Journal of Nursing Education

Major Article 

Stress and Coping Among Nursing Students During Clinical Training: An Integrative Review

Hanish Dev Bhurtun, MSc, RN; Mina Azimirad, MSc, RN; Terhi Saaranen, PhD, RN, PHN; Hannele Turunen, PhD, RN

Abstract

Background:

Nursing students perceive stress during clinical trainings and use various coping strategies to manage it. This integrative review critically appraises previous literature on stress and coping strategies among undergraduate nursing students during clinical training.

Method:

An integrative review procedure was followed. Five electronic databases were searched with various search terms. A total of 1,170 publications were screened, 13 of which were included in the review.

Results:

Most studies applied a cross-sectional, descriptive approach. Students perceived moderate to high levels of stress during their clinical trainings, with problem solving and transference the most common coping techniques. Teachers and nursing staff were a strong stressor because students felt they were constantly being observed and evaluated.

Conclusion:

The findings may provide guidance for how nursing staff can mentor students during clinical practice and establish a more supportive clinical environment. [J Nurs Educ. 2019;58(5):266–272.]

Abstract

Background:

Nursing students perceive stress during clinical trainings and use various coping strategies to manage it. This integrative review critically appraises previous literature on stress and coping strategies among undergraduate nursing students during clinical training.

Method:

An integrative review procedure was followed. Five electronic databases were searched with various search terms. A total of 1,170 publications were screened, 13 of which were included in the review.

Results:

Most studies applied a cross-sectional, descriptive approach. Students perceived moderate to high levels of stress during their clinical trainings, with problem solving and transference the most common coping techniques. Teachers and nursing staff were a strong stressor because students felt they were constantly being observed and evaluated.

Conclusion:

The findings may provide guidance for how nursing staff can mentor students during clinical practice and establish a more supportive clinical environment. [J Nurs Educ. 2019;58(5):266–272.]

Stress is a continuous problem in nursing education. It arises not only in the academic context, but also in the clinical environment (Pulido-Martos, Augusto-Landa, & Lopez-Zafra, 2012). Lazarus and Folkman (1984) defined stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (p. 13). Stress can be both beneficial and detrimental to students (Gibbons, 2010). In small amounts, it may be productive, promote motivation, and empower students to achieve their goals (Behere, Yadav, & Behere, 2011; Gibbons, 2010). However, in greater amounts, unmanaged stress or the inability to cope with chronic stress may negatively affect students, ultimately leading to poor academic performance and/or disease (Pulido-Martos et al., 2012; Sheu, Lin, & Hwang, 2002). Recent years have been characterized by an increased focus on stress among higher education nursing students during their clinical training with an aim to improve clinical education and create successful clinical guidance methods (Al-Zayyat & Al-Gamal, 2014; Alzayyat & Al-Gamal, 2014). Some studies have reported that nursing students experience mild to moderate levels of stress (Alzayyat & Al-Gamal, 2016; Jimenez, Navia-Osorio, & Diaz, 2010; Sheu et al., 2002), whereas others have revealed moderate to high levels (Rasha & Haya, 2016; Suen, Lim, Wang, & Kowitlawakul, 2016).

In addition to investigating levels of stress among nursing students, several studies also have examined its sources. These sources, also called clinical stressors, have been shown to exert either a mild to moderate or moderate to high influence over students. Mild to moderate clinical stressors include caring for patients, fear of the unknown, lack of professional knowledge and skills, and witnessing the suffering of patients and relatives (Alzayyat & Al-Gamal, 2016; Gibbons, 2010; Kim, 2003). Moderate to high clinical stressors include worrying about grades, experiencing pressure from the nature and quality of clinical practice, and the feeling of not meeting teachers' expectations (Alzayyat & Al-Gamal, 2016; Kim, 2003; Labrague et al., 2016). Additionally, working with unknown people, observation by mentors, negative interactions with mentors, being late, fear of making mistakes, initial experience at a unit, and talking with doctors are sources of stress that have been reported to cause even higher levels of stress among nursing students (Kim, 2003; Rasha & Haya, 2016).

Nursing students use several strategies to cope with their stress. Coping can be divided into two categories: problem based and emotion based (Lazarus & Folkman, 1984). Several studies have emphasized that nursing students are more likely to apply problem-based approaches than emotion-based approaches when stressed (Akhu-Zaheya, Shaban, & Khater, 2015; Al-Zayyat & Al-Gamal, 2014; Alzayyat & Al-Gamal, 2016; Labrague et al., 2016). Problem-based coping strategies include problem solving, a positive attitude when coping with everyday issues, using previous experiences to solve problems, seeing things objectively, adopting different strategies to solve problems, and establishing clear objectives (Al-Zayyat & Al-Gamal, 2014; Alzayyat & Al-Gamal, 2016; Labrague, 2013; Sheu et al., 2002). Additionally, Sheu et al. (2002) found that students experiencing low to moderate levels of stress use being optimistic (a problem-based strategy) as their main coping method, whereas those experiencing high levels of stress use avoidance and transference tactics for coping (Yamashita, Saito, & Takao, 2012).

Similarly, researchers recently found that students who reported moderate to high levels of stress tend to use emotion-based coping mechanisms, such as receiving moral support from family, establishing cordial relationships with nursing staff, praying to God, approach coping, and avoidance (Bam, Oppong, & Ibitoye, 2014; Shukla, Kalra, & Pakhare, 2012). One study also indicated that younger nursing students more often use emotion-based coping mechanisms, including being worried, nervous, or anxious, feeling depressed, and feeling miserable, whereas older nursing students commonly use problem-based stress management approaches such as problem-solving skills (Khater, Akhu-Zaheya, & Shaban, 2014). As such, the use of problem-based coping strategies benefited students' learning and clinical education, whereas students who utilized emotion-based coping mechanisms reported poor health and well-being (Sheu et al., 2002; Tully, 2004). This suggests that chronic stress may harm nursing students. More specifically, it may affect the learning, decision making, and thinking processes, as well as cause depression, feelings of loneliness, listlessness or sleepiness, and nervous breakdowns (Labrague, 2013; Sheu et al., 2002; Yamashita et al., 2012).

Study Aims

The aim of this review was to search, extract, appraise, and synthesize previous health care education research relating to stress and coping strategies among nursing students during their clinical training. The research was guided by the following questions:

  • What are the characteristics of studies that have investigated stress and coping among nursing students during their clinical training?
  • What are the levels and sources of stress, along with the associated coping strategies, that have been reported in these studies?

Method

Search Strategy

An integrative review guided by Whittemore's and Knafl's (2005) approach was chosen because it permitted the inclusion of research that used different study designs. We thought this decision would facilitate understanding stress and coping strategies among undergraduate nursing students during their clinical training in a broad and comprehensive manner. Five databases were searched with the help of a library information specialist. These were CINAHL® because the search topic was related to nursing and health care professionals; MEDLINE® because this database mainly encompasses medicine- and health care-related literature; PsycINFO® because of the psychological character of stress; SCOPUS® because this database includes literature related to medicine and social sciences; and ERIC® because of its wide range of indexed materials. Test searches were conducted with various search terms to adequately understand the range of results. Consequently, the search terms were carefully planned to limit unrepresentative search results.

Search terms included stress (equivalent terms such as eustress and distress), coping mechanisms (equivalent terms such as cope, coping, coping strategy, responses to stress, coping techniques), nursing students (equivalent words such as student nurse, undergraduate nursing student, and trainee nurse) and clinical practice (equivalent words such as internship and clinical education) in various combinations.

Inclusion and Exclusion Criteria

Articles were assessed for relevance based on the following criteria: published between January 2007 and August 2018; peer reviewed; written in the English language; and passed a quality appraisal process.

The exclusion criteria were: nonresearch publications; and content that did not relate to undergraduate nursing student stress and coping mechanisms in clinical education or a clinical internship that is part of the bachelor's nursing degree or degree in health care program.

Search Outcomes

The reference management software Refworks® was used to sort the publications. The database search yielded a total of 953 nonduplicate results. The majority of articles were excluded following a review of the title (n = 835), abstract (n = 78), or full-text content (n = 13). Following the exclusion step, 27 articles were identified as meeting the inclusion criteria of this review. The process used to reduce and evaluate the records is illustrated in Figure 1.

PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) diagram showing article selection.

Figure 1.

PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) diagram showing article selection.

Quality Appraisal

The 27 studies that met the inclusion criteria were independently appraised by two researchers using a nine-item standardized appraisal tool (Hawker, Payne, Kerr, Hardey, & Powell, 2002). The nine items included the abstract and title; introduction and aim; reporting method; sampling; analysis; ethics and bias; results; transferability and generalizability; and implications and usefulness. Each of these sections was scored according to four values: good (4); fair (3); poor (2); and very poor (1). In this way, an article could receive a maximum score of 36 points and a minimum score of 9 points. The mean score was 24 and the mode was 29. Consequently, only higher quality publications (i.e., studies that accumulated more than 29 points) were selected. Following the exclusion of lower quality articles, 13 articles were included in this study. Furthermore, both of the researchers' appraisal ratings for each study were analyzed with SPSS software (version 24.0). Cohen's kappa score (κ = 0.66) indicated substantial agreement between the researchers (Gravetter & Wallnau, 2013).

Data Extraction and Synthesis

The narrative conceptual synthesis method was used in data extraction due to the heterogeneous nature of research methodologies employed in the included 13 publications. This method was chosen because it would present a comprehensive view of stress and the associated coping mechanisms among undergraduate nursing students during their clinical training (Khan, Kunz, Kleijnen, & Antes, 2003).

Results

The studies included in this review are summarized in Table A (available in the online version of this article), and the detailed findings, organized according to the three parts of the applied analysis, are discussed in the next section.

Characteristics of the Reviewed PapersCharacteristics of the Reviewed PapersCharacteristics of the Reviewed PapersCharacteristics of the Reviewed Papers

Table A:

Characteristics of the Reviewed Papers

Characteristics of the Studies

Four studies were from Asia—more specifically, Hong Kong (Chan, So, & Fong, 2009), China (Liu, Gu, Wong, Luo, & Chan, 2015; Zhao, Lei, He, Gu, & Li, 2015), and Singapore (Suen et al., 2016). Four studies were from Jordan (Al-Gamal, Alhosain, & Alsunaye, 2018; Al-Zayyat & Al-Gamal, 2014; Alzayyat & Al-Gamal, 2016; Shaban, Khater, & Akhu-Zaheya, 2012). Three studies represented Europe (Gurková & Zeleníková, 2018; Jimenez et al., 2010; Zupiria Gorostidi et al., 2007), and both Saudi Arabia (Rasha & Haya, 2016) and Turkey (Bahadır-Yılmaz, 2016) were represented by one study each. Of these studies, nine used descriptive, cross-sectional designs with sample sizes ranging from 109 to 357 nursing students, three were longitudinal in nature with sample sizes ranging from 65 to 69 nursing students, and one applied a descriptive analytical approach to a sample of 51 nursing students. The Perceived Stress Scale (PSS) and Coping Behavior Inventory (CBI), both developed by Sheu et al. (2002), were the most common (8 of 13 studies) instruments used to measure the levels and sources of stress and coping strategies, respectively. Table A displays the characteristics of the articles included in this review.

Levels and Sources of Stress

All the studies reported levels and sources of stress. Most of them reported that undergraduate students experience moderate levels of stress during their clinical placements (Al-Gamal et al., 2018; Al-Zayyat & Al-Gamal, 2014; Alzayyat & Al-Gamal, 2016; Bahadır-Yılmaz, 2016; Chan et al., 2009; Gurková & Zeleníková, 2018; Jimenez et al., 2010; Liu et al., 2015; Shaban et al., 2012; Suen et al., 2016; Zhao et al., 2015), whereas one study reported only high levels of stress (Rasha & Haya, 2016) and another reported low to moderate levels (Zupiria Gorostidi et al., 2007). In this review, all the included studies that used the PSS explained the levels of stress among participants based on the obtained PSS value. If the PSS value was above the mean level, it would suggest moderate stress levels. However, not all studies included in this review used the PSS and, as such, reporting levels of stress remains unclear because the levels considered moderate by one study might be regarded as mild by another.

Teachers and Nursing Staff. Teachers and nursing staff were identified as the main source of stress during nursing students' clinical training in several studies. For example, one study revealed that being criticized by teachers was the most frequent stressor reported by Turkish nursing students, followed by encountering dying patients (Bahadır-Yılmaz, 2016). Two other studies that applied PSS identified teachers and staff, caring for patients, and assignments and workloads as the main sources of stress among postpsychiatric/mental health clinical training nursing students in Jordan (Al-Zayyat & Al-Gamal, 2014; Alzayyat & Al-Gamal, 2016). Furthermore, another study that explored clinical stressors and coping strategies among 181 second-year undergraduate nursing students in their first clinical training found staff and teachers, the clinical environment and assignment work to be the main sources of stress. These stressors had mean PSS scores of 1.77, 1.88, and 2.34, respectively, with the PSS scale ranging from 0 to 4, where 0 represents not stressed and 4 represents very stressed. One suggested reason for why students perceive stress from teachers and nursing staff was that the latter act as evaluators during clinical trainings. In this way, students feel they are being constantly observed and evaluated (Gurková & Zeleníková, 2018).

Lack of Knowledge and Skills. Three studies described lack of knowledge and skills as a frequent stressor (Chan et al., 2009; Jimenez et al., 2010; Zupiria Gorostidi et al., 2007). One of the included studies explored clinical stressors and biopsychosocial responses among 357 nursing students by using a Spanish-adapted version of PSS and a self-reported Biopsychosocial Response Scale. The results identified lack of knowledge and skills as the main clinical stress. Furthermore, an analysis of the PSS sub-scales revealed that witnessing the pain and suffering of patients and relatives, being unable to provide appropriate responses to doctors', teachers', and patients' questions, and not knowing how to help patients with biopsychosocial problems were items that students perceived to be slightly above moderately stressful. The least stressful items were: unable to get along with other peers in the group; feeling that the requirements of clinical practice exceed one's physical and emotional endurance; and feeling stressed that the teacher's instruction is different from one's expectations. Furthermore, this study also found that students experience clinical stressors more intensely than academic and external stressors (Jimenez et al., 2010). Another study explored sources of stress among 69 nursing students during their clinical training by using a self-reported questionnaire. This study revealed that first- and last-year students perceived the lack of competency and uncertainly as the dominant sources of stress. Of note, this study also found out that the influence of stress-ors diminishes over the course of the nursing program (Zupiria Gorostidi et al., 2007). Additionally, a cross-sectional study conducted in Hong Kong that applied the PSS and CBI identified lack of professional knowledge and skills to be a powerful clinical stressor among nursing students (Chan et al., 2009).

Fear of Making Mistakes and Heavy Workload. Two Chinese studies identified fear of making mistakes and heavy workload as sources of stress for nursing students in their clinical placements (Liu et al., 2015; Zhao et al., 2015). The first study applied a cross-sectional approach and the Chinese version of the Stressors in Nursing Students Scale to investigate stress during clinical training. Clinical stressors were: having too much clinical responsibility, and feeling responsible for what happens to the patient (Liu et al., 2015). The second study also used a cross-sectional approach and used PSS, along with other scales, to measure reported sources of stress, coping strategy, and the effects of self-efficacy during clinical training. The results revealed heavy workload and assignments during the clinical training as one of the dominant stressors (Zhao et al., 2015).

Furthermore, this review revealed that satisfaction in terms of fulfillment is an influential factor in clinical training that contributes to students' stress. Third-year students reported higher levels of stress than first-year students. An inspection of the determinants of stress suggested that female nursing students experience higher levels of stress than their male counterparts (Suen et al., 2016), which is consistent with the results from another study included in this review (Shaban et al., 2012). In addition to examining sources of stress, some of the included studies investigated the association between stress and other psychological constructs other than coping. For instance, one of the studies examined the moderating effects of self-efficacy among nursing students. The students with a stronger sense of self-efficacy tended to stay optimistic and use problem-solving strategies when under stress (Zhao et al., 2015). Additionally, one Singaporean study concluded that nursing student satisfaction is a predictor of stress levels (Suen et al., 2016).

Problem- and Emotion-Based Coping Strategies

Eight of the studies included in this review reported coping strategies, and staying optimistic was the most commonly discussed strategy (Al-Gamal et al., 2018; Al-Zayyat & Al-Gamal, 2014; Alzayyat & Al-Gamal, 2016; Bahadır-Yılmaz, 2016; Chan et al., 2009; Rasha & Haya, 2016; Shaban et al., 2012; Zhao et al., 2015). One study clearly showed that self-confidence and an optimistic approach, both of which can be considered problem-based coping strategies, were the preferred coping styles among Turkish nursing students (Bahadır-Yılmaz, 2016). A Jordanian study also reported that undergraduate nursing students in psychiatric/mental health clinical training mainly use problem solving and staying optimistic to manage stress (Al-Zayyat & Al-Gamal, 2014). However, one study conducted in Hong Kong reported that students adopted transference—more specifically, eating large meals and watching television—as their main coping strategy. This is an interesting finding, as these activities are associated with an emotion-based, rather than a problem-based, coping strategy.

Chan et al. (2009) examined coping behaviors among 205 nursing students using CBI and found that nursing students frequently use staying optimistic as a coping strategy. However, the same study revealed that transference (i.e., watching television and sleeping) was the most popular coping method among nursing students and avoidance was the least popular. Another study (Shaban et al., 2012) reported similar results, identifying staying optimistic and transference as the most common coping strategies and avoidance—namely, avoiding difficulties and expecting miracles—as the least frequently mentioned. Furthermore, the author found avoidance strategies to be positively correlated to stressors linked with patient care. Other infrequently used coping strategies include seeking diversions and self-reliance (Rasha & Haya, 2016). In addition to discussing numerous coping methods, Chan et al. (2009) reported that senior students commonly use problem solving in combination with avoidance, and that students without religious beliefs are characterized by an increased likelihood of using avoidance to cope with stress. Al-Zayyat and Al-Gamal (2014) mentioned that students who used avoidance strategies also had high levels of stress before the psychiatric/mental health clinical training.

Discussion

The results of our review clearly indicated that various methodologies, in terms of settings, study designs, sample sizes, and instruments, have been used to collect data concerning nursing students' levels and sources of stress during clinical practice. Nevertheless, all the studies were quantitative and cross-sectional in nature. The studies may have preferred the cross-sectional design because it is easier and faster to apply. However, given the dynamic nature of stress, students may experience changing levels of stress during their studies; in this way, accurately recalling previous stress experiences may not always be successful. To investigate this dynamic further, one of the studies included in the current review explored the evolution of stress during nursing students' studies. The authors reported that stress levels do indeed change over study years but concluded that nursing students are influenced by the same stressors at the start and end of their studies (Zupiria Gorostidi et al., 2007). Most of the included studies were from Asia and the Middle East, yet all varied greatly in terms of sample size and instruments used to measure stress and coping. Sample sizes ranged from 65 to 357, with the sample primarily collected from one site, and most studies did not report a power analysis. Although most studies used PSS and CBI—both of which are well-established and validated instruments to measure stress and coping, respectively—several studies used other instruments such as self-reported questionnaires and often failed to report conducting a pilot study to test their validity. Difficulties in the comparison of results from various methodologies have been mentioned in previous reviews of stress and coping strategies among nursing students (Alzayyat & Al-Gamal, 2014; Labrague et al., 2016).

Clinical Stressors and Stress Levels Among Nursing Students

The included studies revealed that nursing students encounter several stressors (e.g., caring for patients, assignments during the clinical training, lack of knowledge, being criticized by teachers and excessive workload, and responsibility) in the clinical practice environment. This finding is consistent with what has been reported in previous literature reviews of stress and coping among nursing students (Alzayyat & Al-Gamal, 2014; Labrague et al., 2016). However, this review also found evidence that teachers and nursing staff are a prevalent clinical stressor and cause the highest levels of stress among nursing students during their clinical period. This may be because of the nursing education models used in the countries included in this study. In some countries, clinical teaching is conducted by preceptors, yet others might use doctors or other agency staff for this task. Furthermore, some cultures may accept authoritarian teaching approaches by teachers and nursing staff, which may contribute to increased levels of stress. Although the longitudinal study by Burnard, Haji Abd Rahim, Hayes, and Edwards (2008) of 1,707 nursing students from five different countries (Albania, Brunei, Czech Republic, Malta, and Wales) reported that students shared common stress factors such as suffering and death of patients regardless of their country of origin, cultural variations, such as teacher–student relations and thoughts concerning education processes, may also influence stress levels (Burnard et al., 2007; Robotham, 2006). Another recent study found that Slovak students felt highly stressed when their group was supervised by their nursing teachers (Gurková & Zeleníková, 2018). Similarly, a lack of time for communicating between students, teachers, and nursing staff has also been reported as an important stressor among nursing students (Timmins & Kaliszer, 2002).

None of the studies included in this review were from the United States. However, during our search, we identified two previous studies conducted in the United States that reported a fear of failure, problems with faculty, and negative interactions with teachers and nursing staff as common clinical stressors. However, the levels of stress experienced by students included in these studies were not measured, and the studies were thus excluded from this review. Furthermore, the same studies reported that teachers, family, and friends were a key source of support for coping with such stress (Reeve, Shumaker, Yearwood, Crowell, & Riley, 2013; Wolf, Stidham, & Ross, 2015). Furthermore, this review also revealed that the majority of nursing students perceive moderate levels of stress during clinical training, a finding that is supported by previous literature reviews (Alzayyat & Al-Gamal, 2014; Jimenez et al., 2010; Labrague et al., 2016). However, one study reported that Saudi Arabian nursing students experience high levels of stress (Rasha & Haya, 2016). This finding may be explained by the nature of the clinical stressor—that is, the inability to control important things in life—and/or the fact that these nursing students were in their first clinical training. This finding is consistent with what has been reported in several studies that were published before the date range applied to this review (Al-Zayyat & Al-Gamal, 2014; Sheu et al., 2002).

Coping Strategies

The studies included in this review revealed that nursing students commonly cope with stress by staying optimistic, being self-confident, and using transference and avoidance. Staying optimistic, which was first described by Lazarus and Folkman (1984) as an effective problem-solving approach, was found to be the most popular strategy for coping with stress. This approach includes behaviors that address the stressful situation—for example, setting up objectives, adopting various strategies, and using past experiences to solve problems. In contrast, some of the included studies reported that nursing students use actions classed as emotion based by Lazarus and Folkman (1984) to cope with stress. These strategies included behaviors such as avoidance, transference (e.g., watching television or sleeping), and seeking diversions. These types of actions have been described as ineffective coping strategies because they do not solve the problem and postpone addressing stress rather than effectively managing it. Of note, first-year nursing students tended to use this approach, a finding which may be explained by a lack of knowledge concerning how to use other approaches to effectively diminish stress. Furthermore, students who used emotion-based approaches seemed to report higher levels of stress than students who preferred problem-based approaches (Al-Zayyat & Al-Gamal, 2014). This review also highlighted that the combination of several problem-solving strategies is a highly effective way to cope with stress (Chan et al., 2009).

Implications for Nursing Clinical Education

The research covered in this review may be beneficial to nursing staff, nurse educators, and nursing lecturers. Because it is evident that problem-solving approaches are the most effective coping strategies for handling stress, nursing students should be aware of their significance, as well as understand that the combination of problem-solving techniques can alleviate stress levels. The findings presented in this review also provide a roadmap for nursing education. For example, nurses, nurse educators, and nursing lecturers can plan strategies for preventing stress recurrence among clinical practice students and mentor their students to use problem-based, rather than emotion-based, behavior to cope with stress. Several authors have suggested that the establishment of a supportive clinical training platform and promoting effective strategies for coping with stress facilitate the learning process of nursing students (Al-Zayyat & Al-Gamal, 2014; Alzayyat & Al-Gamal, 2016; Chan et al., 2009; Labrague et al., 2016). These actions could help reduce and prevent stress, facilitate learning, and mitigate anxiety by modifying student behavior (Quinn & Peters, 2017). This review presented evidence that teachers and nursing staff is one of the most stressful aspects of the clinical learning environment; therefore, these actors should focus on how they can make students understand their role as an observer and evaluator. However, additional research is needed to provide more information on how teachers and nursing staff feel about being a clinical stressor for nursing students. However, not all coping strategies may be able to alleviate specific stressors; hence, we endorse a previous literature review that suggested identifying specific coping strategies for various stressors (Labrague et al., 2016).

Validity of This Review

Each step of the research process was carefully considered and planned to ensure the validity of this review. Prior to the database search, the authors thoroughly discussed the search terms, databases, and inclusion criteria with the librarian. Furthermore, two researchers independently performed the appraisal process. Incorporating peer review into the research process will increase the validity of the content (Whittemore & Knafl, 2005); therefore, both researchers extensively discussed the inclusion criteria during the appraisal process and the main researcher tabulated the results in a manner that best answers the research questions. Additionally, as advised by Whittemore and Knafl (2005), the inclusion criteria and appraisal evaluation form were pretested with several random publications to ensure that only relevant, high-quality publications would be selected during the literature search. A PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) checklist was used to systematically proceed through the review process and report the progress (Moher et al., 2015).

Limitations

The reported study included some limitations. This review included only English-language publications that were available with reasonable time and resources; this may have limited the number of relevant papers that were identified and scrutinized. Moreover, the content was limited to stress and coping strategies during clinical training, although students may experience stress and feel anxious in other settings, for example during examinations (Quinn & Peters, 2017), and develop coping strategies throughout their nursing education (Zupiria Gorostidi et al., 2007). Surprisingly, our review included only quantitative papers. This may be explained by a lack of qualitative research in this area. The heterogeneity of the included studies in terms of sample size, design, and instruments, will limit the generalizability of the results. Our review revealed that relatively few studies have been conducted on this topic on a global level. The majority of the identified studies included clear design flaws—for instance, no pilot study was conducted when a developed instrument was presented, no power analysis was performed and/or a specific instrument was used to measure stress and coping without completely reporting validity, and data were collected from one site only; consequently, readers should be cautious when generalizing the presented results. A majority of the articles employed a cross-sectional design and, as such, could not adequately examine the dynamic, temporal nature of stress. The aforementioned issues may have limited the search results and introduced selection bias. Consequently, we cannot make any reliable claims about how stress, and the corresponding coping techniques, evolve during nursing studies as only a few articles included in this review used a longitudinal design.

Conclusion

This study expanded the current knowledge of stress and coping strategies of higher education nursing students during clinical training. A mounting body of evidence has shown stress to be a perceived phenomenon that should be studied further, especially in terms of how it evolves during clinical education across study years. An array of studies from around the world reported that students encounter moderate to high level of stress and that the teachers and nursing staff of the clinical environment are the most significant stressor. In terms of managing stress, nursing students use both problem- and emotion-based coping strategies. Problem-based behaviors, such as staying optimistic, adopting various strategies to solve the problem, and finding meaning for stressful events, are more effective at reducing stress than emotion-based strategies. Future research should identify and review studies that adopted a qualitative design to explore stress and its management among nursing students. Furthermore, future studies should investigate specific coping strategies and their link to clinical stressors. This will allow teachers to support their students more effectively, which in turn may result in improving clinical nursing education.

References

  • Akhu-Zaheya, L.M., Shaban, I.A. & Khater, W.A. (2015). Nursing students' perceived stress and influences in clinical performance. International Journal of Advanced Nursing Studies, 4, 44–48. doi:10.14419/ijans.v4i2.4311 [CrossRef]
  • Al-Gamal, E., Alhosain, A. & Alsunaye, K. (2018). Stress and coping strategies among Saudi nursing students during clinical education. Perspectives in Psychiatric Care, 54, 198–205. doi:10.1111/ppc.12223 [CrossRef]
  • Al-Zayyat, A.S. & Al-Gamal, E. (2014). Perceived stress and coping strategies among Jordanian nursing students during clinical practice in psychiatric/mental health courses. International Journal of Mental Health Nursing, 23, 326–335. doi:10.1111/inm.12054 [CrossRef]
  • Alzayyat, A. & Al-Gamal, E. (2014). A review of the literature regarding stress among nursing students during their clinical education. International Nursing Review, 61, 406–415. doi:10.1111/inr.12114 [CrossRef]
  • Alzayyat, A. & Al-Gamal, E. (2016). Correlates of stress and coping among Jordanian nursing students during clinical practice in psychiatric/mental health course. Stress and Health, 32, 304–312. doi:10.1002/smi.2606 [CrossRef]
  • Bahadır-Yılmaz, E. (2016). Academic and clinical stress, stress resources and ways of coping among Turkish first-year nursing students in their first clinical practice. Kontakt, 18(3), e145–e151. doi:10.1016/j.kontakt.2016.08.001 [CrossRef]
  • Bam, V.B., Oppong, G.A. & Ibitoye, M.B. (2014). Stress and coping mechanisms of nursing students during clinical practice in Ghana. Journal of Science and Technology, 34(2), 50–59.
  • Behere, S., Yadav, R. & Behere, P. (2011). A comparative study of stress among students of medicine, engineering, and nursing. Indian Journal of Psychological Medicine, 33, 145. doi:10.4103/0253-7176.92064 [CrossRef]
  • Burnard, P., Haji Abd Rahim, H.T.B.P.D., Hayes, D. & Edwards, D. (2007). A descriptive study of Bruneian student nurses' perceptions of stress. Nurse Education Today, 27, 808–818. doi:10.1016/j.nedt.2006.11.002 [CrossRef]
  • Chan, C.K.L., So, W.K.W. & Fong, D.Y.T. (2009). Hong Kong baccalaureate nursing students' stress and their coping strategies in clinical practice. Journal of Professional Nursing, 25, 307–313. doi:10.1016/j.profnurs.2009.01.018 [CrossRef]
  • Gibbons, C. (2010). Stress, coping and burn-out in nursing students. International Journal of Nursing Studies, 47, 1299–1309. doi:10.1016/j.ijnurstu.2010.02.015 [CrossRef]
  • Gravetter, F.J. & Wallnau, L.B. (2013). Essentials of statistics for the behavioral sciences (8th ed.). Boston, MA: Cengage Learning.
  • Gurková, E. & Zeleníková, R. (2018). Nursing students' perceived stress, coping strategies, health and supervisory approaches in clinical practice: A Slovak and Czech perspective. Nurse Education Today, 65, 4–10. doi:10.1016/j.nedt.2018.02.023 [CrossRef]
  • Hawker, S., Payne, S., Kerr, C., Hardey, M. & Powell, J. (2002). Appraising the evidence: Reviewing disparate data systematically. Qualitative Health Research, 12, 1284–1299. doi:10.1177/1049732302238251 [CrossRef]
  • Jimenez, C., Navia-Osorio, P.M. & Diaz, C.V. (2010). Stress and health in novice and experienced nursing students. Journal of Advanced Nursing, 66, 442–455. doi:10.1111/j.1365-2648.2009.05183.x [CrossRef]
  • Khan, K.S., Kunz, R., Kleijnen, J. & Antes, G. (2003). Five steps to conducting a systematic review. Journal of the Royal Society of Medicine, 96(3), 118–121. doi:10.1177/014107680309600304 [CrossRef]
  • Khater, W.A., Akhu-Zaheya, L.M. & Shaban, I.A. (2014). Sources of stress and coping behaviours in clinical practice among baccalaureate nursing students. International Journal of Humanities and Social Science, 4(6), 194–202.
  • Kim, K.H. (2003). Baccalaureate nursing students' experiences of anxiety producing situations in the clinical setting. Contemporary Nurse, 14, 145–155. doi:10.5172/conu.14.2.145 [CrossRef]
  • Labrague, L.J. (2013). Stress, stressors, and stress responses of student nurses in a government nursing school. Health Science Journal, 7, 424–435.
  • Labrague, L.J., McEnroe-Petitte, D.M., Gloe, D., Thomas, L., Papathanasiou, I.V. & Tsaras, K. (2016). A literature review on stress and coping strategies in nursing students. Journal of Mental Health, 26, 471–480. doi:10.1080/09638237.2016.1244721 [CrossRef]
  • Lazarus, R.S. & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer.
  • Liu, M., Gu, K., Wong, T.K.S., Luo, M.Z. & Chan, M.Y. (2015). Perceived stress among Macao nursing students in the clinical learning environment. International Journal of Nursing Sciences, 2(2), 128–133. doi:10.1016/j.ijnss.2015.04.013 [CrossRef]
  • Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M. & Stewart, L.A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4, 1. doi:10.1186/2046-4053-4-1 [CrossRef]
  • 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. doi:10.1111/j.1466-7657.2011.00939.x [CrossRef]
  • Quinn, B.L. & Peters, A. (2017). Strategies to reduce nursing student test anxiety: A literature review. Journal of Nursing Education, 56, 145–151. doi:10.3928/01484834-20170222-05 [CrossRef]
  • Rasha, M. & Haya, A. (2016). Perceived stress and coping strategies among newly nurse students in clinical practice. Journal of Education and Practice, 7, 118–128.
  • Reeve, K.L., Shumaker, C.J., Yearwood, E.L., Crowell, N.A. & Riley, J.B. (2013). Perceived stress and social support in undergraduate nursing students' educational experiences. Nurse Education Today, 33, 419–424. doi:10.1016/j.nedt.2012.11.009 [CrossRef]
  • Robotham, D. (2006). Stress and the higher education student: A critical review of the literature. Journal of Further and Higher Education, 30, 107–117. doi:10.1080/03098770600617513 [CrossRef]
  • Shaban, I.A., Khater, W.A. & Akhu-Zaheya, L.M. (2012). Undergraduate nursing students' stress sources and coping behaviours during their initial period of clinical training: A Jordanian perspective. Nurse Education in Practice, 12, 204–209. doi:10.1016/j.nepr.2012.01.005 [CrossRef]
  • Sheu, S., Lin, H.S. & Hwang, S.L. (2002). Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice: The effect of coping behaviors. International Journal of Nursing Studies, 39, 165–175. doi:10.1016/S0020-7489(01)00016-5 [CrossRef]
  • Shukla, A., Kalra, G. & Pakhare, A. (2012). Understanding stress and coping mechanisms in Indian student nurses. Sri Lanka Journal of Psychiatry, 4(2), 29–33. doi:10.4038/sljpsyc.v4i2.5387 [CrossRef]
  • Suen, W.Q., Lim, S., Wang, W. & Kowitlawakul, Y. (2016). Stressors and expectations of undergraduate nursing students during clinical practice in Singapore. International Journal of Nursing Practice, 22, 574–583. doi:10.1111/ijn.12473 [CrossRef]
  • Timmins, F. & Kaliszer, M. (2002). Aspects of nurse education programmes that frequently cause stress to nursing students—Fact-finding sample survey. Nurse Education Today, 22, 203–211. doi:10.1054/nedt.2001.0698 [CrossRef]
  • Tully, A. (2004). Stress, sources of stress and ways of coping among psychiatric nursing students. Journal of Psychiatric and Mental Health Nursing, 11, 43–47. doi:10.1111/j.1365-2850.2004.00682.x [CrossRef]
  • Whittemore, R. & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52, 546–553. doi:10.1111/j.1365-2648.2005.03621.x [CrossRef]
  • Wolf, L., Stidham, A.W. & Ross, R. (2015). Predictors of stress and coping strategies of US accelerated vs. generic baccalaureate nursing students: An embedded mixed methods study. Nurse Education Today, 35, 201–205. doi:10.1016/j.nedt.2014.07.005 [CrossRef]
  • Yamashita, K., Saito, M. & Takao, T. (2012). Stress and coping styles in Japanese nursing students. International Journal of Nursing Practice, 18, 489–496. doi:10.1111/j.1440-172X.2012.02056.x [CrossRef]
  • Zhao, F.F., Lei, X.L., He, W., Gu, Y.H. & Li, D.W. (2015). The study of perceived stress, coping strategy and self-efficacy of Chinese undergraduate nursing students in clinical practice. International Journal of Nursing Practice, 21, 401–409. doi:10.1111/ijn.12273 [CrossRef]
  • Zupiria Gorostidi, X., Huitzi Egilegor, X., Jose Alberdi Erice, M., Jose Uranga Iturriotz, M., Eizmendi Garate, I., Barandiaran Lasa, M. & Sanz Cascante, X. (2007). Stress sources in nursing practice: Evolution during nursing training. Nurse Education Today, 27, 777–787. doi:10.1016/j.nedt.2006.10.017 [CrossRef]

Characteristics of the Reviewed Papers

Author(s) & CountryResearch Question/AimSample Size and DescriptionResearch DesignInstrument/Tool and DescriptionLevel of Stress (Low-Moderate-High)Main Clinical Stressors ReportedMain Coping Strategies Reported
Alzayyat & Al-Gamal, 2016. JordanExplore correlations between students' characteristics, stress levels, stressors and coping strategies(n = 65) second-semester undergraduate nursing students in psychiatric/mental health clinical trainingDescriptive, correlational, longitudinal designPerceived Stress (PSS) Scale (29 items allocated to six subscales rated on a five-point Likert scale) Coping Behaviour Inventory (CBI) (19 items divided into four categories rated using a five-point Likert scale from 0 to 4)ModerateCaring for patients, assignments and workloads, teachers & staffStaying optimistic & problem solving
Alzayyat & Al-Gamal, 2014. JordanExplore clinical stressors, levels of stress and coping strategies(n = 65) second-semester undergraduate nursing students in psychiatric/mental health clinical trainingDescriptive, longitudinalPerceived Stress (PSS) Scale (29 items allocated to six subscales rated on a five-point Likert scale) Coping Behaviour Inventory (CBI) (19 items divided into four categories rated using a five-point Likert scale from 0 to 4)ModerateCaring for patients, assignments and workloads, teachers & staffProblem solving
Al-Gamal et al., 2018. JordanDetermine stress levels and coping strategies(n =121) female undergraduate nursing studentsDescriptive, correlational, cross-sectionalPerceived Stress (PSS) Scale (Arabic translated version) (29 items allocated to six subscales rated on a five-point Likert scale) Coping Behaviour Inventory (CBI) (Arabic translated version) (19 items divided into four categories rated using a five-point Likert type scale from 0 to 4ModerateCaring for patientsProblem solving
Bahadir-Yilmaz, 2016. TurkeyExplore first-year nursing students' stress and coping during clinical training(n =120) first-year nursing students who were enrolled in the School of Health Sciences during the 2014–2015 academic year.Cross-sectional descriptiveWays of Coping Inventory (WCI) (30 items rated on a four-point Likert scale ranging from 0–3) Nursing Education Stress Scale (NESS) (32 items rated on a three-point Likert scale ranging from 1–3)ModerateBeing criticized by teachers & encountering dying patientsBeing self-confident & staying optimistic
Chan et al., 2009. HongKongExplore stress and coping strategies in clinical practice(n = 205) baccalaureate nursing students, excluding first-year studentsCross-sectional descriptivePerceived Stress (PSS) Scale (29 items allocated to six subscales rated on a five-point Likert scale) Coping Behaviour Inventory (CBI) (19 items divided into four categories rated using a five-point Likert scale from 0 to 4)ModerateLack of professional knowledge & skillsTransference, staying optimistic, problem solving & avoidance
Gurnova & Zelenikova, 2018. Czech Republic and SlovakiaInvestigate how supervisory approaches in clinical training affect student stress and coping'(n = 275) Undergraduate nursing studentsCross-sectional descriptivePerceived Stress (PSS) Scale (29 items allocated to six subscales rated on a five-point Likert scale) Coping Behaviour Inventory (CBI)(19 items divided into four categories rated using a five-point Likert scale from 0 to 4) Physio-Psycho-Social Response Scale (PPSRS) (21 items under three sub-scales divided into four categories, all rated using a five-point Likert scale from 0 to 4)ModerateSenior students experienced higher stress than novice students, especially from teachers and peersNot reported
Jimenez et al., 2012. SpainExplore clinical stressors, stress levels and biopsychosocial responses in clinical practice(n = 357) novice and experienced nursing students enrolled in a full-time three-year nursing programmeDescriptive quantitative and cross sectionalPerceived Stress (PSS) Scale (Spanish-adapted version) (30 items allocated to six subscales rated on a five-point Likert scale) Coping Behavior and Biopsychosocial Response Scale (22 items rated using a five-point Likert scale ranging from 0 to 4.ModerateProviding patient care & lack of knowledge and skillsNot reported
Liu et al., 2015. ChinaExplore stress in clinical practice(n = 203) nursing students (sample description not reported)Cross-sectionalStressors in Nursing Students Scale-Chinese Version (SINS-CN) (43 items rated on a five-point Likert scale from 1 to 5)ModerateHeavy workload, fear of making a mistake in clinical placement, having too much clinical responsibilityNot reported
Rasha & Haya, 2016. Saudi ArabiaExplore stress levels and coping strategies(n = 51) nursing students in their first clinical training in the second semester during the 2015–2016 study yearDescriptive Analytical MethodPerceived Stress Scale-14 (14 items rated using a five-point Likert scale from 0 to 4) Coping Orientation for Problem Experiences (54 items under 12 domains)HighUpset & inability to control important things in lifeSeeking diversions & Self-reliance
Shaban et al., 2012. JordanExplore clinical stressors, stress levels and coping strategies during clinical practice(n = 181) second-year undergraduate nursing students doing their first clinical trainingCross-sectionalPerceived Stress (PSS) Scale (29 items allocated to six subscales rated on a five-point Likert scale) Coping Behaviour Inventory (CBI) (19 items divided into four categories rated using a five-point Likert scale from 0 to 4)ModerateAssignments & workload, stress from clinical practice and stress from nursing staffProblem solving, staying optimistic& transference
Suen et al., 2016. SingaporeExplore the contributing factors of stress and clinical environment expectations affect students during their clinical practice(n = 285) undergraduate nursing students, mostly in the first to third year of studiesCross-sectional descriptiveStressors in Nursing Students questionnaire, (43 items rated using a five-point Likert scale from 1 to 5) Clinical Learning Environment Inventory questionnaire (42 items rated using a four-point Likert scale from 1 to 4)Moderate to highSatisfaction in terms of fulfilmentNot reported
Zhao et al., 2015. ChinaExplore coping strategy and the effects of self-efficacy during clinical training(n = 231) undergraduate students who had practiced in a hospital for more than three months and showed good English reading comprehensionCross-sectionalPerceived Stress (PSS) Scale (29 items allocated to six subscales rated on a five-point Likert scale) Coping Behaviour Inventory (CBI) (19 items divided into four categories rated using a five-point Likert type scale from 0 to 4) Generalized Self-Efficacy Scale (10 items rated with a four-point Likert scale)ModerateAssignments & workloadTransference
Zupiria-Gorostidi et al., 2007. SpainExplore sources of stress among nursing students during clinical practice(n = 69) first-year nursing students enrolled in the 1999–2000 academic yearProspective cohort study from 1999 to 2002KEZKAK questionnaire, (41 items rated on a three-point Likert scale)Low to moderateLack of competence & uncertaintyNot reported
Authors

Mr. Bhurtun is Lecturer, Ms. Azimirad is Early Stage Researcher, Dr. Saaranen is University Lecturer and Docent, and Dr. Turunen is Professor and Chair, Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Hanish Dev Bhurtun, MSc, RN, Lecturer, Department of Nursing Science, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland; e-mail: hanishb@student.uef.fi.

Received: November 02, 2018
Accepted: February 20, 2019

10.3928/01484834-20190422-04

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