From the article, identify and explain the components of the sampling technique or method, including but not limited to popul

Sources of stress in nursing students: a systematic review of quantitative studiesinr_939 15..25

M. Pulido-Martos1 PhD, J.M. Augusto-Landa2 PhD & E. Lopez-Zafra3 PhD 1 Associate professor, 2 Associate professor, 3 Professor, Social Psychology, Department of Psychology, University of Jaén, Jaén, Spain

PULIDO-MARTOS M., AUGUSTO-LANDA J.M. & LOPEZ-ZAFRA E. (2012) Sources of stress in nursing

students: a systematic review of quantitative studies. International Nursing Review 59, 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.

Keywords: Clinical Experience, Occupational Stress, Nurse Education, Quantitative Research

Introduction 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 stres- sors, 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

Correspondence address: Dr Manuel Pulido-Martos, Social Psychology, Department of Psychology, University of Jaén, Campus Las Lagunillas S/N, 23071 Jaén, Spain; Tel: +34953211990; Fax: +34953211881; E-mail: [email protected]

Review Article

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses 15

negative effects of stress on the individual are physical, psy- chological 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 institu- tions, 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 nega- tive 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 devel- opment 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) aca- demic 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 standard- ized instruments for assessing the situations that cause stress in students. Compared with other reviews, this systematic review considers a greater number of studies.

Objectives 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 iden- tify characteristically sources of stress of the educational system.

Method 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 environ- mental stress, occupational stress, psychological stress, social stress, stress management, stress reaction, financial strain, physi- ological 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 instru- ments 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

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

16 M. Pulido-Martos et al.

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

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 quali- tative study, it became clear upon reading the study that a quali- tative method was used. Consequently, the final sample was reduced to 23 studies. Table 1 summarizes the characteristics of the selected studies.

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 com- pleted the instrument to measure stress; in other studies, the authors dismiss subjects in the data analysis. Although the origi- nal 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 composi- tion 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 seg- regated 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 transfor- mation of nursing curricula. This transformation often consists of changing from training based on practice developed in hos- pitals 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 innova- tions 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 train- ing. 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 effec- tively 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 stu- dents 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 behav- iours 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 Seyed- fatemi 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) exam- ined 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

Systematic review of sources of stress 17

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

Table 1 Characteristics of the Studies analyzing sources of stress in Nursing students

Author/s and location of research

n Temporal moment

Design Instrument Sources of stress assessed

Birch (1979), England

207 First and second years

Longitudinal Designed ad hoc (56 items) Behavioural Administrative Procedural

Lindop (1991), England

413 All years Cross-sectional Designed ad hoc (144 items) a = 0.99

Stress experience in the educational environment Stress experience in the clinical environment

Clarke & Ruffin (1992), Australia

306 First year Longitudinal Designed ad hoc (28 items) a = 0.58 to 0.93

Interpersonal interaction Emotional demands Study demands Family/personal Technology

Williams (1993), USA

245 First year Cross-sectional, descriptive correlational

Nursing Students’ Concern Survey (Designed ad hoc; 38 items) a = 0.93

Support and guidance Learning Language and communication Clinical Financial Loneliness Family Miscellaneous concerns

Thyer & Bazeley (1993), Australia

79 First year Cross-sectional Modification 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 Africa

81 Second and third years

Cross-sectional Sources of Stress Questionnaire (Designed ad hoc; 60 items) a = 0.83 to 0.89

Factors intrinsic to the job Role in the organization Relationships at work Career development Organizational structure and climate Home–work interface

Rhead (1995), England

106 – Cross-sectional Modification to Nurse Stress Scale questionnaire (Gray-Toft & Anderson 1981) (32 items)

Practical elements Academic elements Issues of death and suffering within nursing

Admi (1997), Israel 46 – Exploratory longitudinal

Nursing Student’s Stress Scale (Designed ad hoc; 25 items) a = 0.61 to 0.93

Inadequate knowledge and training Adverse and embarrassing sights Instructor’s close supervision Insufficient hospital resources Causing pain and suffering Education-reality conflict

Lindop (1999), England

292 All years Cross-sectional, comparative study

Questionnaire used by Lindop (1991) a = 0.86

Stress experiences in the educational environment Stress experiences in the clinical environment

Brown & Edelmann (2000), England

88 – Longitudinal Designed ad hoc Maintaining 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

18 M. Pulido-Martos et al.

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

Table 1 Continued

Author/s and location of research

n Temporal moment

Design Instrument Sources of stress assessed

Sheu et al. (2002), China

561 – Cross-sectional Perceived Stress Scale (Sheu et al. 1997) (29 items) a = 0.89

Stress 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), Ireland

110 Third year Cross-sectional Designed ad hoc (12 items), Pearson correlation test–retest, 14 of 19 items r > 0.50

Theory, 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), USA 61 Final year Cross-sectional, correlational

Clinical experience assessment form (Kleehammer et al. 1990) (16 items) a = 0.88

Communication and procedural aspects of client care

Interpersonal relationships with healthcare providers

Interactions with faculty Evans & Kelly

(2004), Ireland 51 Third year Cross-sectional Lindop’s (1991, 1999)

questionnaire a = 0.94 Clinical stress Academic stress

Jones & Johnston (2006), Scotland

853 First year Longitudinal, comparative survey study

Student Nurse Stress Index (SNSI) (Jones & Johnston 1999) (22 items) a = 0.63 to 0.85

Academic load Clinical concerns Personal problems Interface worries

Zupiria et al. (2007), Spain

69 All years Longitudinal, prospective cohort study

KEZKAZ (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), Iran

366 All years Descriptive cross-sectional study

The Student Stress Survey based on the Student Stress Scale (Insel & Roth 1985) (40 items) a = 0.78

Interpersonal sources of stress Intrapersonal sources of stress Academic Sources of stress Environmental sources of stress

Pryjmachuk & Richards (2007b), England

1005 All years Cross-sectional survey design

SNSI (Jones & Johnston 1999) (22 items) a > 0.70

Academic load Clinical concerns Personal problems Interface worries

Basso et al. (2008), Chile

129 Second and third years

Cross-sectional, quantitative, correlative with descriptive analysis

Adaptation of the KEZKAZ (Zupiria et al. 2003) (26 items) a = 0.84

Competences Teaching

Systematic review of sources of stress 19

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

undertaking clinical practices. Other studies analysed the rela- tionship between the experience of clinical practices and stu- dents’ 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 compari- sons. 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 environ- ment concerning learning, academic stress, degree of stress among nursing students and stress because of interpersonal rela- tionships. Burnard et al. (2008) compared data from five coun- tries (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 respon- sibilities 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 unfa- miliar 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

Table 1 Continued

Author/s and location of research

n Temporal moment

Design Instrument Sources of stress assessed

Burnard et al. (2008) Albania, Brunéi, Czech Republic, Malta, Wales

1707 All years Cross-sectional survey

Stress in Nurse Education questionnaire (SINE) (Rhead 1995) (32 items)

Clinical situations Academic situations

Chan et al. (2009), China

205 First, second and third years

Cross-sectional descriptive

Perceived Stress Scale (Sheu et al. 1997) (29 items) a = 0.89

Stress 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), UK

169 All years Longitudinal, prospective cohort study

SINE (Rhead 1995) (32 items) a = 0.88

Clinical situations Academic situations

Jimenez et al. (2010), Spain

357 All years Cross-sectional design

Adaptation of the Perceived Stress Scale (Sheu et al. 1997) (30 items) a = 0.92

Stress 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

20 M. Pulido-Martos et al.

© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

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 corre- sponded 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 com- pleted, 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 possi- bility 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 stu- dents. Factors causing stress were those associated with academic performance, specifically clinical placements, financial con- straints, 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, longi- tudinal 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 evolu- tion of stressors in a group of nursing students in two educa- tional 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 stres- sors related to education. However, when analyzing specific situ- ations 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 …