies. When taking into account the factors, the emotional demands of nursing and the use of technical equipment were the most stressful.

Basson & van der Merwe (1994) analysed the sources of stress among a sample of students in the second and third year (of a four-year programme) who were carrying out their practice in a hospital in Natal (South Africa). The following six items had the highest mean scores: having to write academic or practical exams; the extent to which working hours influenced the possibility of a fulfilling social life; having to act with accuracy in crisis or emergency conditions; the extent to which students were exposed to demands that exceeded their knowledge and ability; the extent to which shift work affected moods, and social and home life; and exposure to potentially dangerous and contagious diseases, such as AIDS.

Two of the studies focused on stressors for nursing students who were finishing their studies (Evans & Kelly 2004; Timmins & Kaliszer 2002). Evans & Kelly (2004), using Lindop's (1989, 1999) instrument with a sample of third year students at a university hospital in Dublin, found the items with the highest scores for educational factors were exams, an intense amount of work, difficulty of academic work and studying. Among the clinical factors, the situations that generated the highest levels of stress were differences between the ideal practice learned in school and real situations in the healthcare environment, aloofness from more senior staff and an unfriendly environment in hospital wards, being reprimanded in front of staff and patients, and being left for short periods on the ward without trained nurses present. Timmins & Kaliszer (2002) also studied third year students. Factors causing stress were those associated with academic performance, specifically clinical placements, financial constraints, the death of a patient and relationships with the staff in the wards.

Evolution of sources of stress over training

Compared with the transversal studies mentioned above, longitudinal studies allow reliable comparisons about the stressors and about the situations included in the items. These data offer methodological safeguards and an analysis of the evolution of the stressors. Thus, Jones & Johnston (2006) analysed the evolution of stressors in a group of nursing students in two educational systems. They concluded that the sources of stress were unchanged with time. When considering weeks 24/25 and 40/50 of their training, sources of stress with higher scores included academic load followed by interface concerns, clinical concerns and personal problems. Brown & Edelmann (2000) yielded similar conclusions about the stability of the sources of stress by comparing a group of freshmen with a group that accumulated 18 months of training.

Edwards et al.'s (2010) study provide information on sources of stress at five different times over the first three training courses. Although they found significant differences in general stress levels by course, they did not report the differences for the factors (academic stress and clinical stress). However, analysing the order of the items mean scores for the five times suggests that the most intense sources of stress remained stable throughout the training.

In a cross-sectional study, Lindop (1991) reported differences in stressors by academic year. The students agreed on the stressors related to education. However, when analyzing specific situations such as taking exams or the amount of work, the students at higher levels (second and third years) experienced higher levels of stress. There was also general agreement about stressful experiences in the clinical context but were more intense in the last years of the programme.

Sources of stress associated with clinical practice

Because clinical practice is important for future professionals to acquire competence, a group of studies has focused exclusively on the analysis of these activities as sources of stress. The studies included here focus on academic and social stressors arising from work experience in health centres because of conducting clinical practices.

Three cross-sectional studies examined the nature of stressors without regard to academic course and without analysing the evolution of these stressors (Chan et al. 2009; Kim 2003; Sheu et al. 2002). Sheu et al. (2002) find that the most common stressors were related to the lack of knowledge and professional abilities followed by taking care of patients. The specific items related to these most stressful situations were lack of experience and ability to provide nursing care and diagnostics, lack of familiarity with history and medical terms, and concern about poor grades.

Using a similar sample of nursing students and the same instrument, Chan et al. (2009) report that the most common type of stressor among students was a lack of knowledge and professional skills, followed by the stress of the tasks and workload. The third most common stressor proved to be the stress resulting from patient care.

In Kim's (2003) study, clinical situations that caused higher levels of anxiety in the students were being late, being observed by instructors, fear of making mistakes, initial clinical experience on a unit and talking with physicians.

Only two studies have compared different academic courses regarding the sources of stress associated with clinical practice, specifically, Basso et al. (2008) and Jimenez et al. (2010). Basso et al. (2008) compared students in the second and third years (out of 5 years, or ten semesters). Items for the competence factor with the highest frequencies were, in this order, making a mistake in work and harming the patient, being in a situation where the student does not know what to do, and confusing the treatment. Teaching factor was more important for third year than second year students. The items for this factor yielding highest frequencies were receiving contradictory orders from teachers, a tutor that reprimands the student in front of patients and hospital staff, and receiving extra work activities from the teacher in charge of the laboratories, such as connecting the number of patients assigned and the daily operations.

In Jimenez et al.'s (2010) study, the differences by academic year were in two first-order factors. Stress from assignments and workload, a clinical stressor, was perceived with greater intensity by second year students than first year students. First year students perceived academic factor more intensively than the other groups. For second-order factors (clinic, academics and external stressors), the unique differences were among the academic sources, which were perceived with greater intensity by the first year compared with the second and third year students.

In longitudinal studies that allow comparison between academic years (Birch 1979, Admi 1997; Zupiria et al. 2007), there are no significant differences between the types of stressors in different levels of the degree programme. Although Admi (1997) presents different results about the types of sources listed, this study also reports on the stability of the sources by academic year. Birch's (1979) study participants were students from four nursing schools in Northern England. They completed an ad hoc instrument at two different times (8 and 24 months after the beginning of the training period). Although the analysis of the scores for the items shows no significant differences on the two occasions, a detailed analysis shows that as training progresses, the sources of stress that become more important are those related to behavioural aspects, while the importance of administrative aspects diminishes.

Sources of stress in terms of curriculum

With the shift in nursing education to higher education and the significant increase in course load in the curriculum of future professionals, two studies (Lindop 1999; Rhead 1995) have explicitly compared traditional and new curricula. Rhead (1995) compared the intensity of stress perceived by nursing students from two schools in Southwest England. The questionnaire was completed by a group of students from the traditional system [Registered General Nurse (RGN)], based on practical profile programmes, and a group from the new system (Diploma of Higher Education in Nursing), based on a more academic programme. In the traditional system, the students experienced more stress from the practical aspects of their training. The group in the new system did not differ in the intensity of the academic and practical stressors. Similarly, Lindop (1999), following the same procedure as in a previous study (Lindop 1991), compared students from both systems: the traditional (certificate-level training leading to RGN) and a new system (Project 2000 diploma-level training, Adult Branch). The former is practice oriented and the latter is academic oriented. The intense amount of work and the tests were identified as stressors related to the educational environment in both groups, and the amount of work was more stressful for students in the new system.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Method
  6. Results
  7. Discussion
  8. Author contributions
  9. References

From this systematic review, we can conclude that most of the studies took place in Europe, and more than one-fourth of these studies about stress in nursing students were conducted in England. There are data from samples of students from all continents, although they are found in isolated studies. While 30% of studies were longitudinal, 70% of the studies were of a cross-sectional design.

With regard to sample size, the high dispersion should be noted; the range extends from 46 to 1707 students. The mean is 326, which is not a representative value. The median is 205, and the 75th percentile was at 366. However, most studies sample size was smaller than this.

There is great variability regarding the instruments used. Eight of the studies designed ad hoc instruments to measure stress. Only three instruments were used in more than one study, although in some cases, modifications were introduced. Thus, Lindop's (1991) scale was modified by Lindop (1999) and by Evans & Kelly (2004). The Perceived Stress Scale by Sheu et al. (1997) was used by three of the reviewed studies (Chan et al. 2009; Jimenez et al. 2010; Sheu et al. 2002). The Student Nurse Stress Index by Jones & Johnston (1999) was used by them in a subsequent study (Jones & Johnston 2006) and by Pryjmachuk & Richards (2007b). The KEZKAZ by Zupiria et al. (2003) was also used in two other studies (Basso et al. 2008; Zupiria et al. 2007), and the Stress in Nurse Education questionnaire by Rhead (1995) was used by Burnard et al. (2008) and Edwards et al. (2010). In the remaining ten studies, the instruments were different.

This variability is also present in the content and structure of the instruments. In the studies reported, instruments included 12–144 items, all with the purpose of assessing sources of stress in nursing students. The factors identified ranged from two to nine, indicating heterogeneity in the content when evaluating stress.

Two of the studies used instruments that were not specific to assessing stress in nursing students (Basson & van der Merwe 1994; Thyer & Bazeley 1993). The content of the items in Thyer & Bazeley's (1993) study related to academic aspects, whereas Basson & van der Merwe's (1994) study referred to the clinical context in which the practice was conducted. The sources of academic and clinical stress were considered jointly in most of the studies reviewed (Burnard et al. 2008; Chan et al. 2009; Clarke & Ruffin 1992; Edwards et al. 2010; Evans & Kelly 2004; Jones & Johnston 2006; Lindop 1991, 1999; Pryjmachuk & Richards 2007b; Rhead 1995; Seyedfatemi et al. 2007; Sheu et al. 2002; Timmins & Kaliszer 2002; Williams 1993). Other studies specifically assessed the sources of stress related to clinical practice: Admi (1997), Brown & Edelmann (2000), Kim (2003), Zupiria et al. (2007), Basso et al. (2008) and Jimenez et al. (2010). The following studies focused on additional sources of stress among nursing students, such as social relations (Chan et al. 2009; Clarke & Ruffin 1992; Jones & Johnston 2006; Pryjmachuk & Richards 2007b; Seyedfatemi et al. 2007; Sheu et al. 2002; Williams 1993), general personal problems (Chan et al. 2009; Jones & Johnston 2006; Pryjmachuk & Richards 2007b; Seyedfatemi et al. 2007; Sheu et al. 2002), family issues (Clarke & Ruffin 1992; Williams 1993), economic issues (Timmins & Kaliszer 2002; Williams 1993) or loneliness (Williams 1993).

The large number of stressors makes it difficult to compare results between studies; however, the grouping of sources in the results in this review may be useful for future work. Researchers may choose to assess sources of stress according to academic, clinical or social areas.

The research objectives in the studies reviewed highlight the importance of transforming the curriculum and introducing new programmes and how these changes may adversely affect students. Almost half of the studies were designed to examine the aspects of nursing students' training that were perceived as threatening and to determine whether they remain with the transformation of the curriculum. Other variables are taken into account, such as coping strategies used by students and the relationship between constructs such as stress and burnout or self-esteem. Other studies examined the importance of clinical practice in the training of future nurses and how participation can lead to perceptions of stress. In the context of globalization, the results derived from studies focused on cross-cultural stress in nursing students are very useful.

Most of the studies found no significant changes in students' perceptions of the factors that lead to stress in different stages of training (Brown & Edelmann 2000; Edwards et al. 2010; Jones & Johnston 2006). Only Lindop's (1991) research reported on changes in the upper grades (second year and third year vs. first year). Students in the upper grades suffer from more stress related to academic and clinical sources. The factors that ultimately lead to stress are related to a greater extent to the academic world. The items or dimensions occupying the top positions among the concerns of students are evaluations or examinations, the fear of failure, an excessive workload, maintaining grades and study skills.

Implications for practice

In agreement with Timmins & Kaliszer (2002), those responsible for the programmes should consider the time spent by students on the proposed tasks to avoid work overload. Furthermore, alternative forms of assessment beyond the acquisition of skills for testing, such as learning-oriented assessment (Carless et al. 2006), could help to reduce academic stress among students and the reduction of negative psychological symptoms (Deary et al. 2003). Clinical sources that were identified as most stressful include dealing with unfamiliar situations, making errors with patients, learning to apply clinical procedures and managing technical instruments, among others. Following McVicar's (2003) proposal, students should understand that the perceived lack of competence to deal with these situations disappears with further practice. Therefore, the practical period must be understood as an opportunity to learn more than as a stage of evaluation and testing of theoretical knowledge.

Conclusion

Comparing studies was difficult due to the methodological differences between them. However, our revision gives a current state-of-the-art and descriptive information that might be very useful for future research. We point out the importance of educators and clinical facilitators to be sensitive of these stressors and provide students with effective coping strategies to deal with the inevitable sources of stress present during nurse education and training. These strategies may lead to the reduction of negative psychological symptoms associated with perceptions of stress. Future research should consider reviewing papers that have used qualitative methodologies to contribute information to this work.

Author contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Method
  6. Results
  7. Discussion
  8. Author contributions
  9. References

Manuel Pulido-Martos, PhD promoted the study conception, the steps to move forward, made decisions about the process, led the group discussion about the articles and wrote the article in Spanish. Esther Lopez-Zafra and Jose M. Augusto-Landa have searched for the articles to be included in the study and read them to discard or include. They also discussed about the articles in the group sessions. Esther Lopez-Zafra made the revision, made the translation, edited the manuscript with the help of American Journal Experts, revised the final manuscript and led the submission process.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Method
  6. Results
  7. Discussion
  8. Author contributions
  9. References
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