A review of the literature regarding stress among nursing students during their clinical education.

A review of the literature regarding stress
among nursing students during their
clinical education
A. Alzayyat1 RN, BSC, MSC & E. Al-Gamal2 RN, BSC, MSC, PhD
1 Teaching Assistant, 2 Associate Professor, Psychiatric & Mental Health Nursing, Faculty of Nursing, Department of
Community Health Nursing, The University of Jordan, Amman, Jordan
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
Background: There has been increased attention in the literature about stress among nursing students. It has
been evident that clinical education is the most stressful experience for nursing students.
Aim: The aim of this paper was to critically review studies related to degrees of stress and the type of stressors
that can be found among undergraduate nursing students during their clinical education.
Methods: The search strategy involved the utilization of the following databases: MEDLINE (Medical
Literature on-Line), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO
(Psychology Information) and PubMed. Keywords were stress, undergraduate nursing students, clinical
practice. The review included those studies published between 2002 and 2013, conducted in any country as
long as reported in English, and including a focus on the clinical practice experience of nursing students.
Thirteen studies met the eligibility criteria.
Results: Four themes were identified: initial clinical experience, comparison between different academic years,
cross-cultural comparison, and eustress aspects of clinical experience.
Implications for nursing and health policy: This review expands current knowledge in the area of stress in
clinical settings and calls for further research. Nursing teachers should utilize the findings of this review to
direct their students during clinical practice. Moreover, hospital administrators need to promote policies to
promote a training environment where students are supported and inspired.
Keywords: Clinical Practice, Literature Review, Nursing Students, Stress, Nursing Education, Clinical Education,
Nursing
Introduction
Stress has been viewed as a 20th-century sickness (Evans &
Kelly 2004). Stress could be defined as response based (i.e.
emerging from a person’s reactions to incidents), stimulus
based (i.e. consequences of incidents) or interactive (i.e. resulting
from interaction between stimuli and responses) (Furnham
2005). Stress has both beneficial and harmful impacts on individuals
(Behere et al. 2011; Burnard et al. 2007). As a beneficial
impact, stress is able to force us towards achievement (Behere
et al. 2011). Selye (1976) called this impact ‘eustress’. As a
harmful impact, literature reveals that stress has negative
effects that might be classified into three groups: physical
manifestations, such as headache and infections; psychological
manifestations, such as anger, low self-respect and anxiety; and
Correspondence address: Mr Abdulkarim Alzayyat, Faculty of Nursing, Department
of Community Health Nursing, The University of Jordan, Amman 11942, Jordan;
Tel: (962 6) 5355000; Fax: (962 6) 5300244; E-mail: a.alzayyat@gmail.com.
Conflict of interest: No conflict of interest has been declared by the authors.
Ethical approval was obtained from the Research Ethics Committee at the
Faculty of Nursing, The University of Jordan, on 12 December 2012 (Reference
number: 8).
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Nursing Education
© 2014 International Council of Nurses 406
behavioural manifestations, such as weight loss, smoking and
drinking (Arnold & Boggs 2006).
The topic of stress among university students has been extensively
investigated by several researchers (Al-Zayyat & Al-Gamal
2014; Hamdan-Mansour et al. 2009; Pillay & Ngcobo 2010).
Students experience numerous stressors from a variety of
sources, and, typically, they react to these stressors in different
ways (Hamaideh 2011). Sources of stress among university students
could include academic demands (Elias et al. 2011), being
away from home (Seyedfatemi et al. 2007) and financial pressure
(Pillay & Ngcobo 2010).
There has been increased attention in the literature on stress
among nursing students (Nicholl & Timmins 2005). Sources of
stress among nursing students can be varied. Academic sources
include examinations, fear of failure and workload. Clinical
sources include clinical placements, fear of making mistakes and
interactions with other staff members. Personal and social
sources include financial concerns and the absence of leisure
time (Pryjmachuk & Richards 2007). However, only studies that
focused on clinical sources will be discussed here because the
rest of the sources are outside the scope of this review.
Only one published review paper was identified which
addressed sources of stress among nursing students
(Pulido-Martos et al. 2012). This review included studies that
reported quantitative analysis of the stress associated with
nursing curricula. The vast majority of the revised studies in the
review were about academic or social sources of stress. Only 8
studies out of 23 focused on clinical stressors. Therefore, the
current paper is considered to be a novel contribution to the
field, addressing degrees of stress and type of stressors among
undergraduate nursing students during their clinical education.
The scope of the previous review paper has been expanded by
including both qualitative and quantitative studies.
Aim and objectives
The aim of this paper was to critically review studies related to
degrees of stress and type of stressors among undergraduate
nursing students during their clinical education. Beyond this
broad aim, additional objectives of this paper are to: (i) identify
the stressful periods of clinical education, and examine the relevance
of the academic year of study when stress occurs; (ii)
clarify positive and negative impacts of clinical stressors; and
(iii) compare findings from different cultures.
Method
Search strategy
Part of the rigour of systematic searching is the effort made
to ensure that all relevant literature is included to decrease
selection bias (Hamer & Collinson 2005). Four databases were
searched: MEDLINE (Medical Literature on-Line) for its coverage
of international literature on medicine including allied
health professions, biological and physical science, and humanities;
CINAHL (Cumulative Index to Nursing and Allied Health
Literature), because the topic of clinical stressors was more
likely to be addressed by nurses and allied health professionals;
and PsycINFO (Psychology Information) with its emphasis on
psychological topics. Finally, PubMed was consulted for its coverage
of health-related disciplines. Keywords included stress
(equivalent terms such as eustress, distress and occupational
stress), undergraduate nursing students (corresponding terms
of baccalaureate nursing students and nursing education were
included as well) and clinical practice (including the synonyms
clinical training, clinical education and clinical experience) in
different combinations.
Eligibility criteria of this review
Articles were included in the review according to these inclusion
criteria: published between 2002 and 2013 in order to
select recent publications; studies conducted in any country as
long as they were reported in English; included a focus on
stressors among nursing students; and addressing clinical education.
Studies addressing stress reduction interventions for
nursing students were excluded because they were beyond the
scope of this review. All studies were subjected to a standardized
method of critical appraisal, depending upon their design,
to determine the quality and rigour of the findings (Long et al.
2002). To ensure a thorough and comprehensive search, and to
ensure comprehensive consideration of all themes and arguments,
a wide range of resources was accessed, including
searching the university library catalogue and a manual search
through selected journals that were not available electronically.
Sixty studies were identified, of which 13 met the criteria. The
review method is summarized in Fig. 1.
Results
Numerous difficulties in comparing the studies were encountered.
The different sample characteristics, variety of tools utilized
and differences in operational definitions of stress caused
differences in findings. Moreover, there are fundamental differences
globally in the composition of nursing educational programs,
especially in the clinical parts of those programs.
However, detailed findings of the current review are reported in
terms of the subsequent four themes: initial clinical experience,
comparison between different academic years, cross-cultural
comparison and eustress aspects of clinical experience. Table 1
summarizes studies identified in this review.
A review of stress among nursing students 407
© 2014 International Council of Nurses
Initial clinical experience
Literature revealed that the initial period of clinical education is
highly stressful for nursing students (Karabacak et al. 2012;
Shaban et al. 2012; Sheu et al. 2002). Sheu et al. (2002)
employed a cross-sectional design and used the Perceived Stress
Scale (PSS) (Sheu et al. 1997) to address the initial clinical
experience. The sample consisted of 561 Taiwanese students
from one nursing school. Results demonstrated that the most
reported stressors were deficient knowledge and skills, caring
for patients, and assignment workload. However, a convenience
sample was adopted, recruited from a single nursing school, so
generalization is restricted.
In contrast, Karabacak et al. (2012) conducted an experimental
study to address the same issue among Turkish nursing students.
The sample consisted of 52 students who were assigned
randomly to an experimental group (n = 26) and a control
group (n = 26). Students of the control group started hospital
practice immediately after general laboratory training in ‘Essentials
of Nursing’. Conversely, those who participated in the
experimental group repeated all skills in the laboratory for 5
days before their hospital practice. The participants in both
groups completed the Clinical Stress Questionnaire (Pagana
1988). The authors reported that students of the experimental
group experienced less stress compared with those in the
control group. However, although the authors performed a
random assignment to guarantee equality of the study groups,
Nieswiadomy (2008) indicates that pre-test is the only way for
the investigator to verify that the groups were identical before
conducting the desired intervention. The study by Karabacak
et al. lacked this as a post-test only design. Therefore, no confidence
can be placed in such findings.
Comparison between different academic years
Another group of studies analysed clinical stress in terms of students’
academic years (Chen & Hung 2013; Edwards et al. 2010;
Gorostidi et al. 2007; Jimenez et al. 2010; McKenna & Plummer
2013; Suresh et al. 2012). In the Indonesian context, a
hermeneutic phenomenological study (McKenna & Plummer
2013) was conducted to investigate the meaning of lived experience
of clinical stress for six female novice students. The students
were recruited from one nursing school through a
purposive sampling technique. Data were collected from the
Search was conducted to
identify potential
references
Checking
according to the
eligibility criteria
Databases and
keywords identified
New references
identified through
selected reference lists
Additional search to
identify other studies that
used research tools
utilized in this study
Irrelevant and
inappropriate references
discarded (47 studies)
Relevant and appropriate
references included
and critically
appraised (13 studies)
Fig. 1 Search strategy.
408 A. Alzayyat & E. Al-Gamal
© 2014 International Council of Nurses
Table 1 Summary of the studies investigating clinical education stress among nursing students
Author(s) and
setting
n Target nursing
students
Design Instrument or data collection
method
Types of clinical stressors Strengths and limitations
Sheu et al. (2002),
Taiwan
561 Students at initial
clinical experience
Descriptive,
cross-sectional
PSS (Sheu et al. 1997) (29 items)
Cronbach’s alpha (α) = 0.89
Content validity index equals
0.94
Deficient knowledge and skills,
caring of the patients, and
assignment workload
The authors utilized a tool with strong psychometric
properties. Moreover, the sample size was adequate
to achieve statistical conclusion validity (Polit &
Beck 2008). However, the sample was convenience
so the generalization is restricted.
Shaban et al. (2012),
Jordan
270 Students at initial
clinical experience
Descriptive,
cross-sectional
PSS (Sheu et al. 1997) (29 items)
α = 0.87
Content validity was confirmed
by a panel of experts
Assignment workload, clinical
environment, teachers and
nurses
The use of power analysis to calculate the sample size
assists in decreasing the risk of false statistical
outcomes (Faul et al. 2009). Conversely,
generalization is limited because the sample was
convenience.
Karabacak et al.
(2012), Turkey
52 Students at initial
clinical experience
Experimental,
post-test only
control group
CSQ (Pagana 1988) (20 items)
α = 0.7
Construct validity was confirmed
by the factor analysis
CSQ designed to measure stress
degrees not stress types
This study yielded robust findings as control in the
experimental studies is greater than that in
descriptive studies (Polit & Beck 2008). However, the
pre-test was lacking in this study, thus the equality
of the two study groups is doubtful (Nieswiadomy
2008).
McKenna &
Plummer (2013),
Indonesia
6 Novice students Hermeneutic,
phenomenological
Telephone interviews First, feelings of pressure include
assignments and initial clinical
experience. Second, challenging
relationships include
relationships with patients and
nurses.
The study design helps in investigating the meaning of
stressors from students’ perspective (Polit & Beck
2008). Nevertheless, the sample size was very small,
therefore data saturation may be hindered
(Onwuegbuzie & Leech 2007).
Chen & Hung
(2013), Taiwan
101 Junior students Descriptive,
cross-sectional
PSS (Sheu et al. 1997) (29 items)
α = 0. 91
Content validity index equals
0.94
Patients’ care, assignment
workload, teachers and nurses
PSS is reliable and valid. However, this study recruited
a convenience sample, therefore results cannot be
generalized widely. Moreover, information about
sample size calculation is limited in this study.
Jimenez et al. (2010),
Spain
357 Students from all
years
Descriptive,
cross-sectional
Modified PSS (Sheu et al. 1997)
(30 items)
α = 0.92
Spearman–Brown coefficient
equals 0.80 (P < 0.001).
Patients suffering, incapability to
give suitable responses to
teachers’ questions, and
inability to meet patients’
needs
The utilized tool has strong psychometric properties.
However, the use of cross-sectional design hinders
the ability to track changes of stress experiences
(Edwards et al. 2010).
Gorostidi et al.
(2007), Spain
69 First year students Descriptive,
longitudinal
KEZKAK tool (Zupiria et al.
2003) (41 items)
Zupiria et al. reported that
KEZKAK had α = 0.95 and the
construct validity was
confirmed by the factor
analysis
Lack of capability, powerlessness,
uncertainty, and relationships
with clients, teachers and
colleagues
Employing the prospective design enabled the
measuring of changes in stress experiences.
However, the psychometric properties of KEZKAK
were not tested in this study. The sample size of 69
is also small for this study (Polit & Beck 2008).
A review of stress among nursing students 409
© 2014 International Council of Nurses
Table 1 Continued
Author(s) and
setting
n Target nursing
students
Design Instrument or data collection
method
Types of clinical stressors Strengths and limitations
Edwards et al.
(2010), UK
169 Students from all
years
Descriptive,
longitudinal,
cohort
Stress in Nurse Education
questionnaire (Rhead 1995)
(32 items)
α = 0.89
Patients suffering, the pressure of
examinations, having to read
after training, and committing
mistakes
Employing the prospective design enabled the tracking
of changes in stress experiences. However, the results
reflected stressors associated with particular
curriculum program.
Suresh et al. (2012),
Ireland
120 nurses and
128 students
Newly qualified
nurses and fourth
year students
Cross-sectional,
triangulation
Nursing Stress Scale (Gray-Toft &
Anderson 1981) (34 items) and
open-ended questions
α = 0.79
Construct validity was confirmed
by the factor analysis
Unmet learning needs, complex
working relationships, and
workload
Results of this study aid in designing interventions to
facilitate the transition from students to graduate
nurses, therefore helping to maintain this important
human resource within nursing. However, the
personal characteristics of the participants were not
measured in this study and could have added further
insights into the results.
Timmins & Kaliszer
(2002), Ireland
110 Third year students Descriptive,
comparative,
cross-sectional
Questionnaire that designed ad
hoc (12 items).
A 1-week part test–retest
reliability was statistically
significant (r > 0.5, P < 0.05).
Content validity was confirmed
by a panel of experts
Clinical placements, relationships
with nurses, and patients’
death
This study is valuable as it evaluates Irish nursing
students’ clinical stressors from an international
perspective. However, these findings should be
interpreted carefully, given that it was a small
exploratory study.
Burnard et al.
(2008), Albania,
Brunei, Czech
Republic, Malta
and Wales
1707 Students from all
years
Descriptive,
cross-sectional
survey
SNE questionnaire (Rhead 1995)
(32 items)
Edwards et al. (2010) reported
that SNE had
reliability coefficient of 0.89
Death of patients, seeing patient
suffering, and the pressure of
examinations
Investigating clinical stress among nursing students
from international perspective broads the scope of
literature. However, there are cultural variations
among the participants that cannot be accounted for
in a study of this nature (Robotham & Julian 2006).
Moreover, psychometric properties of SNE were not
reported in this study.
Gibbons et al.
(2008), UK
16 Final year students Phenomenological
study
Focus groups Eustressing factors: patient care
chances and practical learning
This study adds unique data about beneficial clinical
stressors in the current literature. Nevertheless, the
students were in final year and this may affect the
results.
Gibbons (2010), UK 171 Final year students Descriptive,
cross-sectional
Index of Sources of Stress in
Nursing Students inventory
(Gibbons 2008) (29 items)
α > 0.70
Face validity was confirmed
Eustressing factors: placement
demands and support
opportunities
Measuring beneficial aspects of clinical stress using a
quantitative method considered exclusive in the
literature. However, the long experience of the
participants may affect the results.
CSQ, Clinical Stress Questionnaire; PSS, Perceived Stress Scale.
410 A. Alzayyat & E. Al-Gamal
© 2014 International Council of Nurses
students by telephone interviews that lasted for around 30 min.
The data analysis revealed the following main themes: ‘feelings
of pressure’ and ‘challenging relationships’. This study is significant
because it reflects the novice students’ perspective of clinical
stress. However, the sample size was very small (only six
participants) and this undermines the usefulness of the
reported findings. The sample size of qualitative studies is recommended
to be between 10 and 20 participants for interview
studies (Francis et al. 2010; Onwuegbuzie & Leech 2007).
Gorostidi et al. (2007) performed a descriptive prospective
study with the intention of assessing the progression of
nursing students’ perception of clinical stress throughout their
program. Sixty-nine students studying at one Spanish nursing
school completed the KEZKAK tool, which is a bilingual questionnaire
in English and Spanish designed to assess nursing
students’ practical training stressors (Zupiria et al. 2003).
There were four data collection points (before starting practical
training, end of the first year, end of the second year and at
the end of students’ studies). The participants reported these
factors as the most significant stressors throughout the course
of their studies: lack of capability, powerlessness and uncertainty,
inability to set limits in relationships with clients, teachers
and colleagues. However, the stressors scores were
diminished throughout the course of clinical education. The
author (Gorostidi et al. 2007) stated that this decrease in stress
levels was probably caused by continuous contact with clinical
work, observational learning and the progressive gaining of
experience.
In another similar study (Edwards et al. 2010), the authors
used the Stress in Nurse Education (SNE) questionnaire (Rhead
1995) with a sample of 169 British nursing students. The students
completed the study tool at different time points of their
study program (after two clinical rotations, at the commencement
of the second year, after five clinical rotations, at the commencement
of the third year, and after the third year). The
results showed that levels of stress significantly varied between
the different data collection times. Contrary to the previous
study findings (Gorostidi et al. 2007), this study indicated that
the highest levels of stress were reported at the final (third) year.
The authors rationalized this finding by suggesting that more
professional stressors are placed on third year students compared
with the students in earlier years. The use of longitudinal
designs in the previous discussed studies (Edwards et al. 2010;
Gorostidi et al. 2007) facilitates measuring the changeable
nature of stress. However, the major limitation of these two
studies is that they reflect the stressors related to the particular
curriculum program. In other words, the generalization of the
findings in other countries with different nursing curricula may
be restricted.
A cross-cultural comparison
Few studies had focused on cross-cultural comparisons
(Burnard et al. 2008; Timmins & Kaliszer 2002). Burnard et al.
(2008) carried out a longitudinal study to compare the perceptions
of 1707 worldwide nursing students concerning levels and
sources of stress during their education. The sample was
selected across five different countries (Albania, Brunei, Czech
Republic, Malta and Wales). The authors used the SNE questionnaire
(Rhead 1995) for data collection. The results indicated
that nursing students internationally share much in common.
The most frequently reported clinical stressors were the death of
a patient and seeing a patient suffering. The types of stressors
reported by Burnard are consistent with those reported by
Edwards et al. (2010) (see Table 1). Burnard’s study broadens
the scope of current literature by investigating clinical stress
among nursing students from an international perspective.
However, there are possible cultural variations among student
groups that cannot be accounted for in a study of this nature.
Those cultural variations may contain factors such as teacher–
student affiliations, feelings and thoughts towards education
processes, and perception about the manner of caring. All of
these issues will probably have impacts on stress levels (Burnard
et al. 2008; Robotham & Julian 2006).
Similarly, Timmins & Kaliszer (2002) conducted a review of
international literature that investigated the stressors among
nursing students and compared Ireland with these results. Based
on themes from this review of the literature, the authors developed
a 12-item questionnaire for data collection. The questionnaire
was distributed to 110 third year nursing students at two
separate hospitals in Dublin. Concerning the clinical stressors,
the findings showed that the majority of the participants considered
that clinical placements, relationships with nurses in the
hospitals and being involved with the death of a client are
sources of stress. This coincided with earlier results in this field.
However, these findings should be interpreted carefully, given
that it was a small exploratory study that dealt with only 12 universal
sources of stress among nursing students. Each of these
individual stressors might be investigated in further detail. For
instance, the clinical settings can have a multiple number of
stressors and this was studied only as one item in the study
questionnaire.
Eustress aspects of clinical experience
Positive effects of clinical stress have received little attention in
the literature (Gibbons 2010). The following studies investigated
the eustress effect of clinical stressors among final year
British nursing students (Gibbons 2010; Gibbons et al. 2008).
Gibbons et al. (2008) conducted a qualitative study to identify
students’ experiences that provoke both eustress and distress.
A review of stress among nursing students 411
© 2014 International Council of Nurses
Sixteen participants were selected from a cluster of nursing students.
The author collected the data through four focus groups.
In relation to clinical stressors, the findings indicated that initial
clinical experience, attitudes of nurses and working on shortstaffed
settings were considered distressing factors. In contrast,
patient care opportunities and experiential learning were considered
as eustressing factors.
Gibbons (2010) conducted a further cross-sectional study
with a convenience sample of 171 nursing students in one
school in the UK. The Index of Sources of Stress in Nursing Students
inventory (Gibbons 2008) was used to measure stress. The
results indicated that placement demands and support opportunities
are capable of providing essential eustress experiences
that help students achieve and learn. These two studies
(Gibbons 2010; Gibbons et al. 2008) are unique in the body of
the literatures because little research considers those stressors
expected to improve nursing students’ well-being and their educational
process. However, participants were final year students;
thus their long experience had probably influenced the given
stress responses compared to those students in the earlier stages
of their studies.
Discussion
Context of the studies reviewed
This review illustrated that most of the studies were conducted
in Europe, primarily in Ireland and the UK. Few studies were
conducted in the Middle East. However, in terms of
globalization, the findings derived from studies that focused on
cross-cultural comparisons reported that nursing students share
similar clinical stress experiences internationally (Burnard et al.
2008; Timmins & Kaliszer 2002). More research studies are
needed in other countries such as the USA and the Middle East.
This helps in addressing the influence of the cultural factors
such as the acceptable ways of stress expression on the nursing
students’ clinical stress experiences (Robotham & Julian 2006).
Methodological considerations
The majority of the studies were descriptive and quantitative in
nature. Only one study was experimental, and two studies were
qualitative. The use of quantitative measures (such as self-report
questionnaires) may yield objective findings, especially if these
measures have adequate psychometric properties (Polit & Beck
2008). However, such structured measures may restrict the
in-depth understanding of the students’ reaction to stress
(Nieswiadomy 2008). Therefore, future studies should pay more
attention to qualitative approaches for investigating clinical
stress among nursing students. Most of the studies were crosssectional,
and only two studies utilized a longitudinal design.
This indicated that the dynamic nature of clinical stress has not
been investigated adequately in the current literature. Future
research should measure this changeable nature of stress by
employing prospective designs (Edwards et al. 2010).
Sample sizes and nature were so varied in these studies, the
range was from 6 to 1707 nursing students. This implied that
the generalizability of the literature findings may be limited in
those studies with small sample sizes. It is highly recommended
for nursing researchers to use a sample size that can achieve
higher levels of power (Faul et al. 2009). In this case, the results
can be transferred and applied in other similar settings (Polit &
Beck 2008).
There was much variability in selected instruments. Only two
tools were utilized in more than one study, and in some cases
modified version was employed. PSS was used by three studies
(Chen & Hung 2013; Shaban et al. 2012; Sheu et al. 2002) and
modified by Jimenez et al. (2010). The SNE questionnaire was
also used by two studies (Burnard et al. 2008; Edwards et al.
2010). One study designed ad hoc instrument to measure stress
(Timmins & Kaliszer 2002). In the remaining five studies, the
utilized tools were different. This variability was also evident in
the structure and content of the utilized instruments. In the
reviewed studies, instruments had 12–41 items, all with the
intent of evaluating clinical stress among nursing students. This
illustrates heterogeneity in the ways of reporting the resulting
clinical stressors. However, the majority of the tools had
adequate psychometric properties (see Table 1 for details). This
illustrates that clinical stress was measured through high-quality
measurement tools, though applied irregularly.
The most common reported stressors
It is difficult to compare findings among studies as a result of
the great number of stressors and use of different tools. Nevertheless,
academic demands, relations in the clinical environment,
and caring for patients and families were considered to be
the highest reported stressors. Accordingly, nurse educators
need to address student needs to handle these stressors effectively.
Such measures may include giving more attention to
clinical parts of training, minimizing the required paper work,
preparing all professionals involved in training of the nursing
students adequately, and offering simulation measures that
enable the students to provide care for patients before entering
the actual clinical context (Al-Zayyat & Al-Gamal 2014).
From a different perspective, the majority of the reviewed
studies were aimed to identify distressing elements of training.
Conversely, few studies have addressed those elements of training
that are perceived as eustressing (Gibbons 2010; Gibbons
et al. 2008). Future research should pay more attention to those
412 A. Alzayyat & E. Al-Gamal
© 2014 International Council of Nurses
beneficial aspects of clinical education that promote knowledge
attainments, skills acquisitions and prospective nurses’ development
(Gibbons 2010).
Stressful periods of clinical education
It has been reported that many nursing students experience
several difficulties during their initial clinical experience (Sheu
et al. 2002). It seems that current nursing curricula do not
prepare nursing students adequately to handle this experience
(Karabacak et al. 2012). Consequently, reviewing nursing curricula
is an important issue for nursing educators (Shaban et al.
2012). The inclusion of video films about clinical settings, inviting
expert guest speakers and frequent field visits (during orientation
period) may decrease initial clinical stress (Penn 2008).
There is inconsistency in the reported findings concerning
those studies that compare stress degrees across different academic
years. Some studies reported that students experienced
higher degrees of clinical stress at early academic years such as
the first year (Gorostidi et al. 2007). On the other hand, other
studies reported that those experienced nursing students (in
third or fourth year) perceived higher degrees of stress than
novices (Edwards et al. 2010; Jimenez et al. 2010). Therefore,
the current literature provides inconclusive data regarding
which stage suffered higher degrees of stress. Carefully controlled
studies (such as randomized controlled trials) are
required to resolve these controversies (Polit & Beck 2008).
Implications of the findings from this review
This review updated nursing researchers, educators and students
regarding stress experiences of nursing students during
their clinical education. The findings of this review present significant
implications for nursing education and call for further
research.
Implications for nursing education
Although the findings are sometimes conflicting, nursing lecturers,
clinical instructors, preceptors and nurses from different
nursing departments can utilize the findings of this review to
direct their students during clinical practice. This might help in
improving the clinical education programs to promote the psychosocial
well-being of the students (Pulido-Martos et al. 2012),
thus improving the patients’ quality of care. Nursing educators
should provide supportive interventions for students from the
initial time of their clinical education (Shaban et al. 2012).
Moreover, nursing educators should encourage students to
discuss their feelings and their stressors in order to provide
appropriate interventions (Penn 2008).
Policy implications for stakeholders in nursing education
Nursing school administrators should establish a student
support system through which the students can be equipped
with effective coping strategies (Robotham & Julian 2006).
Moreover, school administrators should develop training
courses in communication skills for their nursing educators that
enable them to work effectively with students (Al-Zayyat &
Al-Gamal 2014). Hospital administrators need to promote those
policies that facilitate a training environment where students
are supported and inspired while they engage in their clinical
practice (McKenna & Plummer 2013). Furthermore, hospital
administrators should develop continuous education programs
for their staff on the appropriate way to deal with students
(Gorostidi et al. 2007).
Implications for future research
It is important that nursing researchers conduct methodological
studies with the purpose of establishing and refining a standardized
instrument for assessing stress among nursing students
during their clinical education (Pulido-Martos et al. 2012).
Future research should give more attention to the beneficial
aspects of clinical education (Gibbons 2010). Additional
research is needed to explore the perception of clinical instructors
regarding the stressors faced by nursing students during
clinical education (Penn 2008).
Limitations of the review
The following limitations were identified in this review. First,
the prerequisite is that the included studies written in English
may have precluded valuable data published in different languages.
Second, the heterogeneity of the included studies in
terms of sample characteristics, utilized tools and the differences
in the operational definitions of the stress led to difficulties
when attempting to generalize the results.
Conclusion
This paper discussed stress among nursing students in clinical
settings. The findings of this review present worthy data for
clinical educators in identifying nursing students’ stressors,
facilitating their clinical education and establishing successful
clinical teaching methods. Moreover, this review provides
up-to-date empirical data (about clinical stress among nursing
students) and calls for further research. Future research is recommended
to broaden the scope of this review by addressing
the coping strategies that are utilized by nursing students to deal
with clinical stress.
Acknowledgement
The authors would like to thank The University of Jordan-
Deanship of Academic Research (Grant No. 2013-2014/ 12) for
funding this study.
A review of stress among nursing students 413
© 2014 International Council of Nurses
Author contributions
Abdulkarim Alzayyat: Study conception and design, literature
review, drafting of manuscript, and final approval of the version
to be submitted. Ekhlas Al-Gamal: Study conception and
design, drafting of manuscript, critical revisions of manuscript
for important intellectual content, and final approval of the
version to be submitted.
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