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

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.

Full text

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

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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, Augusto‐Landa, & Lopez‐Zafra, 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; Pulido‐Martos et
al., 2012).
There is ample literature on this subject from
within western countries. After a systematic review of
23 studies, Pulido‐Martos 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

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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

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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
Strengths and Limitations
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.