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Levels of Stress and Coping Strategies Used by Nursing Students in Asian Countries: An Integrated Literature Review

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Abstract

Introduction: High-stress levels can directly or indirectly impede academic learning, performance, and health of the nursing students. There is ample literature reporting levels of stress and coping strategies used by the nursing students from within western world. However, this may not be applicable to Asian context. Therefore, there is a need to synthesize evidence regarding stress and coping of nursing students from Asia. Purpose: The purpose of this paper was to critically review and appraise existing studies and identify data gaps regarding stress and coping strategies among nursing students in the Asian context. Methods: Literature search was performed using keywords and different combinations of keywords such as “level of stress, stressors, coping strategies, nursing students, interns, undergraduate nurses” from PubMed, EMBASE, Cochrane, CINHAL, ASSIA, PsycInfo, Science Direct, and Google Scholar and other sources such as research gate, websites, reference lists, and Higher Education Commission of Pakistan’s Electronic Library. The search limit was focused on Asian countries and limited studies were found in this area. The review included nine studies published between 2007 and 2014 from India, Pakistan, Iran, Philippines, Hong Kong, and Jordan. Results: The critical appraisal of the studies was done in terms of study population, purpose, methodology, and ethical considerations. The key findings of the studies were described under four themes; levels of stress, common stressors, coping strategies, and association among stress, coping, and the demographic variables. Most of the studies reported that the nursing students experience moderate stress levels. In terms of coping, students used more positive coping strategies than negative strategies. Conclusion: This review underlined the strength and limitations of the studies identifying the levels of stress and coping strategies of nursing students in Asian context. A number of methodological limitations were found in these studies indicating that this topic has not been adequately investigated. Therefore, further research is needed to expand the literature in this area.
The Journal of Middle East and North Africa Sciences 2016; 2(4) http://www.jomenas.org
50
Levels of Stress and Coping Strategies Used by Nursing Students in Asian Countries: An
Integrated Literature Review
Ahtisham Younas
Memorial University of Newfoundland and Labrador, St John’s, Canada
ay6133@mun.ca, & ahtishamyounas66@gmail.com
ABSTRACT
Introduction: High-stress levels can directly or indirectly impede academic learning, performance, and health of the nursing
students. There is ample literature reporting levels of stress and coping strategies used by the nursing students from within
western world. However, this may not be applicable to Asian context. Therefore, there is a need to synthesize evidence
regarding stress and coping of nursing students from Asia.
Purpose: The purpose of this paper was to critically review and appraise existing studies and identify data gaps regarding
stress and coping strategies among nursing students in the Asian context.
Methods: Literature search was performed using keywords and different combinations of keywords such as “level of stress,
stressors, coping strategies, nursing students, interns, undergraduate nurses” from PubMed, EMBASE, Cochrane, CINHAL,
ASSIA, PsycInfo, Science Direct, and Google Scholar and other sources such as research gate, websites, reference lists, and
Higher Education Commission of Pakistan’s Electronic Library. The search limit was focused on Asian countries and limited
studies were found in this area. The review included nine studies published between 2007 and 2014 from India, Pakistan,
Iran, Philippines, Hong Kong, and Jordan.
Results: The critical appraisal of the studies was done in terms of study population, purpose, methodology, and ethical
considerations. The key findings of the studies were described under four themes; levels of stress, common stressors, coping
strategies, and association among stress, coping, and the demographic variables. Most of the studies reported that the nursing
students experience moderate stress levels. In terms of coping, students used more positive coping strategies than negative
strategies.
Conclusion: This review underlined the strength and limitations of the studies identifying the levels of stress and coping
strategies of nursing students in Asian context. A number of methodological limitations were found in these studies indicating
that this topic has not been adequately investigated. Therefore, further research is needed to expand the literature in this area.
To cite this article
[Younas, A. (2016). Levels of Stress and Coping Strategies Used by Nursing Students in Asian Countries: An Integrated
Literature Review. The Journal of Middle East and North Africa Sciences, 2(4), 50-57].
(P-ISSN 2412- 9763) - (e-ISSN 2412-8937). http://www.jomenas.org. 7
Keywords: Levels of stress, coping strategies, nursing students, Asian countries, nursing education, nursing practice
1. Introduction:
Stress is defined as a pattern of negative
physiological states and psychological responses. It
occurs in situations where individuals perceive threats
to their well-being, which they may be unable to meet
(Lazarus & Folkman, 1984). Stress affects individuals
in different ways and is considered a cause of
physical, emotional, and psychological ill health
(Ortqvist & Wincent, 2008). Continuous stress may
trigger both negative and positive responses. These
responses depend upon the coping abilities of
individuals (Schneiderman, Ironson, & Siegel, 2005).
Coping refers to the dynamic cognitive and behavioral
efforts to handle both external and internal stressors
(Lazarus & Folkman, 1984). It has been recognized as
a stabilizing factor that may assist individuals in
psychosocial adaptation during stressful events
(Walton, 2002). The use of effective coping strategies
enables the return to a stable state thereby reducing
the negative effects of stress (Sheu, Lin, & Hwang,
2002).
Numerous studies identified levels of stress
and coping strategies used by university students. It
was reported that nursing students face more clinical
The Journal of Middle East and North Africa Sciences 2016; 2(4) http://www.jomenas.org
51
and academic stressors throughout their training
period, as compared to students in other health-related
disciplines, such as pharmacy, dentistry, physical
therapy and medicine (Beck et al., 1997; Mohamed &
Ahmed, 2012; Stecker, 2004). It has also been
reported that the nursing students find the clinical
component more stressful than the theoretical
component of education (Eifried, 2003; Pulido
Martos, AugustoLanda, & LopezZafra, 2012;
Sharif & Masoumi, 2005; Sheu et al., 2002).
High levels of stress not only compromise the
delivery of patient care but also affect the health and
clinical practice of nursing students. It could also
result in inadequate coping mechanisms which could
be an obstacle in dealing with the challenges of the
nursing profession (Singh, 2011; Lewis & Shaw,
2007). Although stressors and stress cannot be
avoided, the ability to cope with them plays a key role
in achieving success as a nurse. On the other hand,
failure to resolve stress in the long term could have
potential professional and personal consequences
(Nicholl & Timmins, 2005).
Determining stress and coping strategies
among nursing students will have important
implications for the nursing profession. It will help in
creating supportive learning environments, improving
student learning, and enhancing nursing practice and
patient care (Del Prato et al., 2011; PulidoMartos et
al., 2012).
There is ample literature on this subject from
within western countries. After a systematic review of
23 studies, PulidoMartos et al., (2012) concluded
that most of the studies on this subject have been done
in Europe and England. However, there is limited
literature in the Asian world. The studies conducted in
western countries may not be applicable to Asia
because of the context. Therefore, this paper will
synthesize the evidence regarding stress and coping of
nursing students from Asian countries.
2. Purpose:
The purpose of this paper was to critically
review and appraise existing literature and identify
data gaps regarding stress and coping strategies
among nursing students in the Asian context. This
integrated literature review will also suggest areas of
future research.
3. Critical Appraisal:
High-stress levels can directly or indirectly
impede students’ academic learning, performance,
and health (Kaur et al., 2009; Labrague, 2014). If the
stress is not dealt with effectively, it may produce
various detrimental effects on the emotional, physical,
and social well-being of students (Nancy, 2011; Singh
et al., 2011). Understanding levels of stress and
coping strategies of the nursing students in Asian
countries is critical. This will help in recognizing their
abilities to manage their overall health.
3.1. Data Sources and Searches
A comprehensive search of PubMed,
EMBASE, Cochrane, CINHAL, ASSIA, PsycInfo,
Science Direct, and Google Scholar databases using
keywords and different combinations of keywords
such as “level of stress, stressors, coping strategies,
nursing students, interns, undergraduate nurses” was
performed. Most of the studies determined the level
of stress and coping strategies used by student and
practicing nurses in western countries and were
therefore excluded. The literature search was
expanded to research gate, websites, reference lists of
relevant articles, and Higher Education Commission
of Pakistan’s Electronic Library. The search limit was
focused on Asian countries and limited studies were
found in this area.
3.2. Article Selection
Initially, 25 articles were selected after reading
the titles and abstracts. The inclusion criteria for final
selection was: (i) the studies conducted in the Asian
context (ii) the studies included nursing students or
interns as samples, (iii) and the study included one or
more data collection instruments. The final selection
of these studies was done after critical reading of the
complete article considering the identification of
major themes and findings.
3.3. Overview of the Results
Nine studies conducted between 2007 and
2014 from India, Pakistan, Iran, Philippines, Hong
Kong, and Jordan met the inclusion criteria. The
summary of these studies is provided in Table I. The
detailed findings and critique of these studies are
reported in following subsections.
3.4. Study Purpose, target population and setting
Most of the studies determined the levels of
stress and coping strategies among baccalaureate
nursing students (Chan, So, & Fong, 2009; Kaur et al.,
2009; Khater, Akhu-Zaheya, & Shaban, 2014; Nancy,
2011; Prasad et.al, 2013; Seyedfatemi, Tafreshi, &
Hagani, 2007; Labrague, 2014; Sikander & Aziz,
2012) except one by Singh et al., (2011). The target
population of this study was nursing interns of the
Institute of Nursing Education in Chandigarh, India
(Singh, S. Sharma, & R. Sharma, 2011).
Chan et al., (2009) and Labrague (2014)
excluded the first year nursing students because of
lack of clinical experience. Prasad et.al, (2013) only
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52
conducted their study on first year nursing students at
Yenepoya Nursing College, Mangalore, India.
Each of these studies clearly stated its purpose
and setting. However, the inclusion and exclusion
criteria for study samples was not explicitly stated.
Seven studies identified both clinical and academic
stress levels. Only Khater et al., (2014) and Chan et
al., (2009) identified the clinical stress levels of
nursing students in Jordan and Hong Kong
respectively.
3.5. Conceptual/Theoretical framework
Kaur et al., (2009) based their study on Lazarus
and Folkman’s Stress, Appraisal, and Coping theory
(1984). The rest of the studies did not use any
conceptual/theoretical framework but clearly defined
the study variables. Sikander & Aziz (2012) neither
used any framework nor clearly defined the study
variables.
3.6. Study methodology
This review showed that the majority of studies
were descriptive in nature. Only Sikander and Aziz
(2012) used an analytical cross-sectional design. The
commonly used instruments were Perceived Stress
Scale (PSS), Adolescent Coping Orientation for
Problem Experiences Inventory (ACOPE), Physio-
Psycho-Social Response Scale, Stress and Coping
Inventory of Lazarus and Folkman (1984) and Coping
Behavior Inventory developed by Sheu et al., (2002).
Seven studies used PSS (Chan, So, & Fong, 2009;
Prasad et.al, 2013; Nancy, 2011; Seyedfatemi et al.,
2007; Labrague, 2014; Khater et al., 2014; Singh et
al., 2011). Three studies utilized Physio-Psycho-
Social Response Scale (Chan, So, & Fong, 2009;
Labrague, 2014; Singh et al., 2011). Two studies used
ACOPE (Nancy, 2011; Seyedfatemi et al., 2007) and
one study used Stress and Coping Inventory of
Lazarus & Folkman (Sikander & Aziz, 2012) and
Coping Behavior Inventory (Chan, So, & Fong,
2009). Kaur et al., (2014) and Singh et al., (2011) also
developed new self-administered questionnaires for
measuring stress and coping. These two studies, in
addition to Sikander and Aziz (2012), did not ensure
the validity and reliability of the instruments and no
pilot testing was done before the use of instruments.
Some of the studies used Cronbach’s alpha method
for ensuring the reliability and expert opinion for
validity of the instruments (Prasad et.al, 2013;
Labrague, 2014).
3.7. Data analysis
All of these studies used both descriptive and
inferential statistics for data analysis. The commonly
used statistical tests were T-Test, ANOVA, and
Friedman test. The rationale for using these tests was
explicitly stated. However, none of the studies applied
the normality test which should have been done
because of the small sample size. Furthermore, some
of the studies also applied correlation and regression
analysis to find out the association among stress,
coping, and the demographic variables (Khater et al.,
2014; Labrague, 2014; Prasad et.al, 2013; Chan et al.,
2009)
4.8. Ethical considerations
The majority of the studies obtained ethical
approval from their respective institutional review
boards. Informed consent was obtained from the
participants and necessary steps were taken to ensure
their confidentially and anonymity. Kaur et al.,
(2009), Singh et al., (2011), and Nancy (2011) did not
obtain ethical approval.
4. Key findings:
It was challenging to compare results among
these studies because of a great number of stressors,
coping strategies, and use of different tools.
Therefore, the key findings are reported in terms of
subsequent themes such as levels of stress, common
stressors, coping strategies, and association among
stress, coping, and demographic variables.
4.1. Level of Stress
Most of the studies revealed that the nursing
students and interns experience moderate stress
during their academic and clinical studies (Chan, So,
& Fong, 2009; Sikander & Aziz, 2012; Singh et al.,
2011; Kaur et al., 2009; Labrague, 2014; Nancy,
2011; Khater et al., 2014). These studies employed a
small convenient sample from a single nursing
institution, thereby limiting the generalization of these
findings. These researchers did not use any structured
method such as power analysis for sample size
estimation. Khater et al., (2014) used a large sample
of 597 nursing students and applied power analysis
for sample size calculation. However, the use of
convenient sampling and data collection from only
two institutions limits the generalization.
In contrast, Prasad et.al, (2013) reported a mild
level of stress among students of Yenepoya Nursing
College Mangalore, India but did not provide any
explanation for this finding. Kaur et al., (2009)
utilized the stress and coping theory of Lazarus and
Folkman (1984), but they used self-administered and
non-valid and non-reliable data collection tools.
These factors limit the generalization of these
findings.
All of the reviewed studies used a self-
administered questionnaire which could have led to
reporting bias. Also, respondents could have
The Journal of Middle East and North Africa Sciences 2016; 2(4) http://www.jomenas.org
53
answered in a socially desirable manner. This
limitation was acknowledged in all of the studies.
Most of the studies reported that first year
nursing students experience more stress than senior
students because of exposure to new and unfamiliar
environments (Kaur et al., 2009; Khater et al., 2014;
Nancy, 2011; Prasad et.al, 2013; Seyedfatemi et al.,
2007). In contrast, Sikander and Aziz (2012)
conducted their study at Shifa College of Nursing
Islamabad, Pakistan and found that second-year
students experience higher stress than other years due
to an increase in both theory and clinical workload.
4.2. Common Stressors
The most commonly stated academic stressor
was assignment workload (Kaur et al., 2009; Khater
et al., 2014; Nancy, 2011; Seyedfatemi et al., 2007;
Labrague, 2014; Sikander & Aziz, 2012) whereas the
commonly reported clinical stressors were lack of
knowledge, inadequate training, and long clinical
hours (Chan et al., 2009; Kaur et al., 2009; Labrague,
2014; Seyedfatemi et al., 2007; Sikander & Aziz,
2012). Singh et al., (2011) and Labrague (2014)
reported that stress affected the emotional and
behavioral health of the Indian and Filipino students.
However, Sikander and Aziz (2012) reported that the
stress mainly influenced the social life of the Pakistani
students.
4.3. Coping Strategies
The majority of studies reported that students
used more positive coping strategies than negative
strategies. The most common positive coping
strategies were problem-solving, transference,
optimism, seeking family and professional support,
and leisure activities (Chan et al., 2009; Khater et al.,
2014; Seyedfatemi et al., 2007; Sikander & Aziz,
2012;). The most commonly reported negative coping
strategies were crying and isolation (Kaur et al., 2009;
Nancy, 2011).
4.4. Association among Stress, Coping, and
Demographic Variables
Four out of nine studies determined an
association of stress and the demographic variables.
Nancy (2011), Sikander and Aziz (2012), and Prasad
et.al, (2013) found no association among the
demographic variables and levels of stress. However,
Labrague (2014) and Khater et al., (2014) reported
that student’s age is negatively associated with the
stress level.
5. Discussion: Direction for Future Research:
This review illustrated that the dynamic nature
of stress has not been adequately investigated in the
current literature. The overall strength of these studies
is weak because of the discussed limitations and the
cross-sectional design. Although most of the studies
used structured data collection tools, these structured
measures may limit the in-depth understanding of
stress and coping of nursing students. Therefore, more
studies are required in the Asian countries particularly
Pakistan, to address this problem.
Stress levels of nursing students may change
over time or across situations due to the transitional
nature of nursing education. Similarly, coping
strategies change from one stage of a complex
stressful experience to another (Lazarus, 1993). Most
of the studies determined level of stress and coping
strategies among nursing students at single point in
time. There is limited evidence how these levels can
change over time and under different conditions.
Future studies should measure this phenomenon using
a mixed-method design or a longitudinal design. A
longitudinal study can also validate the findings
concerning levels of stress across different academic
years. This is consistent with the findings from some
of these studies that stress and coping strategies might
vary at different points in time because of the
transitional nature of nursing students’ life (Khater et
al., 2014; Seyedfatemi et al., 2007).
There was variability in the use, structure, and
content of data collection instruments. The
instruments had 14-66 items for determining the
academic and clinical stress levels and coping
strategies among nursing students. This shows
heterogeneity in the ways of reporting the stressors.
Future research should establish or refine
standardized instruments for measurement of stress
and coping.
These studies reported that most of the
demographic variables, except age, are not associated
with the students’ levels of stress. Future correlational
studies for exploring the relationship of the
demographic variables and levels of stress could be
conducted to validate/refute this finding.
Sample sizes were varied in these studies. This
inferred that the generalizability of these findings is
limited because greater power cannot be achieved. If
future cross sectional study is desired, then it should
use a larger and random sample. The sampling should
be done from various nursing institutions of a
particular country. It should also be based on a
conceptual/theoretical framework in order to guide
more structured inquiry of the variables.
6. Limitations of the review:
The heterogeneity of the reviewed studies in
terms of sample characteristics, data collection tools,
and the operational definitions of the study variables
may have led to difficulties when attempting to
generalize the results. Inclusion of only nine studies
The Journal of Middle East and North Africa Sciences 2016; 2(4) http://www.jomenas.org
54
from few Asian countries and four studies from India
only may impede a comprehensive understanding of
the subject in Asian context.
7. Conclusion:
This review underlined the strength and
limitations of the studies identifying the levels of
stress and coping strategies of nursing students in
Asian context. A number of methodological
limitations were found in these studies indicating that
this topic has not been adequately investigated.
Therefore, further research is needed to expand the
literature in this area. The findings of this paper also
presents suggestions for future research to the nursing
researchers and educators.
Corresponding Author:
Ahtisham Younas, M.N.(c)
Memorial University of Newfoundland and Labrador,
St John’s, Canada.
E-mail: ay6133@mun.ca, &
ahtishamyounas66@gmail.com
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Received March 02, 2016; revised March 08, 2016; accepted March 11, 2016; published online April 01, 2016.
Appendix
Table I: Summary of the Reviewed Studies
Authors & location
of research
Purpose
Sample
size
Study
design
Instrument
Sikander and Aziz
(2012)
Islamabad,
Pakistan
Determine the stressors
and coping strategies in
nursing students
studying at Shifa
college of Nursing,
Islamabad, Pakistan.
78
Analytical
Cross-
Sectional
Stress and coping
inventory of
Lazarus &
Folkman (1984).
The study is considered one of
the initial studies exploring
stress among nursing students.
Therefore, it serves as baseline
for future studies.
The sample size was small and
convenient. The study variables
were not explicitly defined. The
psychometric properties of
research instrument were not
tested. There may be a conflict
of interest as the researchers
were the faculty members of
the same institution.
Prasad, Suresh,
Thomas, Pritty,
Beebi, and
Multazim (2013)
Yenepoya Nursing
College,
Mangalore, India
The study aimed to
determine the level of
stress and coping
mechanisms adopted by
I Year B.Sc. nursing
students.
60
Descriptive
Cross-
Sectional
Perceived stress
scale, Structured
coping scale, and
Socio-
demographic
proforma.
The study was conducted by
novice researchers (Fourth
Year nursing students). The
sample size was small and
convenient.
The Normality test was not
applied before using parametric
tests.
Nancy (2011)
A private nursing
institute of Punjab
affiliated with
Baba Farid
University of
Health sciences,
Faridkot, India
To assess the stress
level and coping
strategies used by
nursing students.
180
Descriptive
Cross-
Sectional
Perceived Stress
Scale -14 and
ACOPE.
The study was not approved
from Ethical Review board.
Permission was only taken
from the college authority.
The psychometric properties of
research instrument were not
tested and no pilot study was
undertaken.
The sample size was small and
convenient. The study variables
were not explicitly defined. The
Normality test was not applied
before using parametric tests.
The Journal of Middle East and North Africa Sciences 2016; 2(4) http://www.jomenas.org
56
Chan, So, and
Fong, (2009)
Hong Kong
To examine Hong Kong
baccalaureate nursing
students' stress and their
coping strategies in
clinical practice.
205
Descriptive
Cross-
Sectional
Perceived Stress
Scale, Physio
Psycho–Social
Response Scale,
and Coping
Behavior
Inventory.
The sample size was small and
convenient. The study variables
were not explicitly defined. The
Normality test was not applied
before using parametric tests.
Singh, S. Sharma,
and R. Sharma
(2011)
National Institute
of Nursing
Education in
Chandigarh, India
To find out the level of
stress and coping
strategies used by
nursing interns of
National Institute of
Nursing Education,
PGIMER, Chandigarh.
44
Descriptive
Cross-
Sectional
Stress scale,
Perceived Stress
Scale, and Physio-
psycho-social
response scale
The study was not approved
from Ethical Review board.
The psychometric properties of
research instrument were not
tested and no pilot study was
undertaken. Expert opinion was
sought to ensure validity and
reliability of data collection
instruments.
The sample size was small and
convenient. The study variables
were not explicitly defined. The
Normality test was not applied
before using parametric tests.
Seyedfatemi,
Tafreshi, and
Hagani (2007)
Iran Faculty of
Nursing &
Midwifery
To identify sources of
stress in nursing
students and to
determine how they
cope with stressful
events.
366
Descriptive
Cross-
Sectional
Student Stress
Survey and
ACOPE.
The sample size was small and
convenient. The study variables
were not explicitly defined. The
Normality test was not applied
before using parametric tests.
Labrague
(2014)
Philippines
The aim of the study
was to identify the level
of stress, common
sources of stress, and
physio- psycho-social
responses to stress and
to identify the
determinants of stress
among student nurses
enrolled in a
government nursing
school.
6
1
Descriptive
cross-
sectional
Perceived Stress
Scale and Physio
Psycho–Social
Response Scale.
The sample size was small and
convenient. The Normality test
was not applied before using
parametric tests.
Khater, Akhu
Zaheya, and
Shaban (2014)
Northern Jordan
The purpose of this
study is to assess stress
level and sources of
stress among nursing
students in Jordan, as
well as identifying the
coping strategies
utilized by nursing
students.
597
Descriptive
cross-
sectional
Perceived Stress
Scale and Coping
Behavior
Inventory
Power analysis was used for
sample size estimation.
The study variables were not
explicitly defined.
The sample size was
convenient. The Normality test
was not applied before using
parametric tests.
The Journal of Middle East and North Africa Sciences 2016; 2(4) http://www.jomenas.org
57
Kaur, Das,
Amrinder, Kanika,
Meena,
Gagandeep, and
Arash, (2009).
India
The purpose of the
study was to identify
the stressors and coping
strategies of
baccalaureate nursing
students at one of the
premier institutes of the
country.
205
Descriptive
cross-
sectional
Newly developed
self-administered
questionnaire to
assess stress and
coping strategies
The study was based on Stress
and Coping Theory of Lazarus
and Folkman (1984).
The study was not approved
from Ethical Review board.
The psychometric properties of
research instrument were not
tested and no pilot study was
undertaken. The questionnaires
used were not valid and
reliable.
The sample size was small and
convenient. The study variables
were not explicitly defined. The
Normality test was not applied
before using parametric tests.
... We found stress-related outcomes for nine MENA countries: Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. The reported primary outcomes are measures of stress levels (six systematic reviews [63][64][65][66][67][68]) and stress coping strategies (one systematic review [69]). The included systematic reviews did not report stressors as a primary outcome. ...
... The included systematic reviews did not report stressors as a primary outcome. Five systematic reviews [63][64][65][66]69] searched any country (global coverage), one systematic review [67] searched for data on Saudi Arabia only, and one systematic review [68] searched Asian countries. ...
... All included systematic reviews conducted a comprehensive literature search and described the characteristics of the included studies. Only two systematic reviews [64,68] searched grey literature sources. Except for the systematic review of Younas, 2016 [68], all systematic reviews documented the scientific quality of their included studies. ...
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Background In nursing students, high stress levels can lead to burnout, anxiety, and depression. Our objective is to characterize the epidemiology of perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa region. Methods We conducted an overview of systematic reviews. We systematically searched PubMed, Embase, PsycInfo, and grey literature sources between January 2008 and June 2020 with no language restrictions. We included any systematic review reporting measurable stress-related outcomes including stress prevalence, stressors, and stress coping strategies in nursing students residing in any of the 20 Middle East and North Africa countries. We also included additional primary studies identified through a hand search of the reference lists of relevant primary studies and systematic reviews. Results Seven systematic reviews and 42 primary studies with data from Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan were identified. Most studies included nursing students undergoing clinical training. The prevalence range of low, moderate, and high perceived stress among nursing students was 0.8–65%, 5.9–84.5%, and 6.7–99.2%, respectively. Differences related to gender, training period, or the type of tool used to measure stress remain unclear given the wide variability in the reported prevalence measures across all stress levels. Common clinical training stressors were assignments, workload, and patient care. Academic training-related stressors included lack of break/leisure time, low grades, exams, and course load. Nursing students utilized problem focused (dealing with the problem), emotion focused (regulating the emotion), and dysfunctional (venting the emotions) stress coping mechanisms to alleviate their stress. Conclusions Available data does not allow the exploration of links between stress levels, stressors, and coping strategies. Limited country-specific prevalence data prevents comparability between countries. Reducing the number or intensity of stressors through curriculum revision and improving students’ coping response could contribute to the reduction of stress levels among students. Mentorship, counseling, and an environment conducive to clinical training are essential to minimize perceived stress, enhance learning, and productivity, and prevent burnout among nursing students.
... Students in nursing experience many stressors during their academic life (Pulido-Martos, Augusto-Landa & Lopez-Zafra, 2012;Younas, 2016), affecting their ability to care for their patients and themselves (Clark, 2014). It has also been noticed that patients and their families perceive nurses and nursing students engaged in self-care positively. ...
... Their studies noted that nursing students have a positive attitude towards self-care management. However, the results were contrary to the finding of Pulido-Martos, Augusto-Landa, and Lopez-Zafra, (2012) and Younas, (2016) who stated that nursing students neglect their self-care. AUP nursing students have affirmed their commitment to their self-care while studying. ...
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Self-care management has become a theoretical discussion among health professionals and students. As a result of its importance, the International Council for Nurses has incorporated it in its standard of competence. Self-care encourages health and is a fundamental value of the scope and standards of practice. Nursing students are advised to have proper self-care. This study looked into the self-care management practices of nursing students at the Adventist University of the Philippines and how they align with the institutional outcomes. This quantitative study conveniently samples 47 nursing students as respondents. The study adopted the Circle of Human Potential ' questionnaire by Dossey and Keegan (2009), which assessed self-care management in the areas of physical, relationship, emotional, spiritual, mental, and choice. The application fo SPSS 23 was used for the descriptive and T'Test analysis as demanded by the research questions. The results of the study revealed that there is a positive self-care management attitude among nursing students. The ranked of self-care management from highest to the least in the order of spiritual, mental, emotional, relational, choice, and physical assessments. It further revealed that there was no significant difference in self-care management when considering the gender of the students. The outcomes of the study were in accordance with the AUP institutional outcomes of spirituality, critical thinking, professional expertise, service, health and wellness, and positive attitude. The study recommends that nursing students keep up with their positive self-care management.
... as completing higher levels of education, joining the workforce and managing their personal/social issues. [3][4][5] These sources of stress in nursing education can lead to mental health problems such as stress, anxiety and depression. [5][6][7] A survey study of nursing students found depression, anxiety, and stress ranked at 35.8%, 37.3%, and 41.1% respectively. ...
... Path diagram of TPB model of nursing students' intention to seek professional psychological help Vol.22 No.3 ...
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Nursing students are a high risk group for mental health problems; however they rarely seek professional psychological help. The purpose of this descriptive, cross-sectional study was to examine factors predicting nursing students' intention to seek professional psychological help by using the Ajzen's theory of planned behavior as a framework. The participants were 343 students from a faculty of nursing in Thailand who were screened for psychological distress. Participants were asked to complete self-reported questionnaires, including a demographic data questionnaire, the Depression Anxiety Stress Scale, and the Professional Psychological Help-Seeking Questionnaire. Data were analyzed using descriptive statistics and multiple regression. The findings showed that three independent variables, attitudes toward behavior, subjective norm, and perceived behavioral control that accounted for 16.3%of variance in the participants' intention to seek professional help. Attitudes toward behavior and subjective norm can significantly predict the intention to seek professional psychological help, but the other did not. In addition, behavioral beliefs, normative beliefs, and control beliefs could predict attitudes toward behaviors, subjective norm, and perceived behavioral control, respectively. The findings underscore the importance of working closely with counseling services and the professions in order to ensure nursing students' access to needed support, to increase positive attitudes toward the help-seeking behavior of nursing students and their significant groups, and create cultures of seeking such help across nursing campuses.
... These findings are in concurrence with the work reported more frequent indulging in problem-solving coping strategies brings positive main effect in reducing psychophysiological symptoms and improved overall well-being in nursing students and vice versa. [28,34] However, the role of positive coping strategies to handle stress cannot be overlooked and abundantly mentioned in earlier literature in different populations. ...
Preprint
BACKGROUND: Coronavirus disease (COVID-19) causes significant psychological distress among nursing students. College-bound nursing students might have preferred different types of coping strategies to deal with psychological distress. This study aims to measure the psychological distress and role of coping styles to mediate the stress level among the baccalaureate nursing students amid the COVID-19 pandemic.
... Nursing students should improve their practical skills by practicing diligently in a simulated environment before the clinical practicum. In this study, positive coping styles were more often adopted by nursing students than negative coping styles, consistent with many previous studies [15,29]. The explanations are as follows. ...
Article
Full-text available
Objectives This study aimed to explore the level of stress, types of stressors, type of coping styles, and factors influencing stress levels and coping styles among nursing students during the initial period of the clinical practicum. Methods A cross-sectional survey design was used. In September 2017, participants were recruited from a tertiary hospital in Zhejiang Province, China, using a convenience sampling method. A demographic characteristics questionnaire, the Intern Nursing Student Stressor Scale, and the Simple Coping Style Questionnaire were used to collect data. Data were analysed using descriptive analysis, independent sample t-tests, one-way analysis of variance, Pearson's correlation analysis, and multiple linear regression analysis. Results A total of 158 nursing students were recruited, most of whom were female, undergraduates, and from rural areas. The nursing students perceived a moderate level of stress during the initial period of the clinical practicum. The need for knowledge and skills was the most common source of stress. Positive coping styles were most commonly adopted. Nursing students who were undergraduates, only children, and chose nursing major involuntarily experienced higher stress levels than junior college students, who were not only children, and who chose nursing major voluntarily. Nursing undergraduates were more likely to use positive coping styles than junior college students. Male nursing students and those experiencing higher stress levels related to the “environment and equipment of the wards” and the “nature and content of the work” were more likely to use negative coping styles. Conclusion Nursing educators should offer targeted guidance based on the stress reported during the clinical practicum and the demographic characteristics of the nursing students. Guidance should be provided to encourage nursing students to adopt effective coping strategies and reduce stress.
... Moreover, stress can negatively affect students' behaviors, such as their nutritional intake, work productivity, and social interaction [8][9][10][11][12]. Nursing students most commonly experience stress within three domains: academic concerns, clinical practice, and social factors [9,[12][13][14]. ...
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Abstract: Introduction: Nursing students experience higher levels of stress than those in other health-related disciplines; however, there are limited data exploring stress among these students in a Saudi context. Aim: This study examines sources of stress among nursing students at an academic institution in Jeddah, Saudi Arabia, using a descriptive quantitative cross-sectional research design. Methods: Data were collected from a convenience sample of 500 undergraduate nursing students, with a response rate of 71.8%, using an adapted Stress in Nursing Students (SINS) questionnaire. Results: Nursing student sources of stress fell into three categories: academic concerns, clinical practice, and social factors. Discussion: The results demonstrate commonality between other countries’ sources of stress for nursing students but highlight cultural factors unique to Saudi Arabia. This study shows opportunities for cross-cultural learning and areas needing cultural tailoring to reduce stress among nursing students.
... Numerous studies have identified the levels of stress and coping strategies used by nursing students. Studies have shown that nursing students experience moderate levels of stress and use more positive coping strategies than negative strategies [11,12]. However, one study showed that the passive coping strategy was used more frequently by nursing students as their perceived stress levels increased [13]. ...
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Nursing students experience various stressors during their initial clinical practicum. As these stressors negatively affect learning and performance, coping strategies are essential. Therefore, this research study explored the relationship between coping styles and stress levels using a cross-sectional study with a convenience sample of 184 nursing students. Clinical practicum stress and coping styles were assessed via electronic questionnaires, and the data were analyzed using descriptive statistics, t-tests, and variance analyses. The highest score for clinical practice stress was for the practical education environment and practical work burden. The total stress score differed significantly according to coping style (t = −2.36, p = 0.020), and the total stress score of the passive coping group was higher. Among the sub-categories of stress, the scores of the education environment (t = −2.68, p = 0.008) and having undesirable role models (t = −2.14, p = 0.034) were significantly higher in the passive coping group. Although practical work burden was the highest stress factor in the active coping style group, the stress on the environment was highest in the passive coping group. The findings show that professors and clinical educators should recognize the various coping styles and incorporate different teaching methods in the clinical setting.
... 33 When confronted with stressful, unpleasant factors in clinical environments, students try to use coping strategies. 34 Some studies have demonstrated that students tended to use positive 35 or avoidance strategies. 36 37 Coping strategies including transference, staying optimistic and problem-solving were other solutions to reduce students' stress. ...
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Introduction On entry into the clinical environment, nursing students are confronted with many challenges. It is a common problem throughout the world, including Iran. Although many studies have been conducted on the problems of nursing students in the clinical environment, limited information is available on nursing students’ experiences of the clinical learning environment and the way they respond to these experiences. Identifying nursing students’ experiences is essential to develop interventions to reduce challenges. Objective This study aimed to explore nursing students’ experiences in a clinical learning environment and the way they responded to these experiences. Design The present study was conducted based on the qualitative research design of the grounded theory methodology. Setting This study was conducted at schools of nursing in academic settings in Iran. Participants The participants included 19 nursing students, 4 nursing instructors and 3 clinical nurses. Methods The data were collected using semistructured interviews, field notes and observation, and were analysed using Strauss and Corbin’s approach. Results Students, as a result of the inadequacy of the educational environment, were faced with ‘confusion of identity’, stating this as their main concern. When confronted with this concern, they employed specific strategies, some of which prevented them from getting into unpleasant conditions. These strategies did not help students solve their problems and also prevented them from accepting their professional roles and responsibilities. Conversely, some other strategies led them to advanced professional development and enabled them to accept their role and the clinical environment. Conclusion According to the results of this study, educational policymakers should focus on improving the clinical environment. Identifying professional models and increasing their influence on management, education and clinical education, as well as teaching positive and constructive strategies, will promote positive strategies in coping with inadequate educational contexts. This is necessary for the professional development of nursing students.
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Purpose: The purpose of the study was to examine the effects of mindfulness-based stress reduction (MBSR) on stress levels and mindfulness of nursing students. Methods: The study was quasi-experimental and included pretest-posttest control groups. Results: No differences were detected between the pretest scores of the scales of the students of both groups. Students in the intervention group demonstrated increased mindfulness and decreased stress levels (p < 0.05). Practical implications: MBSR applied in the present study effectively reduced the stress of nursing students and increased their mindfulness.
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The purpose of this study is to assess stress level and sources of stress among nursing students in Jordan, as well as identifying the coping strategies utilized by nursing students. Participants included 597 nursing students from two faculties of Nursing in Jordan. A descriptive design was employed in this study. Participants were asked to complete demographic data, a perceived stress scale (PSS) and a coping behaviour inventory (CBI) scale. Results showed that of the participants, 286 (47.82%) had stress levels above the mean. The most common type of stressors perceived were related to assignment followed by stress related to patients' care and stress from nursing staff and teachers. The most common coping behaviour utilized by the students was problem solving. Clinical educators and clinical staff should appreciate the complexity of students' responses to stress, and as such, should not follow general principles in dealing with students in their clinical practice.
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Background: Stress is a fact of life that every human deals with on a daily basis. In the transitional nature of student life in professional courses like nursing, initial period of course is stressful and it adversely affects the emotional, physical, social, and academic functions. Even though the perception and response to stress and way of coping differs individually, it may produce questionable behavioral patterns in student nurses during the course of their study like feeling of loneliness, nervousness, sleeplessness, and worrying. Thus, the student nurse faces a lot of challenges and problems at the time of I Year. Objectives: The present study aimed to determine the level of stress and coping mechanisms adopted by I Year B.Sc. nursing students. Materials and Methods: A total of 60 I Year B.Sc. nursing students were selected by using non-probability convenient sampling technique. The tools used for data collection were perceived stress scale, structured coping scale, and socio- demographic proforma. Results: The studies revealed that majority of students (95.1%) were in the age group of 17-19 years. The results showed that only one student (1.7%) has severe stress, 46.7% has moderate stress, and remaining 51.6% has mild stress, and majority of the students (100) had average coping. There was no significant correlation (-1.167) between stress and coping mechanism of I Year B.Sc. nursing students. Conclusion: Majority of students had mild stress and average coping. The nurse administrator should plan and organize educational program for nursing students, in order to prepare them to cope up with any stressful situations. Hence, the researcher emphasizes the need for more research to improve the knowledge and by applying the research finding for future.
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Context: Nursing education is stressful and students go through various pressures throughout their study period. It has been reported that nursing students may encounter different stressors; relating to their academia. These stressors serve as a source of stress and are believed to affect students' health and academic performance. Objective: Determine the stressors and coping strategies in nursing students studying at Shifa college of Nursing, Islamabad- Pakistan. Methods: Analytical cross-sectional study was carried out and data was collected from 78 nursing students of all years of BSc. Nursing by using student's stress and coping inventory of Lazarus & Folk man (1984). Findings: The score of stress level in nursing theory = 2.37, clinical experience = 2.35, College environment= 2.39 and social / personal environment= 251. The p-value of one way ANOVA amongst classes was significant for clinical experience (P = 0.000), college environment (P = 0.00) and social / personal environment (P = 0.000). Most common coping strategies used by the students were; discuss feeling with friends or class mates (Mean= 2.75), did what is expected of me (Mean= 2.84), self analysis to understand the situation better (Mean= 2.38), accept the situation (Mean= 3.1) and become involved in other activities (Mean2.75, SD= 0.99). Conclusion: Significant stressors reported by the students are modifiable and can be reduced by changing assessment criteria, develop eff ective feedback system, strengthening the role of faculty advisors, training of faculties as counselors, providing recreational opportunities to students.
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Background: Stress during nursing education and training has been documented. Although the body of evidence regarding stress among student nurses is growing over the world, there is little in the literature assessing stress among Filipino nursing students enrolled in a government nursing school. Aim: The present study explored the level of stress, stressors, and physio-psycho-social responses to stress among Filipino student nurses in a government nursing school. Method and Material: A descriptive design was adopted in this study. A total of 61 students who were enrolled in the nursing program were taken as study respondents. Research data were collected utilizing the Perceived Stress Scale (PSS) and Physio-psycho-social Response Scale (PPSRS). Data analysis was performed with the statistical package for the social sciences (SPSS) version 16. Results: Findings indicated that student nurses experienced moderate level of stress [mean (SD) = 2.18 (0.43)] and were in good physio-psycho-social health [mean (SD) =1.49 (0.45)]. Stress from assignments and workload [mean (SD) =2.68 (0.58)] was the most common stressor identified, while emotional symptoms [mean (SD) =1.82 (0.67)] were the most common response to stress. In addition, students who reported higher level of stress were significantly more likely to experience poor physio-psycho-social health (r=0.3463,p=0.0063). Result also revealed that perceived stress level decrease according to the year of attendance. Conclusions: Results indicated that stress is very common in nursing education and it may have an impact on the physio-psycho-social health of the students. Knowledge on student nurses’ stress levels, its sources, and stress responses would serve as an important input in identifying and planning effective interventions and strategies to reduce or prevent stress in nursing education and training thus, facilitating their learning both in the academe and clinical setting.
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Nurse educators are facing the challenge of creating new ways of teaching and facilitating enhanced learning experiences in clinical practice environments that are inherently complex, highly demanding, and unpredictable. The literature consistently reports the negative effects of excess stress and unsupportive relationships on wellbeing, self-efficacy, self-esteem, learning, persistence, and success. However, understanding contributing factors of stress, such as the student's experiences of uncaring and oppressive interactions, is clearly not adequate. The transformation of nursing education requires a paradigm shift that embraces collegiality, collaboration, caring, and competence for students and the faculty. This paper reviews the literature on stress and its effects on nursing students. Grounded in theory related to stress and human caring, this paper focuses on the clinical environment and faculty-student relationships as major sources of students' stress and offers strategies for mitigating stress while fostering learning and professional socialization of future nurses.
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Background: Mounting literature on stress and coping in nursing students are available; however, most of the findings are confined to a single cultural group. Aims: This study was conducted to determine the level of stress, its sources and coping strategies among nursing students from three countries: Greece, the Philippines and Nigeria. Methods: Using a descriptive, comparative research design, 547 nursing students (161 Greek nursing students, 153 Filipino nursing students, 233 Nigerian nursing students) participated in the study from August 2015 to April 2016. Two standardized instruments were used, the Perceived Stress Scale (PSS) and the Coping Behavior Inventory (CBI). Results: Findings revealed that the degree of stress and the type of stressors and coping styles utilized by nursing students differ according to the country of origin. The year of study predicted overall stress (β = –0.149, p < 0.001) while advanced age predicted overall coping (β = 0.008, p = 0.037) in the nursing students. Conclusions: Strengthening nursing students’ positive coping skills may be helpful for them to effectively deal with various stressors during their educational experiences while maximizing learning. Implementing empirically tested approaches maybe useful to prevent the recurrence of stress and lessen its impact such as stress management counseling, counseling programs, establishing peer and family support systems, and formulating hospital policies that will support nursing students.
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Role stress has received a lot of research attention in psychological, sociological, and organizational studies over the last several decades. Based on a literature review of about 300 journal articles, this article examines prominent consequences of role stress. Specific focus is on researching differences in relationships between facets of role stress (i.e., role ambiguity, role conflict, and role overload) and frequently cited consequences using techniques of meta-analysis. Findings indicate that each role stress facet has a different relationship with the eight consequences studied. Role stress research can benefit from looking at each facet individually in addition to role stress generally.
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The purpose of this study was to investigate the perception of level and sources of stress in students of two baccalaureate nursing programs, to compare these groups in their perceived stress and to compare the nursing groups to those enrolled in other health-related disciplines: Medicine, Pharmacy and Social Work. The study was descriptive correlational in design. The sample consisted of 552 full-time university students enrolled in years 2, 3 and 4 of their programs in selected disciplines. Data were collected by means of a questionnaire consisting of three main instruments: the Beck-Srivastava Stress Inventory (BSSI), the General Health Questionnaire 30-item version (GHQ-30) and a demographic profile. Data were analyzed using the SPSSx Statistical Package and included analysis of variance, frequency distribution, measures of correlation, item analysis and factor analysis. The results revealed that baccalaureate nursing students, regardless of year in program or university of attendance, experienced higher levels of stress and higher levels of physiological and psychological symptoms than students in other health-related disciplines. Identified stressors among the disciplines are also reported in the article.