research paper on stress among nursing students

Information

• Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

• Active Journals
• Find a Journal
• Proceedings Series
• For Authors
• For Reviewers
• For Editors
• For Librarians
• For Publishers
• For Societies
• For Conference Organizers
• Open Access Policy
• Institutional Open Access Program
• Special Issues Guidelines
• Editorial Process
• Research and Publication Ethics
• Article Processing Charges
• Testimonials
• Preprints.org
• SciProfiles
• Encyclopedia

Article Menu

• Subscribe SciFeed
• Recommended Articles
• PubMed/Medline
• Google Scholar
• on Google Scholar
• Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

Stressors and coping strategies among nursing students during the covid-19 pandemic: scoping review.

1. Introduction

Aim of the study, 2. materials and methods, 2.1. research question formulation using picot, 2.2. key words, 2.3. inclusion criteria, 2.4. exclusion criteria, 2.5. search strategies, 2.6. study selection process, 2.7. quality assessment, 2.8. charting of the data, 3.1. results of the search, 3.2. characteristics of the reviewed studies, 3.3. main findings, 3.3.1. theme 1: nursing students’ stressors, stress from distance learning, stress from assignments and workload, stress from clinical training, stress from covid-19 infection, 3.3.2. theme 2: coping strategies, seeking information and consultation, staying optimistic, transference, 4. discussion, 5. recommendation, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

• Cooke, J.E.; Eirich, R.; Racine, N.; Madigan, S. Prevalence of posttraumatic and general psychological stress during COVID-19: A rapid review and meta-analysis. Psychiatry Res. 2020 , 292 , 113347. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Chakraborty, I.; Maity, P. COVID-19 outbreak: Migration, effects on society, global environment and prevention. Sci. Total Environ. 2020 , 728 , 138882. [ Google Scholar ] [ CrossRef ]
• Elmer, T.; Mepham, K.; Stadtfeld, C. Students under lockdown: Comparisons of students’ social networks and mental health before and during the COVID-19 crisis in Switzerland. PLoS ONE 2020 , 15 , e0236337. [ Google Scholar ] [ CrossRef ]
• Labrague, L.J.; McEnroe-Petitte, D.M.; Gloe, D.; Thomas, L.; Papathanasiou, I.V.; Tsaras, K. A literature review on stress and coping strategies in nursing students. J. Ment. Health 2017 , 26 , 471–480. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Fitzgerald, A.; Konrad, S. Transition in learning during COVID-19: Student nurse anxiety, stress, and resource support. Nurs. Forum. 2021 . [ Google Scholar ] [ CrossRef ]
• Mariani, R.; Renzi, A.; Di Trani, M.; Trabucchi, G.; Danskin, K.; Tambelli, R. The Impact of Coping Strategies and Perceived Family Support on Depressive and Anxious Symptomatology During the Coronavirus Pandemic (COVID-19) Lockdown. Front. Psychiatry 2020 , 11 , 587724. [ Google Scholar ] [ CrossRef ]
• Savitsky, B.; Findling, Y.; Ereli, A.; Hendel, T. Anxiety and coping strategies among nursing students during the covid-19 pandemic. Nurse Educ. Pract. 2020 , 46 , 102809. [ Google Scholar ] [ CrossRef ]
• Pérez, E.Z.; Canut, M.T.L.; Pegueroles, A.F.; Llobet, M.P.; Arroyo, C.M.; Merino, J.R. Critical thinking in nursing: Scoping review of the literature. Int. J. Nurs. Pract. 2014 , 21 , 820–830. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Hawker, S.; Payne, S.; Kerr, C.; Hardey, M.; Powell, J. Appraising the evidence: Reviewing disparate data systematically. Qual. Health Res. 2002 , 12 , 1284–1299. [ Google Scholar ] [ CrossRef ]
• Deo, P.K.; Raut, S.B.J.; Adhikari, B.; Shrestha, J. Factors Associated with Perceived Stress, Anxiety, Depression, Insomnia during COVID-19 Outbreak among Nursing Students. Int. J. Sci. Res. 2020 , 9 , 23–29. [ Google Scholar ]
• Begam, B.; Devi, K. A Study to Assess the Perceived Stress among Nursing Students during COVID-19 Lockdown. Int. J. Sci. Healthc. Res. 2020 , 5 , 388–393. [ Google Scholar ]
• Masha’al, D.; Rababa, M.; Shahrour, G. Distance Learning-Related Stress Among Undergraduate Nursing Students During the COVID-19 Pandemic. J. Nurs. Educ. 2020 , 59 , 666–674. [ Google Scholar ] [ CrossRef ]
• Hussien, R.M.; Elkayal, M.M.; Shahin, M.A.H. Emotional Intelligence and Uncertainty among Undergraduate Nursing Students during the COVID-19 Pandemic Outbreak: A Comparative Study. Open Nurs. J. 2020 , 14 , 220–231. [ Google Scholar ] [ CrossRef ]
• Begum, D.F. Knowledge, Attitudes, and Practices towards COVID-19 among B.Sc. Nursing Students in Selected Nursing Institution in Saudi Arabia during COVID-19 Outbreak: An Online Survey. Saudi J. Nurs. Health Care 2020 , 3 , 194–198. [ Google Scholar ] [ CrossRef ]
• Zeynep, T. Nursing Students’ Anxiety Levels and Coping Strategies during the COVID-19 Pandemic. Int. Arch. Nurs. Health Care 2020 , 46 , 102809. [ Google Scholar ]
• Lovrić, R.; Farčić, N.; Mikšić, Š.; Včev, A. Studying During the COVID-19 Pandemic: A Qualitative Inductive Content Analysis of Nursing Students’ Perceptions and Experiences. Educ. Sci. 2020 , 10 , 188. [ Google Scholar ] [ CrossRef ]
• Gallego-Gomez, J.I.; Campillo-Cano, M.; Carrion-Martinez, A.; Balanza, S.; Rodriguez-Gonzalez-Moro, M.T.; Simonelli-Munoz, A.J.; Rivera-Caravaca, J.M. The COVID-19 Pandemic and Its Impact on Homebound Nursing Students. Int. J. Environ. Res. Public Health 2020 , 17 , 7383. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Subedi, S.; Nayaju, S.; Subedi, S.; Shah, S.K.; Shah, J.M. Impact of E-learning during COVID-19 Pandemic among Nursing Students and Teachers of Nepal. Int. J. Sci. Healthc. Res. 2020 , 5 , 68–76. [ Google Scholar ]
• Aslan, H.; Pekince, H. Nursing students’ views on the COVID-19 pandemic and their percieved stress levels. Perspect Psychiatr. Care 2020 . [ Google Scholar ] [ CrossRef ]
• Kochuvilayil, T.; Fernandez, R.S.; Moxham, L.J.; Lord, H.; Alomari, A.; Hunt, L.; Middleton, R.; Halcomb, E.J. COVID-19: Knowledge, anxiety, academic concerns and preventative behaviours among Australian and Indian undergraduate nursing students: A cross-sectional study. J. Clin. Nurs. 2021 , 30 , 882–891. [ Google Scholar ] [ CrossRef ]
• Lockwood, C.; Dos Santos, K.B.; Pap, R. Practical Guidance for Knowledge Synthesis: Scoping Review Methods. Asian Nurs. Res. (Korean Soc. Nurs. Sci.) 2019 , 13 , 287–294. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Schmidt, B.M.; Colvin, C.J.; Hohlfeld, A.; Leon, N. Defining and conceptualising data harmonisation: A scoping review protocol. Syst. Rev. 2018 , 7 , 226. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Bdair, I.A. Nursing students’ and faculty members’ perspectives about online learning during COVID-19 pandemic: A qualitative study. Teach. Learn. Nurs. 2021 , 1 . [ Google Scholar ] [ CrossRef ]
• Fogg, N.; Wilson, C.; Trinka, M.; Campbell, R.; Thomson, A.; Merritt, L.; Tietze, M.; Prior, M. Transitioning from direct care to virtual clinical experiences during the COVID-19 pandemic. J. Prof. Nurs. 2020 , 36 , 685–691. [ Google Scholar ] [ CrossRef ]
• Ulenaersa, D.; Grosemans, J.; Schrootena, W.; Bergs, J. Clinical placement experience of nursing students during the COVID-19 pandemic: A cross-sectional study. Nurse Educ. Today 2020 , 99 , 104746. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Hayter, M.; Jackson, D. Pre-registration undergraduate nurses and the COVID-19 pandemic: Students or workers? J. Clin. Nurs. 2020 , 29 , 3115–3116. [ Google Scholar ] [ CrossRef ]
• Ramos-Morcillo, A.J.; Leal-Costa, C.; Moral-Garcia, J.E.; Ruzafa-Martinez, M. Experiences of Nursing Students during the Abrupt Change from Face-to-Face to e-Learning Education during the First Month of Confinement Due to COVID-19 in Spain. Int. J. Environ. Res. Public Health 2020 , 17 , 5519. [ Google Scholar ] [ CrossRef ]
• Cleofas, J.V. Life Interruptions, Learnings and Hopes among Filipino College Students during COVID-19 Pandemic. J. Loss Trauma 2020 , 1–9. [ Google Scholar ] [ CrossRef ]
• Bahçecioğlu Turan, G.; Köse, S.; Aksoy, M. Analysis of nursing students’ obsessive and coping behaviors during the COVID-19 pandemic. Perspect. Psychiatr. Care 2021 . [ Google Scholar ] [ CrossRef ]

Click here to enlarge figure

Share and Cite

Majrashi, A.; Khalil, A.; Nagshabandi, E.A.; Majrashi, A. Stressors and Coping Strategies among Nursing Students during the COVID-19 Pandemic: Scoping Review. Nurs. Rep. 2021 , 11 , 444-459. https://doi.org/10.3390/nursrep11020042

Majrashi A, Khalil A, Nagshabandi EA, Majrashi A. Stressors and Coping Strategies among Nursing Students during the COVID-19 Pandemic: Scoping Review. Nursing Reports . 2021; 11(2):444-459. https://doi.org/10.3390/nursrep11020042

Majrashi, Aisha, Asmaa Khalil, Elham Al Nagshabandi, and Abdulrahman Majrashi. 2021. "Stressors and Coping Strategies among Nursing Students during the COVID-19 Pandemic: Scoping Review" Nursing Reports 11, no. 2: 444-459. https://doi.org/10.3390/nursrep11020042

Article Metrics

Article access statistics, further information, mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals

• Open access
• Published: 05 May 2021

Perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa: an overview of systematic reviews

• Sonia Chaabane 1 ,
• Karima Chaabna 1 ,
• Sapna Bhagat 1 ,
• Amit Abraham 1 ,
• Sathyanarayanan Doraiswamy 1 ,
• Ravinder Mamtani 1 &
• Sohaila Cheema 1  

Systematic Reviews volume  10 , Article number:  136 ( 2021 ) Cite this article

27k Accesses

38 Citations

19 Altmetric

Metrics details

In nursing students, high stress levels can lead to burnout, anxiety, and depression. Our objective is to characterize the epidemiology of perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa region.

We conducted an overview of systematic reviews. We systematically searched PubMed, Embase, PsycInfo, and grey literature sources between January 2008 and June 2020 with no language restrictions. We included any systematic review reporting measurable stress-related outcomes including stress prevalence, stressors, and stress coping strategies in nursing students residing in any of the 20 Middle East and North Africa countries. We also included additional primary studies identified through a hand search of the reference lists of relevant primary studies and systematic reviews.

Seven systematic reviews and 42 primary studies with data from Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan were identified. Most studies included nursing students undergoing clinical training. The prevalence range of low, moderate, and high perceived stress among nursing students was 0.8–65%, 5.9–84.5%, and 6.7–99.2%, respectively. Differences related to gender, training period, or the type of tool used to measure stress remain unclear given the wide variability in the reported prevalence measures across all stress levels. Common clinical training stressors were assignments, workload, and patient care. Academic training-related stressors included lack of break/leisure time, low grades, exams, and course load. Nursing students utilized problem focused (dealing with the problem), emotion focused (regulating the emotion), and dysfunctional (venting the emotions) stress coping mechanisms to alleviate their stress.

Conclusions

Available data does not allow the exploration of links between stress levels, stressors, and coping strategies. Limited country-specific prevalence data prevents comparability between countries. Reducing the number or intensity of stressors through curriculum revision and improving students’ coping response could contribute to the reduction of stress levels among students. Mentorship, counseling, and an environment conducive to clinical training are essential to minimize perceived stress, enhance learning, and productivity, and prevent burnout among nursing students.

Peer Review reports

Mental health-related conditions are becoming increasingly prevalent among healthcare professionals worldwide [ 1 ]. Professions involving constant close human contact and emotional engagement such as nursing, are vulnerable to stress and burnout, which could manifest even before employment [ 2 , 3 , 4 ]. A standard baccalaureate nursing program is a very demanding 4-year college or university education [ 5 , 6 ]. Nursing students experience stress when curricular demands exceed their resources to deal with these demands [ 7 ]. Specifically, the clinical training component is dynamic and challenging and was identified as anxiety-producing situations by students during their initial clinical training period [ 8 ].

Psychological stress can impact nursing students’ academic and clinical performance [ 4 ] as well as their future work life as these may be associated with harmful substance use [ 9 , 10 ] and reduced empathy [ 11 ]. Stress is also associated with serious mental health disorders [ 12 , 13 , 14 ] including depression which is one of the leading causes of disability globally [ 15 ]. The prevalence of depression among nursing students in Arab states is reported to be 28% [ 4 ], approximately six times higher than the prevalence in the general population [ 16 , 17 ]. Moreover, nursing is a female-dominated profession [ 4 ] and evidence shows that female college students [ 18 , 19 , 20 ] are more susceptible to depression than their male counterparts [ 21 ].

The Middle East, as with many regions worldwide, has a shortage of professional nurses [ 22 , 23 ]. Published literature has previously reported that a significant percentage of nursing students leave school before program completion [ 24 , 25 ] as a consequence of stress [ 26 , 27 ]. Stress reduction programs have been identified to be one of the most effective interventions to decrease attrition in nursing programs [ 25 ]. Stress coping strategies are also important determinants that influence overall mental health and well-being [ 28 ]. Additionally, published studies report that emotional and behavioral problems, among high stress exposure groups, such as in nursing students may affect their lifetime risk of mental health disorders [ 29 , 30 , 31 , 32 ]. Understanding stressors that affect nursing students during their training and what coping strategies are utilized by them to address the various stressors is critical. This will enable nursing schools and educators to evaluate and utilize evidence-based interventions and support programs aimed at minimizing attrition in nursing training programs which in turn can help address the shortage of nurses in the region [ 33 ].

Several studies [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ] and systematic reviews [ 45 , 46 , 47 ] have assessed stress levels, stressors, and coping strategies among medical students; however, there is a paucity of research and reviews on the subject for nursing students in the region. Our systematic overview synthesizes evidence from published systematic reviews on perceived stress among nursing students in the Middle East and North Africa (MENA) countries. Specifically, we aim to (1) synthesize prevalence data on various stress levels, (2) identify stressors among nursing students, (3) describe stress coping strategies utilized by nursing students in the region, and (4) provide recommendations for stress management.

We conducted a systematic overview of published systematic reviews on stress, stressors, and coping strategies among nursing students in the MENA region. Our systematic overview is part of a series of research and publications aimed to improve the quality of evidence generated in the MENA region by synthesizing available literature on population health issues in the region [ 48 , 49 , 50 ]. This overview draws from an a priori protocol registered with the International Prospective Register of Systematic Reviews (PROSPERO registration number CRD42017076736) [ 51 ]. The methodology of the present systematic overview was informed by the Cochrane Collaboration handbook [ 52 ] and was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Table S1 ) [ 53 ], and the Preferred Reporting Items for Overviews of Systematic Reviews (PRIO-harms) tool (Table S2 ).

Search strategy and literature sources

Two independent reviewers (AA and SC1) systematically searched PubMed, Embase, and PsycInfo for any type of review on stress, stressors, and coping strategies on any country in the MENA region published between January 2008 and June 2020. Search terms related to stress, coping strategies/behaviors, and countries’ names were used. The full-search strategy is available in Supplementary , Panel 1 and was validated by a specialized librarian. Additionally, we searched, up to June 2020, literature sources (including grey literature) potentially relevant to the region with no language restrictions including Google Scholar, OpenGrey, E-Marefa, and ALMANHAL platform. We supplemented our literature search by checking the reference lists of relevant included studies and systematic reviews.

Inclusion and exclusion criteria

In this review, we include countries in the MENA region where Arabic, English, French, and/or Urdu are the primary official languages and/or the medium of instruction in the colleges/universities [ 51 ]. The 20 countries included are Algeria, Bahrain, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, the United Arab Emirates (UAE), and Yemen. We included any systematic review reporting measurable stress-related outcomes including stress prevalence, sources of stress, and stress coping strategies or behaviors in nursing students residing in any of the above countries. To ensure a comprehensive up-to-date synthesis of the available data, we also included additional primary studies that had not been identified by included systematic reviews as recommended by the PRIO-harms for preferred reporting items for overviews of systematic reviews [ 54 ].

A systematic review was defined as a literature review that had explicitly used a systematic literature search of at least one electronic database to identify all studies that met pre-defined eligibility criteria along with a study selection process [ 55 ]. Reviews not reporting a systematic methodology, such as narrative reviews, were excluded. We included published systematic reviews since 2008—the publication year of the first version of the Cochrane Handbook for Systematic Reviews of Interventions [ 55 ].

Data screening and data extraction

Using Rayyan software, duplicates were removed [ 56 ]. Two independent reviewers (AA and SB) conducted a multi-stage screening following a standard process. Three reviewers (AA, SB, SC1) independently extracted the data from the included systematic reviews. Discrepancies in the inclusion of systematic reviews and the extracted data were resolved through discussions with the involvement of a fourth reviewer (KC) and under the supervision of the senior authors (SC2 and RM). Extracted data included characteristics of the included systematic reviews as well as the primary studies. From each included systematic review, the following characteristics were extracted: the geographical coverage, literature search period, data literature sources, name of the MENA country for which data was retrieved, along with the number of included studies, targeted review population, and reported stress-related outcomes. From each included primary study, the following characteristics were collected: study design and sample size, years of data collection, population characteristics (type, age, gender), and stress-related outcomes (definition or level, measurement tool, and/or prevalence measure). Study characteristics and any additional data on a stress-related outcome found in an included primary study but not reported by the systematic review were also extracted. In case of discordance between reported data in the systematic review and the primary study, data from the primary study publication was retained.

Methodological quality assessment

The methodological quality of the included systematic reviews and primary studies was assessed by two independent reviewers (SB, SC1). The AMSTAR measurement tool [ 57 ] was used to perform the quality assessment of the included systematic reviews.

A customized tool was used to assess the quality of the included primary studies to accommodate the specific issues related to the methodology and the assessed outcomes. A quality assessment checklist was based on the Cochrane approach for risk of bias (ROB) assessment [ 58 ] using an adapted PICOTS framework [ 59 ] to assess the quality of included studies with a focus on bias and precision assessment. Classification of studies as low and high risk of bias was based on three quality domains: the description of the study subjects (age and gender), setting (academic year or clinical training), and the validity of the outcome measurement (the use of a validated tool). The precision assessment was based on two quality domains: the sampling methodology (probability-based versus non-probability-based sampling), and the sample size required to reach a study power of at least 80% (≥ 100 versus < 100). For instance, if probability-based sampling was used in a given study, the study was classified with a low (versus high) risk of bias for that domain. Studies were considered as having high (versus low) precision if the total sample size consisted of at least 100 participants. For a perceived stress prevalence of 50% and a sample size of 100, the 95% confidence interval (CI) is 48–52% [ 60 ]—a reasonable 95% CI estimate for perceived stress prevalence measure. Studies with missing information for any of the domains were classified as having an unclear risk of bias for that specific domain.

The characteristics of the included systematic reviews and primary studies were synthesized narratively. To quantify the stress levels among nursing students in the MENA region, available data on the prevalence of perceived stress was summarized using prevalence ranges according to three stress levels: low, moderate, and high, as defined by the different tools utilized in the studies. Prevalence measure variations according to gender, nature of ongoing training, and the type of measurement tools were explored. A measurement tool was considered validated if a validation record in the specific language was retrievable from published literature.

Reported stressors among nursing students are categorized according to the training period: clinical, academic, and stressors external to training periods. For our review, clinical training stressors are classified into six domains as per the perceived stress scale for stressors [ 61 ]. The total number of studies reporting each stressor as a source of stress in the study population is also summarized.

Reported stress coping strategies among nursing students in the MENA countries are categorized according to three mechanisms as per the theory of psychological stress and coping [ 62 ]: problem-focused (dealing with the problem), emotion-focused (regulating the emotion), and dysfunctional coping (venting the emotions). We summarize the total number of studies reporting each coping mechanism and each specific stress coping strategy.

Recommendations for stress management are synthesized based on the available evidence into three main categories: nursing students, the nursing institutions, and nursing faculty and educators.

Characteristics of the included systematic reviews and primary studies

In our overview, we include 7 systematic reviews and 42 primary studies on the epidemiology of perceived stress among nursing students containing data for at least 1 MENA country (Fig. 1 ). The included systematic reviews along with the primary studies are described in Tables S3 and S4 , respectively. We found stress-related outcomes for nine MENA countries: Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. The reported primary outcomes are measures of stress levels (six systematic reviews [ 63 , 64 , 65 , 66 , 67 , 68 ]) and stress coping strategies (one systematic review [ 69 ]). The included systematic reviews did not report stressors as a primary outcome. Five systematic reviews [ 63 , 64 , 65 , 66 , 69 ] searched any country (global coverage), one systematic review [ 67 ] searched for data on Saudi Arabia only, and one systematic review [ 68 ] searched Asian countries. Thirteen primary studies report prevalence measures on perceived stress, 36 on stressors, and 23 on stress coping strategies.

PRISMA 2009 flowchart of the systematic review’s inclusion

Methodological quality assessment of the included systematic reviews and primary studies

Quality assessment results of the systematic reviews included in our overview are described in Table S5 . None of the included systematic reviews reported a priori design, the list of excluded studies, or the conflict of interest for the included studies as per the AMSTAR recommendations [ 57 ]. Nor did any of the systematic reviews combine primary study findings through meta-analysis. All included systematic reviews conducted a comprehensive literature search and described the characteristics of the included studies. Only two systematic reviews [ 64 , 68 ] searched grey literature sources. Except for the systematic review of Younas, 2016 [ 68 ], all systematic reviews documented the scientific quality of their included studies.

Quality assessment of the included primary studies is summarized in Table S6 . All included primary studies provide a detailed description of the study subjects and the research setting. A total of 35 out of 42 primary studies (82.5%) used a validated tool to measure to assess the prevalence of perceived stress ((Perceived Stress Scale (PSS), Stress Assessment Scale (SAS), Physio-Psychosocial Stress Scale (PPSS)), stressors (PSS, Stressors in Nursing Students Scale (SINS), Student Stress Survey (SSS), Students Stress and Coping Inventory (SSCI), Student Clinical Stressor Scale (SCSS), Student Nurse Stress Index (SNSI)), or stress coping strategies ((The Coping Behaviors Inventory (CBI), abbreviated version of the full COPE Inventory (Brief COPE), Coping Orientation to Problems Experienced (COPE), Adolescent Coping Orientation for Problem Experiences (ACOPE), Revised Ways of Coping Strategies Questionnaire (RWCSQ), and Students Stress and Coping Inventory (SSCI)). Only 28 out of 42 primary studies (67.5%) had a sample size of 100 or above and 20 out of 42 primary studies (47.6%) used a probability-based sampling.

Overview of studies with stress prevalence data

Table 1 summarizes stress prevalence data retrieved from 13 included studies with data from Egypt, Jordan, Iraq, and Saudi Arabia. A total of 38 prevalence measures involving 2804 nursing students were found. Prevalence measures were categorized into three stress levels, low, moderate, or high, as per the tool utilized in the study. Retrieved prevalence data on perceived stress were collected between 2008 and 2019. Most of the included studies involved combined populations of male and female nursing students. Prevalence ranges reported in female only studies were comparable to reported prevalence ranges among combined populations of male and female nursing students. The prevalence range of low perceived stress among all nursing students was 0.8–65%, for moderate perceived stress was 5.9–84.5% and for high perceived stress was 6.7–99.2%. The stress prevalence range among students during the clinical training was comparable to that found in all academic years combined. Twelve out of 13 primary studies with prevalence data utilized a validated tool to measure the prevalence of perceived stress. The PSS was the most widely used psychological instrument for measuring stress perception. We found wide variability in the perceived stress prevalence measures for all stress levels.

Some studies reported significantly higher stress levels in nursing students living in rural areas [ 70 ], having a father with low school education or non-professional background (e.g., farmers or manual workers) [ 70 ], low grades in the previous year [ 70 ], low family income [ 71 , 72 ], enrolled in community courses [ 73 , 74 ], spending six or more hours studying per day [ 72 ], 6 h or less of sleep per night [ 72 ], and suffering from overweight and obesity [ 71 ] (Table S4 ). The impact of age [ 71 , 75 , 76 , 77 , 78 ], gender [ 71 , 76 , 79 , 80 ], marital status [ 77 , 78 ], stages/levels of student’s study [ 77 , 78 , 79 , 80 , 81 , 82 , 83 ], and student’s interest in nursing [ 74 , 75 ], on stress levels seems to be inconsistent (Table S4 ).

Overview of studies with data on stressors

Table 2 summarizes the various types of stressors reported among nursing students. A total of 36 primary studies reported data on stressors among nursing students in Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine, and Bahrain: 26 reported data on stressors during the clinical period, 15 during the academic period, and in 15, the exact academic or clinical period could not be determined. In addition to stressors during the clinical and academic periods, studies also identified stressors ‘external’ to the training periods. We grouped the external stressors to be related to the ‘physical environment’ or being ‘intrapersonal.’

Based on the total number of primary studies, stressors related to clinical training are most commonly reported among nursing students followed by academic stressors. The predominantly reported specific stressors during clinical training are associated with assignments and workload (e.g., pressure from the nature and quality of clinical practice, a feeling that requirements of clinical practice are exceeding their physical and emotional endurance) and patient care (e.g., lack of experience and ability in providing nursing care and in making judgments, ‘do not know how to help patients with physio-psycho-social problems’). Lack of break/leisure time, getting lower grades than anticipated, and examination and course load are the main specific sources of academic stressors. External stressors related to the physical environment include lack of recreation facilities; absence of a calm, safe, and secure environment; and congested classrooms. External stressors related to intrapersonal reasons reported by the nursing students include uncertainty about their future career, change in sleep pattern, and financial problems.

No significant differences are observed in the type and level of stressors between students in private nursing schools and those in public schools [ 79 ] or according to the place of residence [ 84 , 90 ], age [ 79 , 84 , 90 ], gender [ 84 , 90 ], religion [ 84 ], marital status [ 79 , 90 ], and grade point average (GPA) of the last term (Table S4 ).

Overview of studies with data on stress coping strategies

Table 3 summarizes the stress coping strategies that nursing students use to deal with stress. A total of 23 primary studies reported data on stress coping strategies used by nursing students in Saudi Arabia, Egypt, Jordan, Oman, Pakistan, and Sudan: 19 studies report the use of problem-focused coping, 20 studies the use of emotion-focused coping, and 17 studies the use of dysfunctional coping. The most widely used problem-focused stress coping strategies are active coping (e.g., problem understanding and solving) and seeking social support for instrumental reasons (e.g., asking others for help and developing social support). Whereas, positive reinforcement and growth (e.g., staying optimistic and wishful thinking) and turning to religion (e.g., use of religion, prayer, invocation, and finding comfort in religion or spiritual beliefs) are the most widely used emotion-focused stress coping strategies. The most commonly used forms of dysfunctional coping strategies are mental disengagement (e.g., transference, become involved in other activities) and behavioral disengagement (e.g., avoidance, social withdrawal).

The reported relationship between stress levels and the used coping strategies is inconsistent. Two included studies [ 81 , 91 ] suggest a significantly negative correlation between the total PSS score (stress level) and the use of specific coping strategies, namely problem-solving. Only one study reported higher stress levels among students who utilized coping strategies like avoidance or transference strategies [ 100 ].

Some included studies suggested differences in the type of specific coping strategies used according to gender [ 71 , 85 ], academic level [ 71 ], and living with family or alone [ 85 ]. The coping strategies used by the students also varied according to the stressor. During clinical training, students experiencing stress from assignments and patient care, peers, daily life, teachers, and nursing staff were found to frequently use avoidance [ 85 , 92 ], transference [ 92 ], problem solving [ 85 , 92 ], and staying optimistic [ 92 ]. Common external (physical environmental or intrapersonal) stressors were linked to the use of transference [ 92 ], problem solving [ 92 ], and staying optimistic [ 92 ].

Overview of stress management recommendations for nursing students, nursing faculty and educators, and nursing institutions

Recommendations reported in the included systematic reviews on how nursing students, nursing faculty and educators, and nursing institutions can aim to reduce stress levels, and manage stressors to maximize knowledge gain and productivity among nursing students are synthesized (Table 4 ).

Our overview synthesizes the evidence on nursing students in the MENA countries about perceived stress, stressors, and the stress coping strategies utilized by them to manage stress. We reviewed 7 systematic reviews and 42 primary studies that include data from nine the MENA countries namely, Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Prevalence data from the majority of studies suggest that moderate and high stress levels predominate among nursing students in the region. Differences related to gender, training period, or the type of tool used to measure stress remain unclear given the wide variability in the reported prevalence measures across all stress levels. Commonly reported stressors among nursing students are related to clinical training (assignments, workload, and patient care), and academic training (lack of break/leisure time, grades, and examination and course load). Studies report the utilization of three predominant stress coping mechanisms: problem-focused (dealing with the problem), emotion-focused (regulating the emotion), and dysfunctional coping (venting the emotions). The most commonly utilized strategies within the problem-focused mechanism include active coping which in turn includes, specific strategies namely “problem understanding and solving” and “seeking social support.” Similarly, within emotion-focused mechanism, positive reinforcement and growth strategy, which includes “staying optimistic” and “wishful thinking” were more common. In the case of dysfunctional coping mechanism, behavioral, and mental disengagement, “avoidance” and “transference” were the most commonly used strategies and specific strategies respectively.

Variation in perceived stress prevalence data and comparison with international data

While moderate stress levels are reported in studies conducted in China [ 133 ], Hong Kong [ 134 ], and Nepal [ 135 ], our findings suggest that the stress level among nursing students in the MENA region ranges from moderate to high. The prevalence range of stress levels similar to that observed in our study has also been found in medical students in the region [ 36 , 40 , 41 , 46 , 136 , 137 ], internationally [ 34 , 37 , 38 , 43 , 45 , 138 ], and among midwifery students [ 66 ]. The wide variability in the stress prevalence measures found in our review could be explained by certain characteristics of the tools used. Some questionnaires used to measure stress levels in the included studies evaluate stress during the previous month [ 139 ] and some others during an undetermined period [ 71 , 99 , 140 ]. Also, certain questionnaires used are designed to measure stress levels in any life situation [ 139 ] and some others have been adapted to be used among nursing students [ 71 , 72 , 93 , 99 , 140 ]. The wide range of prevalence measures across all levels of stress could be also explained by the limited sample size of the primary studies and representativeness of the selected students. Some evidence shows increased levels of stress as the nursing students progress in their educational program [ 102 , 141 ], whereas, some other studies conclude no change in the stress level [ 129 ] between the academic years [ 135 ].

Similar to our findings, studies conducted in non-MENA countries have reported clinical training stressors, particularly clinical assignments and workload, as the most common stressors among nursing students [ 133 , 134 , 135 ]. Specifically, we also found that patient care is a common stressor for nursing students during their clinical training. Procedures related to patient care, examination frequency, and the amount of overall workload during clinical training must be revisited.

A global systematic review excluding the MENA concluded that the most common stressors among nursing students are academic stressors (workload and problems associated with studying) followed by clinical stressors (such as fear of unknown situations, mistakes with patients or handling of technical equipment) [ 129 ]. This can be explained by the predominance of studies including nursing students in the preparatory and preclinical years (years 1–2) which are generally characterized by more academic workload than clinical years (years 3–4) in this systematic review [ 129 ].

Most of the published literature focuses on assessing academic and clinical stressors. The importance and potential impact of stressors external to training periods, such as the physical environment and intrapersonal stressors have been less studied. Likewise, the lack of a standardized approach to categorize stressors in these studies makes it difficult to compare results between studies. The grouping of stressors in this overview may be useful for future research on this topic. Researchers may choose to assess stressors based on academic, clinical, or factors external to training.

Data on the use of coping strategies

The wide variation found in coping strategies utilized by nursing students in the MENA countries and worldwide [ 133 , 134 , 135 , 142 ] can be explained by the differences in cultural, socio-economic, and geographic contexts [ 142 ]. Comparable to our findings, emotional (e.g., expressions of empathy) and instrumental social support (e.g., tangible aid and service), and religion are identified to be commonly used stress coping mechanisms by nursing students in Hong Kong [ 134 ] and Malaysia [ 142 ]. Other dysfunctional coping strategies, such as the use of alcohol or illicit drugs were not assessed in the included studies.

The relationship between socio-economic factors and stress levels or stressors could not be confirmed, as most of the included primary studies are cross-sectional and not designed to assess causal associations. A possible link between stress levels and factors, such as gender [ 90 ] and living with family or alone [ 85 ] can be established on the basis of studies included in our review.

Relationship between stress levels, stressors, and coping strategies

Published literature indicates a potential link between stressors and the coping strategies utilized by nursing students [ 71 , 85 ]. A recent study demonstrated a statistically significant correlation of the six domains of stressors during clinical practice comprising of patient care, clinical educators/instructors and ward staff, clinical assignments and workload, peers and nursing students from other colleges, lack of professional knowledge and skills, and the clinical environment) with coping strategies [ 142 ]. Available data on the relationship between stress levels and the used coping strategies is limited and inconsistent [ 81 , 91 , 100 ]. Data from another study, however, suggests that the use of optimism, self-efficacy, and resilient coping by nursing students can have an impact on their perceived stress [ 37 ]. Additional studies designed to assess these potential associations are needed to establish the evidence.

Recommendations for stress management

To manage stress among nursing students, it is highly recommended by several published studies that nursing institutions must recognize their role in improving stress management [ 63 , 64 , 65 , 67 , 69 , 86 , 100 , 115 , 116 , 117 , 118 , 119 , 120 , 121 ]. Nursing institutions are encouraged to provide a supportive clinical learning environment and to establish a strong support system to equip both nursing students and educators with effective coping strategies. Although evidence is absent about the type of intervention that would be effective to reduce excessive stress among nursing students, some statistically significant effect was found for interventions which focused on reducing the number or intensity of stressors through curriculum revision or improving students’ coping response by indulging in art therapy and biofeedback-assisted relaxation training [ 143 ].

Strengths and limitations

To our knowledge, this is the most comprehensive, up-to-date, systematic overview synthesizing several dimensions of stress and coping behavior in a key population of the health care system for the MENA region. We searched multiple grey and non-grey literature sources for systematic reviews and primary studies to provide comprehensive evidence on the epidemiology of perceived stress among nursing students in the region. This compilation of evidence will serve as a benchmark for nursing students, nursing faculty and educators, and nursing institutions to help direct future interventions to optimize learning and prepare nursing students to manage stress effectively. Moreover, most of the included primary studies (12 out of 13) with prevalence data utilized a validated tool to measure the prevalence of perceived stress which minimizes the bias from the measurement tool. Most of the validated tools utilized in the studies are designed to assess clinical stressors in nursing students [ 61 , 90 , 119 , 140 , 144 , 145 , 146 ].

Some included systematic reviews had specific inclusion criteria, such as, nursing students undergoing clinical training only or with a certain standard of methodological quality, which could explain the limited number of included primary studies in the systematic reviews. Moreover, none of the included systematic reviews have included studies published in a language other than English which could have led to an incomplete selection of primary studies relevant for the MENA countries. Out of the seven included systematic reviews, five had global geographical coverage and did not search grey literature or specific sources relevant for countries of the MENA region. Despite our best efforts to include all available data, data on the topic in other country-specific grey literature sources could exist. The included systematic reviews have searched data up to August 2018. In the absence of recent systematic reviews and to complete the collected data with recent studies published in the past 2 years, we conducted a hand search of primary studies in grey and non-grey literature sources. Despite this updated search, other recent primary studies could have been missed. Out of the seven included systematic reviews, five [ 63 , 65 , 66 , 68 , 69 ] were found through a hand search. This is explained by the fact that none of the hand searched systematic reviews have mentioned a term related to the MENA countries in the searchable fields of the used data platforms.

Our findings suggest that the stress level among nursing students in the MENA region ranges from moderate to high. The limited data on stress prevalence among nursing students in all the MENA countries prevents the estimation of its magnitude with certainty; hence, comparability of stress prevalence between countries and other regions is also not possible. Differences due to gender, clinical training period, or type of tool used remain unclear given the wide variability in the reported prevalence measures across all stress levels. Nursing students commonly report stressors related to both clinical and academic training components of the nursing curriculum. Studies report an equal utilization of three predominant stress coping strategies by the nursing students: problem focused (dealing with the problem), emotion focused (regulating the emotion), and dysfunctional (venting the emotions). The link between stressors, and coping strategies and stress levels remains unclear. Although the significance of using the problem-solving approach to manage stress is well-established, there is a need to identify effective strategies to reduce excessive stress and increase the utility of positive coping strategies. Nursing institutions should establish a strong support system for students and educators to equip them with effective coping strategies. Reducing the number or intensity of stressors through curriculum revision and improving students’ coping response could contribute to the reduction of stress levels among students. Nursing faculty and educators are encouraged to mentor students to develop and strengthen problem-based, rather than emotion-based behavior to cope with stress and to provide a supportive clinical learning environment. While stress may not be preventable, it appears coping with stressors especially during the clinical training of the nursing curriculum is essential to maximize knowledge gain and productivity and prevent burnout among nursing students.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

The Preferred Reporting Items for Overviews of Systematic Reviews

Middle East and North Africa

The United Arab Emirates

Risk of bias

Perceived Stress Scale

Stress Assessment Scale

Physio-Psychosocial Stress Scale

Stressors in Nursing Students Scale

Student Stress Survey

Students Stress and Coping Inventory

Student Clinical Stressor Scale

Student Nurse Stress Index

Coping Behaviors Inventory

Coping Orientation to Problems Experienced

Adolescent Coping Orientation for Problem Experiences

Revised Ways of Coping Strategies Questionnaire

Barry S, Ward L. Undergraduate nursing students’ understandings of mental health: a review of the literature. Issues Ment Health Nurs. 2017;38(2):160–75. https://doi.org/10.1080/01612840.2016.1251515 .

Article   PubMed   Google Scholar  

Moreira DP, Furegato ARF. Stress and depression among students of the last semester in two nursing courses. Rev Lat Am Enfermagem. 2013;21(spe):155–62. https://doi.org/10.1590/S0104-11692013000700020 .

Rudman A, Gustavsson JP. Burnout during nursing education predicts lower occupational preparedness and future clinical performance: a longitudinal study. Int J Nurs Stud. 2012;49(8):988–1001. https://doi.org/10.1016/j.ijnurstu.2012.03.010 .

Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: A systematic review and meta-analysis. Nurse Educ Today. 2018;63:119–29. https://doi.org/10.1016/j.nedt.2018.01.009 .

Phillips A. Nursing Education in Saudi Arabia. Ann Saudi Med. 1989;9(2):195–7. https://doi.org/10.5144/0256-4947.1989.195 .

Article   Google Scholar  

The American Association of Colleges of Nursing (AACN). Nursing Education Programs / Baccalaureate Education. 2020. Available from: https://www.aacnnursing.org/Nursing-Education-Programs/Baccalaureate-Education . Accessed 20 May 2020.

Moffat KJ, McConnachie A, Ross S, Morrison JM. First year medical student stress and coping in a problem-based learning medical curriculum. Med Educ. 2004;38(5):482–91. https://doi.org/10.1046/j.1365-2929.2004.01814.x .

Elliott M. The clinical environment: a source of stress for undergraduate nurses. Aust J Adv Nurs. 2002;20(1):34–8.

PubMed   Google Scholar  

Newbury-Birch D, Walshaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug Alcohol Depend. 2001;64(3):265–70. https://doi.org/10.1016/S0376-8716(01)00128-4 .

Article   CAS   PubMed   Google Scholar  

Ashton CH, Kamali F. Personality, lifestyles, alcohol and drug consumption in a sample of British medical students. Med Educ. 1995;29(3):187–92. https://doi.org/10.1111/j.1365-2923.1995.tb02828.x .

Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ. 2004;38(5):522–34. https://doi.org/10.1046/j.1365-2929.2004.01820.x .

Gibbons C. Stress, coping and burn-out in nursing students. Int J Nurs Stud. 2010;47(10):1299–309. https://doi.org/10.1016/j.ijnurstu.2010.02.015 .

Xie Z, Wang A, Chen B. Nurse burnout and its association with occupational stress in a cross-sectional study in Shanghai. J Adv Nurs. 2011;67(7):1537–46. https://doi.org/10.1111/j.1365-2648.2010.05576.x .

Mészáros V, Cserháti Z, Oláh A, Perczel Forintos D, Adám S. Coping with work-related stress in health care professionals -- strategies for the prevention of burnout and depression. Orv Hetil. 2013;154(12):449–54. https://doi.org/10.1556/OH.2013.29572 .

Institute for Health Metrics and Evaluation (IHME). Findings from the global burden of disease study 2017. Seattle: IHME; 2018.

Google Scholar  

World Health Organization. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization; 2017.

Ferrari AJ, Somerville AJ, Baxter AJ, Norman R, Patten SB, Vos T, et al. Global variation in the prevalence and incidence of major depressive disorder: a systematic review of the epidemiological literature. Psychol Med. 2013;43(3):471–81. https://doi.org/10.1017/S0033291712001511 .

Young CB, Fang DZ, Zisook S. Depression in Asian–American and Caucasian undergraduate students. J Affect Disord. 2010;125(1):379–82. https://doi.org/10.1016/j.jad.2010.02.124 .

Buchanan JL. Prevention of depression in the college student population: a review of the literature. Arch Psychiatr Nurs. 2012;26(1):21–42. https://doi.org/10.1016/j.apnu.2011.03.003 .

Steptoe A, Tsuda A, Tanaka Y, Wardle J. Depressive symptoms, socio-economic background, sense of control, and cultural factors in university students from 23 countries. Int J Behav Med. 2007;14(2):97–107. https://doi.org/10.1007/BF03004175 .

Olvera Alvarez H, Provencio-Vasquez E, Slavich G, Laurent J, Browning M, McKee-Lopez G, et al. Stress and health in nursing students. Nurs Res. 2019;68(6):453–63. https://doi.org/10.1097/NNR.0000000000000383 .

Article   PubMed   PubMed Central   Google Scholar  

Shukri R. Status of nursing in the Arab world. Ethn Dis. 2005;15(1 Suppl 1):S1-88–9.

Sheikh JI, Cheema S, Chaabna K, Lowenfels AB, Mamtani R. Capacity building in health care professions within the Gulf cooperation council countries: paving the way forward. BMC Med Educ. 2019;19(1):83. https://doi.org/10.1186/s12909-019-1513-2 .

Courage MM, Godbey KL. Student retention: policies and services to enhance persistence to graduation. Nurse Educ. 1992;17(2):29–32. https://doi.org/10.1097/00006223-199203000-00015 .

Smith-Wacholz HC, Wetmore JP, Conway C, McCarley M. Retention of nursing students: an integrative review. Nurs Educ Perspect. 2019;40(6):328–32. https://doi.org/10.1097/01.NEP.0000000000000477 .

Lindop E. Individual stress and its relationship to termination of nurse training. Nurse Educ Today. 1989;9(3):172–9. https://doi.org/10.1016/0260-6917(89)90041-5 .

Lindop E. Factors associated with student and pupil nurse wastage. J Adv Nurs. 1987;12(6):751–6. https://doi.org/10.1111/j.1365-2648.1987.tb01379.x .

Shikai N, Uji M, Chen Z, Hiramura H, Tanaka N, Shono M, et al. The role of coping styles and self-efficacy in the development of dysphoric mood among nursing students. J Psychopathol Behav Assess. 2007;29(4):241–8. https://doi.org/10.1007/s10862-007-9043-3 .

Harrington R, Fudge H, Rutter M, Pickles A, Hill J. Adult outcomes of childhood and adolescent depression: I. Psychiatric status. Arch Gen Psychiatry. 1990;47(5):465–73. https://doi.org/10.1001/archpsyc.1990.01810170065010 .

Hofstra MB, Van der Ende JAN, Verhulst FC. Continuity and change of psychopathology from childhood into adulthood: a 14-year follow-up study. J Am Acad Child Adolesc Psychiatry. 2000;39(7):850–8. https://doi.org/10.1097/00004583-200007000-00013 .

Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ, Poulton R. Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Arch Gen Psychiatry. 2003;60(7):709–17. https://doi.org/10.1001/archpsyc.60.7.709 .

Hofstra MB, Van Der Ende JAN, Verhulst FC. Child and adolescent problems predict dsm-iv disorders in adulthood: a 14-year follow-up of a dutch epidemiological sample. J Am Acad Child Adolesc Psychiatry. 2002;41(2):182–9. https://doi.org/10.1097/00004583-200202000-00012 .

Deary IJ, Watson R, Hogston R. A longitudinal cohort study of burnout and attrition in nursing students. J Adv Nurs. 2003;43(1):71–81. https://doi.org/10.1046/j.1365-2648.2003.02674.x .

Voltmer E, Kötter T, Spahn C. Perceived medical school stress and the development of behavior and experience patterns in German medical students. Med Teach. 2012;34(10):840–7. https://doi.org/10.3109/0142159X.2012.706339 .

Castaldelli-Maia JM, Lewis T, Marques dos Santos N, Picon F, Kadhum M, Farrell SM, et al. Stressors, psychological distress, and mental health problems amongst Brazilian medical students. Int Rev Psychiatry. 2019;31:7–8, 603–7.

Shawi AFA, Abdullateef AN, Khedher MA, Rejab MS, Khaleel RN. Assessing stress among medical students in Anbar governorate, Iraq: a cross-sectional study. Pan Afr Med J. 2018;31:96.

Heinen I, Bullinger M, Kocalevent R-D. Perceived stress in first year medical students - associations with personal resources and emotional distress. BMC Med Educ. 2017;17(1):4. https://doi.org/10.1186/s12909-016-0841-8 .

Melaku L, Mossie A, Negash A. Stress among medical students and its association with substance use and academic performance. J Biomed Educ. 2015;2015:9.

Ludwig AB, Burton W, Weingarten J, Milan F, Myers DC, Kligler B. Depression and stress amongst undergraduate medical students. BMC Med Educ. 2015;15(1):141. https://doi.org/10.1186/s12909-015-0425-z .

Abdulghani HM, AlKanhal AA, Mahmoud ES, Ponnamperuma GG, Alfaris EA. Stress and its effects on medical students: a cross-sectional study at a college of medicine in Saudi Arabia. J Health Popul Nutr. 2011;29(5):516–22.

Abdulghani HM. Stress and depression among medical students: a cross sectional study at a Medical College in Saudi Aarabia. Pak J Med Sci. 2008;24(1):12–7.

Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ. 2005;39(6):594–604. https://doi.org/10.1111/j.1365-2929.2005.02176.x .

Sherina MS, Rampal L, Kaneson N. Psychological stress among undergraduate medical students. Med J Malaysia. 2004;59(2):207–11.

CAS   PubMed   Google Scholar  

Kiessling C, Schubert B, Scheffner D, Burger W. First year medical students’ perceptions of stress and support: a comparison between reformed and traditional track curricula. Med Educ. 2004;38(5):504–9. https://doi.org/10.1046/j.1365-2929.2004.01816.x .

Esan O, Esan A, Folasire A, Oluwajulugbe P. Mental health and wellbeing of medical students in Nigeria: a systematic review. Int Rev Psychiatry. 2019:1–12.

Elzubeir MA, Elzubeir KE, Magzoub ME. Stress and coping strategies among Arab medical students: towards a research agenda. Educ Health (Abingdon). 2010;23(1):355.

CAS   Google Scholar  

Witt K, Boland A, Lamblin M, McGorry PD, Veness B, Cipriani A, et al. Effectiveness of universal programmes for the prevention of suicidal ideation, behaviour and mental ill health in medical students: a systematic review and meta-analysis. Evid Based Ment Health. 2019;22(2):84–90. https://doi.org/10.1136/ebmental-2019-300082 .

Doraiswamy S, Jithesh A, Chaabane S, Abraham A, Chaabna K, Cheema S. Perinatal mental illness in the Middle East and North Africa Region-a systematic overview. Int J Environ Res Public Health. 2020;17(15):5487.

Article   PubMed Central   Google Scholar  

Chaabna K, Cheema S, Abraham A, Alrouh H, Lowenfels AB, Maisonneuve P, et al. Systematic overview of hepatitis C infection in the Middle East and North Africa. World J Gastroenterol. 2018;24(27):3038–54. https://doi.org/10.3748/wjg.v24.i27.3038 .

Chaabane S, Chaabna K, Abraham A, Mamtani R, Cheema S. Physical activity and sedentary behaviour in the Middle East and North Africa: an overview of systematic reviews and meta-analysis. Sci Rep. 2020;10(1):9363. https://doi.org/10.1038/s41598-020-66163-x .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Chaabna K, Cheema S, Abraham A, Alrouh H, Mamtani R, Sheikh JI. Gray literature in systematic reviews on population health in the Middle East and North Africa: protocol of an overview of systematic reviews and evidence mapping. Syst Rev. 2018;7(1):94. https://doi.org/10.1186/s13643-018-0751-4 .

Becker L, Oxman A. Overviews of reviews. In: Cochrane handbook for systematic reviews of interventions version 510: The Cochrane Collaboration; 2011. p. 607–31. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/9780470712184.ch22 .

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006–12. https://doi.org/10.1016/j.jclinepi.2009.06.005 .

Bougioukas KI, Liakos A, Tsapas A, Ntzani E, Haidich A-B. Preferred reporting items for overviews of systematic reviews including harms checklist: a pilot tool to be used for balanced reporting of benefits and harms. J Clin Epidemiol. 2018;93:9–24. https://doi.org/10.1016/j.jclinepi.2017.10.002 .

Higgins J, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0: The Cochrane Collaboration; 2011. Available from: www.handbook.cochrane.org

Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. https://doi.org/10.1186/s13643-016-0384-4 .

Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7(1):10. https://doi.org/10.1186/1471-2288-7-10 .

Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Clinical research ed). 2011;343:d5928.

Institute of Medicine of the National Academies. Finding what works in health care: standards for systematic reviews. Washington, DC: The National Academies Press; 2011.

Daniel WW. Biostatistics: a foundation for analysis in the health sciences. 7th ed. New York: Wiley; 1999.

Sheu S, Lin HS, Hwang SL. Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice: the effect of coping behaviors. Int J Nurs Stud. 2002;39(2):165–75. https://doi.org/10.1016/S0020-7489(01)00016-5 .

Baqutayan S. Stress and coping mechanisms: a historical overview. Mediterr J Soc Sci. 2015;6(2 S1):479.

Labrague LJ, McEnroe-Petitte DM, Gloe D, Thomas L, Papathanasiou IV, Tsaras K. A literature review on stress and coping strategies in nursing students. J Ment Health. 2017;26(5):471–80. https://doi.org/10.1080/09638237.2016.1244721 .

Alzayyat A, Al-Gamal E. A review of the literature regarding stress among nursing students during their clinical education. Int Nurs Rev. 2014;61(3):406–15. https://doi.org/10.1111/inr.12114 .

Bhurtun HD, Azimirad M, Saaranen T, Turunen H. Stress and coping among nursing students during clinical training: an integrative review. J Nurs Educ. 2019;58(5):266–72. https://doi.org/10.3928/01484834-20190422-04 .

McCarthy B, Trace A, O’Donovan M, Brady-Nevin C, Murphy M, O'Shea M, et al. Nursing and midwifery students’ stress and coping during their undergraduate education programmes: an integrative review. Nurse Educ Today. 2018;61:197–209. https://doi.org/10.1016/j.nedt.2017.11.029 .

Labrague LJ, McEnroe–Petitte DM, De Los Santos JAA, Edet OB. Examining stress perceptions and coping strategies among Saudi nursing students: a systematic review. Nurse Educ Today. 2018;65:192–200.

Younas A. Levels of stress and coping strategies used by nursing students in Asian countries: an integrated literature review. J Middle East North Afr Sci. 2016;2(4):50–7. https://doi.org/10.12816/0032673 .

Labrague LJ, McEnroe-Petitte DM, Al Amri M, Fronda DC, Obeidat AA. An integrative review on coping skills in nursing students: implications for policymaking. Int Nurs Rev. 2018;65(2):279–91. https://doi.org/10.1111/inr.12393 .

Amr A, El-Gilany A-H, El-Moafee H, Salama L, Jimenez C. Stress among Mansoura (Egypt) baccalaureate nursing students. Pan Afr Med J. 2011;8:26.

Madian A, Abdelaziz M, Ahmed H. Level of stress and coping strategies among nursing students at Damanhour University, Egypt. Am J Nurs Res. 2019;7(5):684–96. https://doi.org/10.12691/ajnr-7-5-3 .

Abd El All NH, Abou Shousha AAEF. Stress factors and coping strategies as perceived by nursing students = عوامل الضغوط و إستراتیجیات المواجهة من وجهة نظر طلبة كلیة التمریض . Zagazig Nurs J. 2015;11(1):16–32.

Elsayes H, Obied H. Association between senior nursing students’ perceived stress and learning environment in clinical practice. J Nurs Educ Pract. 2017;8(3):126. https://doi.org/10.5430/jnep.v8n3p126 .

Khater W, Akhu-Zaheya L, Shaban I. Sources of stress and coping behaviours in clinical practice among baccalaureate nursing students. Int J Humanit Soc Sci. 2014;4:194–202.

Alsaqri SH. Stressors and coping strategies of the Saudi nursing students in the clinical training: a cross-sectional study. Educ Res Int. 2017;2017:8.

Aziz F. Stressors and coping strategies among baccalaureate nursing students at Shifa College of Nursing Islamabad, Pakistan. Int J Nurs Educ. 2012;4:193.

Eswi AS, Radi S, Youssri H. Stress/ stressors as perceived by baccalaureate Saudi nursing students. Middle-East J Sci Res. 2013;14:193–202.

Al-Barrak MY, El-Nady MT, Fayad EA. Sources of stress as perceived by nursing students at King Saud University. Med J Cairo Univ. 2011;79:541–53.

Watson R, Rehman S, Ali PA. Stressors affecting nursing students in Pakistan. Int Nurs Rev. 2017;64(4):536–43. https://doi.org/10.1111/inr.12392 .

Kareem MS. Stress level among nursing students in hawler medical university at Erbil CIty-Iraq. Malays J Nurs. 2019;11(1):82–8. https://doi.org/10.31674/mjn.2019.v11i01.012 .

Basal A. Foundations of stressors and coping behaviors in different clinical practice areas among undergraduate nursing students in faculty of nursing Tanta University; 2018.

Mohamed BM, Ahmed ES. Perception of nursing students towards clinical stressors in the Faculty of Applied Medical Sciences – Al Jouf University – Saudi Arabia. J Am Sci. 2012;8:608–17.

Aedh AI, Elfaki NK, Mohamed IA. Factors associated with stress among nursing students (Najran University-Saudi Arabia). IOSR J Nurs Health Sci. 2015;4(6):33–8.

El Rafaey NM. Clinical setting related stressors perceived by medical surgical nursing students. J Nurs Health Sci. 2020;9(3):01–5.

Shdaifat E. Stress and coping strategies among nursing students. Global J Health Sci. 2018;10(5):33. https://doi.org/10.5539/gjhs.v10n5p33 .

Parveen A, Inayat S. Evaluation of factors of stress among nursing students. Adv Pract Nurs. 2017;02(2):136.

Afzal M, Hussain M, Waqas A, Sehar N. Sources of stress among the nursing students of private universities of Pakistan. S Am J Nurs. 2016.  https://doi.org/10.21522/TIJNR.2015.02.01.Art004 .

Bashir R. Sources of stress among nursing students of university of Lahore (LSN): Thesis. University of Lahore; 2014.

Al Zu’bi MAKM, Shawabka GAF. Assessment of stress factors for nursing student toward training in the critical areas of Princess Basma Hospital. J Middle East North Afr Sci. 2018;4(4):8–12.

Fashafsheh I, Ayed A, Alkaissi A. Stressors affecting baccalaureate nursing students in the clinical area in Palestinian Universities. J Health Med Nurs. 2015;14:42–52.

Al-Gamal E, Alhosain A, Alsunaye K. Stress and coping strategies among Saudi nursing students during clinical education. Perspect Psychiatr Care. 2018;54(2):198–205. https://doi.org/10.1111/ppc.12223 .

Ahmed WAM, Mohammed BMA. Nursing students’ stress and coping strategies during clinical training in KSA. J Taibah Univ Med Sci. 2019;14(2):116–22. https://doi.org/10.1016/j.jtumed.2019.02.002 .

Mohammed Q, Sajit K. Stress and its associated factors among students of the College of Nursing University of Baghdad. Iraqi Natl J Nurs Spec. 2016;29:30–7.

Ajweh AM, Shukri R, Kazem A, Saloom W. Stressors and coping strategies among nursing students at the College Nursing in Sultan Qaboos University. Int J Learn Man Sys. 2015;3:51–69.

Hamaideh SH, Al-Omari H, Al-Modallal H. Nursing students’ perceived stress and coping behaviors in clinical training in Saudi Arabia. J Ment Health. 2017;26(3):197–203. https://doi.org/10.3109/09638237.2016.1139067 .

Ismaile S, et al. Open J Nurs. 2017;07(04):10.

Subhi Al-Zayyat A, Al-Gamal E. Perceived stress and coping strategies among Jordanian nursing students during clinical practice in psychiatric/mental health courses. Int J Ment Health Nurs. 2014;23(4):326–35. https://doi.org/10.1111/inm.12054 .

Shaban IA, Khater WA, Akhu-Zaheya LM. Undergraduate nursing students’ stress sources and coping behaviours during their initial period of clinical training: a Jordanian perspective. Nurse Educ Pract. 2012;12(4):204–9. https://doi.org/10.1016/j.nepr.2012.01.005 .

Maged R, El A, Hosny H, Ata A. Conflict management styles, assertiveness and stress among nursing students; 2019. p. 49–59.

Alzayyat A, Al-Gamal E. Correlates of stress and coping among jordanian nursing students during clinical practice in psychiatric/mental health course. Stress Health. 2016;32(4):304–12. https://doi.org/10.1002/smi.2606 .

John B, Al-Sawad M. Perceived stress in clinical areas and emotional intelligence among baccalaureate nursing students. J Indian Acad Appl Psychol. 2015;41(3):75–84.

Naqvi A, Alrasheed F, Ahmad R, Ahmad N. Academic stress and prevalence of stress-related self-medication among undergraduate female students of health and non-health cluster colleges of a public sector University in Dammam, Saudi Arabia. J Pharm Bioallied Sci. 2018;9:251–8.

Alghamdi S, Aljabri S, Jafari G, Alzebali R, Alkunaidiri N, Kalantan N. Sources of stress among undergraduate nursing students. Global J Health Sci. 2019;11(9):116. https://doi.org/10.5539/gjhs.v11n9p116 .

Shalaby S, AlDilh SMS. Exploring the relationship between perceived stress and academic achievement among critical care nursing students. Athens J Health. 2015;2(4):283–96. https://doi.org/10.30958/ajh.2-4-4 .

Shalaby S, Aljezani A. Exploring the relationship between perceived educational environment and academic achievement among critical care nursing students. Clin Nurs Stud. 2018;7(1):1. https://doi.org/10.5430/cns.v7n1p1 .

Yehia DBM, Jacoub SM, Eser SM. Predictors of coping strategies among nursing college students at AL-Zaytoonah University of Jordan. J Educ Pract. 2016;7(15):149–54.

Khalil Abdulqawi MS, Brair SL. Coping strategies regarding stress among bachelor nursing students in clinical practice, Khartoum State, 2018. Al Neelain Med J. 2018;(22). ISSN 1858-6155.

Hassanein S, Elshair I, Abdrbo A, Hassan E. Coping strategies as predictors of coursework stress among university nursing students. J Nurs Educ Pract. 2016;7(2):99–106.

Al Masaed AS. Relationships of positive and negative psychological stress coping strategies with locus of control and some variables among a sample of Al-al Bayt University students. 2013;7(3):19. مجلة الدراسات التربویة والنفسیة.

Mahfouz R, Alsahli H. Perceived stress and coping strategies among newly nurse students in clinical practice. J Educ Pract. 2016;7(23):118–28.

al Zamil L. Perceived level of stress, & coping strategies among Saudi nursing student. IOSR J Nurs Health Sci. 2017;06:06–13.

Ibrahim SR, Sayed FS. Stress level and coping behaviors of psychiatric nursing students pre and post clinical practice. J Nurs Health Sci. 2018;7(Issue 2 Ver. IV):54–64.

COPE Inventory. Measurement instrument database for the social science. Carver, C.S; 2013. Retrieved from www.midss.ie .

Carver CS. You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med. 1997;4(1):92–100. https://doi.org/10.1207/s15327558ijbm0401_6 .

Robotham D, Julian C. Stress and the higher education student: a critical review of the literature. J Furth High Educ. 2006;30(2):107–17. https://doi.org/10.1080/03098770600617513 .

Folkman S, Lazarus RS. The relationship between coping and emotion: implications for theory and research. Soc Sci Med. 1988;26(3):309–17. https://doi.org/10.1016/0277-9536(88)90395-4 .

Raymond J, Sheppard K. Effects of peer mentoring on nursing students’ perceived stress, sense of belonging, self-efficacy and loneliness. J Nurs Educ Pract. 2017;8(1):16. https://doi.org/10.5430/jnep.v8n1p16 .

Klainin-Yobas P, Keawkerd O, Pumpuang W, Thunyadee C, Thanoi W, He H-G. The mediating effects of coping on the stress and health relationships among nursing students: a structural equation modelling approach. J Adv Nurs. 2014;70(6):1287–98. https://doi.org/10.1111/jan.12283 .

Seyedfatemi N, Tafreshi M, Hagani H. Experienced stressors and coping strategies among Iranian nursing students. BMC Nurs. 2007;6(1):11. https://doi.org/10.1186/1472-6955-6-11 .

Zhao FF, Lei XL, He W, Gu YH, Li DW. The study of perceived stress, coping strategy and self-efficacy of C hinese undergraduate nursing students in clinical practice. Int J Nurs Pract. 2015;21(4):401–9. https://doi.org/10.1111/ijn.12273 .

Del Prato D, Bankert E, Grust P, Joseph J. Transforming nursing education: a review of stressors and strategies that support students’ professional socialization. Adv Med Educ Pract. 2011;2:109–16. https://doi.org/10.2147/AMEP.S18359 .

Ghodasara SL, Davidson MA, Reich MS, Savoie CV, Rodgers SM. Assessing student mental health at the Vanderbilt University School of Medicine. Acad Med. 2011;86(1):116–21. https://doi.org/10.1097/ACM.0b013e3181ffb056 .

Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. J Psychiatr Res. 2013;47(3):391–400. https://doi.org/10.1016/j.jpsychires.2012.11.015 .

Puthran R, Zhang MWB, Tam WW, Ho RC. Prevalence of depression amongst medical students: a meta-analysis. Med Educ. 2016;50(4):456–68. https://doi.org/10.1111/medu.12962 .

Nelwati N, McKenna L, Plummer V. Indonesian student nurses’ perceptions of stress in clinical learning: a phenomenological study. J Nurs Educ Pract. 2013;ISSN 1925-4040:56–65.

Zupiria Gorostidi X, Huitzi Egilegor X, Jose Alberdi Erice M, Jose Uranga Iturriotz M, Eizmendi Garate I, Barandiaran Lasa M, et al. Stress sources in nursing practice. Evolution during nursing training. Nurse Educ Today. 2007;27(7):777–87. https://doi.org/10.1016/j.nedt.2006.10.017 .

Lo R. A longitudinal study of perceived level of stress, coping and self-esteem of undergraduate nursing students: an Australian case study. J Adv Nurs. 2002;39(2):119–26. https://doi.org/10.1046/j.1365-2648.2000.02251.x .

Maalouf FT, Alamiri B, Atweh S, Becker AE, Cheour M, Darwish H, et al. Mental health research in the Arab region: challenges and call for action. Lancet Psychiatry. 2019;6(11):961–6. https://doi.org/10.1016/S2215-0366(19)30124-5 .

Pulido-Martos M, Augusto-Landa JM, Lopez-Zafra E. Sources of stress in nursing students: a systematic review of quantitative studies. Int Nurs Rev. 2012;59(1):15–25. https://doi.org/10.1111/j.1466-7657.2011.00939.x .

Chan CK, So WK, Fong DY. Hong Kong baccalaureate nursing students’ stress and their coping strategies in clinical practice. J Prof Nurs. 2009;25(5):307–13. https://doi.org/10.1016/j.profnurs.2009.01.018 .

Yamashita K, Saito M, Takao T. Stress and coping styles in Japanese nursing students. Int J Nurs Pract. 2012;18(5):489–96. https://doi.org/10.1111/j.1440-172X.2012.02056.x .

Penn TD. Enhancing student comfort in psychiatric clinical settings. Teach Learn Nurs. 2008;3(2):53–5. https://doi.org/10.1016/j.teln.2007.10.001 .

Zhao FF, Lei XL, He W, Gu YH, Li DW. The study of perceived stress, coping strategy and self-efficacy of Chinese undergraduate nursing students in clinical practice. Int J Nurs Pract. 2015;21(4):401–9. https://doi.org/10.1111/ijn.12273 .

Yan ATC. Prediction of perceived stress of Hong Kong nursing students with coping behaviors over clinical practicum: a cross-sectional study. J Biosci Med. 2019;7(5):50–60. https://doi.org/10.4236/jbm.2019.75008 .

Devkota R, Shrestha S. Stress among bachelor level nursing student. Nepal Med Coll J. 2018;20(1-3):33–40.

Carter A, Elzubeir M, Abdulrazzaq Y, Revel A, Townsend A. Health and lifestyle needs assessment of medical students in the United Arab Emirates. Med Teach. 2003;25(5):492–6. https://doi.org/10.1080/01421590310001605633 .

El-Gilany A-H, Amr M, Hammad S. Perceived stress among male medical students in Egypt and Saudi Arabia: effect of sociodemographic factors. Ann Saudi Med. 2008;28(6):442–8. https://doi.org/10.5144/0256-4947.2008.442 .

Saipanish R. Stress among medical students in a Thai medical school. Med Teach. 2003;25(5):502–6. https://doi.org/10.1080/0142159031000136716 .

Perceived Stress Scale (PSS). From: Cohen S, Kamarck T, Mermelstein R. A global measure of oerceived stress. J Health Soc Behav. 1983;24(4):385–96.

Jones MC, Johnston DW. The derivation of a brief Student Nurse Stress Index. Work Stress. 1999;13(2):162–81. https://doi.org/10.1080/026783799296129 .

Lindop E. Individual stress among nurses in training: why some leave while others stay. Nurse Educ Today. 1991;11(2):110–20. https://doi.org/10.1016/0260-6917(91)90146-2 .

Ab Latif R, Mat Nor MZ. Stressors and coping strategies during clinical practice among diploma nursing students. Malays J Med Sci. 2019;26(2):88–98. https://doi.org/10.21315/mjms2019.26.2.10 .

Turner K, McCarthy VL. Stress and anxiety among nursing students: a review of intervention strategies in literature between 2009 and 2015. Nurse Educ Pract. 2017;22:21–9. https://doi.org/10.1016/j.nepr.2016.11.002 .

Algaralleh A, Altwalbeh D, Alzayyat A. Preliminary psychometric properties of the Arabic version of Sheu and colleagues Perceived Stress Scale among nursing students at Jordanian universities. J Multidiscip Healthc. 2019;12:777–87. https://doi.org/10.2147/JMDH.S214456 .

Watson R, Deary IJ, Thompson DR, Li G. The stress in nursing students scale (SINS): principal components analysis of longitudinal data from Hong Kong. J Clin Nurs. 2010;19(7-8):1170–2. https://doi.org/10.1111/j.1365-2702.2009.03159.x .

Folkman S. Stress: appraisal and coping. In: Gellman MD, Turner JR (eds).  Encyclopedia of behavioral medicine. New York; Springer; 2013. https://doi.org/10.1007/978-1-4419-1005-9_215 .

Download references

Acknowledgements

We would like to thank Danielle Jones, Lecturer, English as a Second Language, Weill Cornell Medicine-Qatar for editing the manuscript. We acknowledge Open Access funding provided by the Qatar National Library.

This research received no specific grant.

Author information

Authors and affiliations.

Institute for Population Health, Weill Cornell Medicine–Qatar, Ar-Rayyan, Qatar

Sonia Chaabane, Karima Chaabna, Sapna Bhagat, Amit Abraham, Sathyanarayanan Doraiswamy, Ravinder Mamtani & Sohaila Cheema

You can also search for this author in PubMed   Google Scholar

Contributions

Sonia Chaabane (SC1), Karima Chaabna (KC), Sapna Bhagat (SB), Amit Abraham (AA), Sathyanarayanan Doraiswamy (SD), Ravinder Mamtani (RM), and Sohaila Cheema (SC2) collectively contributed to the conception of the study. SC1, KC, SB, AA, and SC2 were involved in the literature search, screening, and extraction steps. Analysis and manuscript drafting were implemented by SC1 with support from KC, AA, SD, SC2, and RM. All authors read, edited, and approved the final manuscript.

Corresponding author

Correspondence to Sohaila Cheema .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

The authors report no potential conflicts of interest.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: table s1..

The 2009 PRISMA checklist for reporting a systematic review. Table S2. PRIO-harms checklist for reporting an overview of systematic reviews (OoSRs). Table S3. Characteristics of the included systematic reviews. Table S4. Prevalence of stress, stressors and coping strategies among nursing students in the MENA countries with available data. Table S5. Quality assessment of included systematic reviews. Table S6. Quality assessment of included studies.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Chaabane, S., Chaabna, K., Bhagat, S. et al. Perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa: an overview of systematic reviews. Syst Rev 10 , 136 (2021). https://doi.org/10.1186/s13643-021-01691-9

Download citation

Received : 23 October 2020

Accepted : 26 April 2021

Published : 05 May 2021

DOI : https://doi.org/10.1186/s13643-021-01691-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Nursing students
• Coping strategies
• Systematic review

Systematic Reviews

ISSN: 2046-4053

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

• Open access
• Published: 04 September 2024

Comparison of professional competency and anxiety of nursing students trained based on two internship models: a comparative study

• Roya Dokoohaki 1 ,
• Masoume Rambod   ORCID: orcid.org/0000-0002-7334-9364 1 ,
• Nilofar Pasyar 1 ,
• Ali Mohammad Parviniannasab 2 ,
• Maryam Shaygan 1 ,
• Majid Najafi Kalyani 1 ,
• Zinat Mohebbi 1 &
• Azita Jaberi 1  

BMC Medical Education volume  24 , Article number:  968 ( 2024 ) Cite this article

Metrics details

Improving the professional competency of nursing students during the internship is critical. This study aimed to compare the professional competency and anxiety of nursing students trained based on two internship models.

This is a two-group posttest-only quasi-experimental design study. One hundred nursing students who passed internship models A (a previous internship model) and B (an intervention with more educator support and a more planned and programmed process) were randomly enrolled in this study. Internship model groups A and B were conducted for the students in semesters 7 and 8. The outcomes assessed in both groups were “The Competency Inventory for Registered Nurses” and Spielberger “State-Trait Anxiety Inventory”. T-test and MANOVA were used to analyze the data.

The mean scores of competency were 134.56 (SD = 43.23) and 160.19 (SD = 35.81) for the nursing students in the internship model groups A and B, respectively. The mean scores of nursing students’ anxiety were 92.14 (SD = 15.36) and 80.44 (SD = 18.16) in the internship model groups A and B, respectively. MANOVA test showed a significant difference between the groups regarding professional competency (F = 10.34, p  = 0.002) and anxiety (F = 11.31, p  = 0.001).

Conclusions

The internship model group B could improve the professional competency of nursing students to a great extent and they experienced mild anxiety; it is suggested that this intervention should be done for nursing students. Conducting more studies to evaluate the effect of this model on the nursing students’ competency and anxiety after graduation and as a novice nurse is suggested.

Peer Review reports

Introduction

Increasing clinical setting complexity necessitates further attention to nursing students’ competency [ 1 ]. The 7th and 8th semesters, when students spend more time in clinical environments, are one of the best times for improving nursing students’ competency. The use of clinical models, including internship, may be useful at this time. In the internship period, nursing students are directly supervised by the Nursing Unit Managers (NUMs) and clinical nurses and indirectly by the academic professor as a supervisor [ 2 ].

Internship, as an education model, was beneficial for the students, teachers, and patients. It not only improved health preservation but also increased the nursing students’ skills [ 3 ]. In the internship model, efforts were made to achieve clinical competency [ 2 ]. It improved nursing students’ knowledge, skills, and attitude [ 4 ]. It allows the knowledge acquired during the entire course to be (re) evaluated so that the professional competence is improved. Moreover, the teaching-learning methods are built according to critical pedagogy [ 5 ]. The students practiced self-management and tried to control the situations and stress [ 2 ]. It was mentioned that it improved professional identity and self-efficacy [ 6 ]. This model of education led to nursing students’ interaction with staff nurses and invisible evaluation [ 7 ]. It also reduced the gap between theory and practice [ 8 ] and increased nursing students’ process-based performance [ 9 ]. Moreover, it developed coping strategies for workplace adversities [ 6 ]. A study on the internship of community health nursing showed that service-based learning was effective in improving nursing students’ health education competencies and its subscales including skill, knowledge, community presence, attitude, and professional preparation [ 10 ].

Although this model of education in clinical setting has some advantages, it has some challenges such as lack of support and difficult planning [ 7 ]. Researchers reported that anxiety and low self-confidence in clinical competence settings were the challenges in nursing students’ internship period [ 11 ]. Lack of self-confidence caused anxiety and fear [ 11 ]. During this period, students showed anxiety with symptoms such as nervousness, fear, frequent urination, hand and foot tremors, panic, somatic pain, palpitation, facial flushing, sleep disturbance, etc. [ 11 ].

Considering the effects of the internship program in other countries and Iran, the researchers evaluated the difference between the existing program in Shiraz (nursing students’ internship model A) and other parts of the world. The researchers also raised the question of how to improve the nursing students’ professional competency during the internship and how to reduce their anxiety. In the comparison of the running program (nursing student’s internship model A) with the other countries, there were differences. The first one was the duration of the program that was about 12 weeks. Secondly, the students were not full-time employees in the clinical environment, and they left the ward at 1:00 PM. Next, they were only oriented to general information about the program and did not receive basic nursing trainings. In addition, nursing students were not paid during the course and insured.

Literature review showed that in the nursing students’ internships, exploitation and lack of incentive were the barriers to success in this program [ 12 ]. On the other hand, support, self-efficacy, internship structure, and setting were the factors that affected the students’ adjustment [ 13 ]. Work experience, environment, and critical thinking were the factors effective in development of nursing competence [ 14 ]. Moreover, a supportive internship system using motivation strategies as a helpful method improved nursing students’ performance [ 15 ]. In addition, researchers suggested that all the actors involved in nursing students’ internships should facilitate the efficacy of teaching and learning [ 16 ]. Furthermore, another study recommended that stakeholders should use increased educational preparation for the internship stage to evolve healthcare market supply and need [ 17 ].

In order to solve those limitations and promote the program based on the above-mentioned suggestions at the global level, in addition to solving the above points, changes were made in the model A and it was named “nursing student’s internship model B”. For this purpose, director of the Nursing School of Shiraz University of Medical Sciences, their academic teachers, the nursing director of Nemazee hospital, and the director of the provincial nursing office support were considered. More detailed planning was considered to implement and manage the internship model. During the formative evaluation of the model, several meetings between Shiraz Nursing School and the clinical environment were held to identify and resolve deficiencies. Therefore, to improve the evidence-based practice, this study aimed to compare the professional competency and anxiety of nursing students trained based on the two internship models. The following hypotheses were posed:

Nursing student’s internship model B improves the nursing students’ professional competency compared to model A.

Nursing student’s internship model B reduces the nursing students’ anxiety compared to model A.

Study design

This is a comparative study with nonequivalent control group posttest-only quasi-experimental design. In this interventional study with no concurrent controls, a new nursing student’s internship model (B) is proposed. It helps the researchers to select group (B) to be trained using this model and then compare their outcomes to that of a previous nursing student’s internship model group (A). In fact, internship model group (A) was considered as a control group. It should be noted that the students were in two different groups and were selected for each group at two consecutive semesters.

The setting of this study was Nursing and Midwifery School of Shiraz University of Medical Sciences (SUMS). The intervention of nursing student’s internship model group A was carried out routinely from September 2022 to June 2023 and its data were collected in June 2023. The intervention in the nursing student’s internship model group B started from September 2023 and data collection was done in June and July 2024.

Participants

The undergraduate nursing students who were in the seventh and eighth semesters, had passed internship model (A/B) for at least one semester (model A was applied in one semester and model B in the other semester), and were willing to participate were enrolled in this study. Exclusion criteria included a known case of psychiatric disorder confirmed by the doctor according to the student report, incomplete completion of the questionnaires, guest students, and those transferred from another university since the 6th semester because these students might be different from those in the university under study in terms of experience and professional competency. One hundred nursing students participated in this study.

Fifty students were randomly selected among the subjects who passed the internship model (A) Moreover, students who participated in the internship model B were randomly selected to group (B) In order to conduct random sampling for each group, we obtained the list of students in Nursing and Midwifery School of SUMS; based on a random number table, 50 students were selected for each group. For sampling, an individual from outside the team participated.

Sample size

Given that there was no study for comparison on the two groups to evaluate the professional competency and anxiety of nursing students during their internship, the sample size was determined using the study of Liou et al.’s study [ 18 ], which compared the performance competence pre-graduate nursing students and hospital nurses. Based on α = 0.02, β = 0.2, the proportion of subjects that were in the internship model group A = 0.5, proportion of subjects that were in the internship model group B = 0.5, µ 2 - µ 1 of competency = 25.54, SD = 41.35 in Liou et al.’s study and using “Sample Size Calculators for designing clinical research” ( https://sample-size.net/sample-size-means/ ) to compare the mean of a continuous measurement in two samples, the sample size was determined 43 nursing students in each group. Then, considering 15% dropout, it was determined as 50 subjects for each group.

Outcomes and measurements

The outcomes assessed in both groups were professional competency and anxiety. In the demographic form, the gender and age of the nursing students were collected. The professional competency of nursing students was measured using the self-report questionnaire named “The Competency Inventory for Registered Nurses”. It was developed in China by Liu et al. in 2007. Firstly, the inventory had 58 items [ 19 ]. In exploratory factor analysis, three items were deleted and the inventory with 55 items was approved. This inventory consists of the dimensions of clinical care, leadership, interpersonal relation, legal/ethical practice, professional development, teaching/coaching, and critical thinking/research aptitude. Higher scores indicate a higher nursing professional competency. Each item of this inventory was scored using a 5-point Likert scale ranging from score zero (not competent at all) to four (very competent). The total score is 0 to 220 [ 1 ]. A higher score indicates greater competence of the nurse [ 1 , 19 ]. The competence level was placed in three levels of high competence (165–220), medium (110–165) and low (< 110). The reliability of the professional competency inventory was assessed by Liu et al. in 2007, and it was confirmed using Cronbach’s alpha of 0.89 and 0.79–0.86 for the dimensions. The content validity of this checklist was confirmed by Liu et al. and reported as 0.85 [ 1 , 19 ]. Ghasemi et al. assessed the psychometrics of this inventory in the Persian language and the reliability of this checklist using Cronbach’s alpha was 0.90; also, its dimensions were 0.71–0.90 [ 20 ]. As Table  1 shows, in this study, reliability was estimated 0.98 for the professional competency and 0.93–0.95 for its dimensions using Cronbach’s alpha.

The anxiety of nursing students was measured using Spielberger State-Trait Anxiety Inventory (STAI). It was developed by psychologists Charles Spielberger. This inventory has 40 items. Twenty items indicate state anxiety and twenty show trait anxiety. Each item was scored on a four-point Likert scale (not at all = 1, somewhat = 2, moderately so = 3, and very much so = 4). For the total inventory, the minimum score was 40 and maximum score was 160. A lower score means less anxiety and a higher score indicates more anxiety [ 21 ]. The convergent validity and internal consistency of the Persian version of State-Trait Anxiety Inventory were approved [ 22 ]. The normal level of anxiety is shown in Table  2 . In this study, Cronbach’s alpha for total anxiety, state, and trait anxiety was 0.94, 0.91, and 0.89, respectively.

Data collection procedure

Data for this study were collected using the above-mentioned questionnaires. The nursing students of each group were invited to a class in the hospital and clinical setting, the questionnaires were distributed among them, and the students completed them in the presence of the researcher.

Interventions

Internship model a.

As Table  3 shows, in internship model A, at the beginning of semester seven, an introductory meeting was held for the students about the new program. The students in semesters seven and eight were trained in emergency, recovery, operation room, burn, hemodialysis, pediatric departments, neonatal intensive care unit (NICU), intensive care unit (ICU), and Coronary care unit (CCU) by their academic professors. Then, the students passed their internship period after each department/unit. It was in 12 weeks. The nursing students were rotated in critical care, pediatric and medical-surgical units. This period was conducted in the morning shift.

During the internship period, the students were supervised by the ward NUMs or head nurse, and the academic professors randomly followed up and visited the students. The professor talked to the students more about the physical and communication challenges in clinical environment and tried to solve them. In addition, she asked the NUMs and nurses to play a role in the education of students according to their training department and course. The evaluation of students was done by NUMs using evaluation checklists. In addition, if the students had a problem, they informed the head of the department in the faculty.

Internship model B

As Table  3 shows, in the internship model B, at the beginning of semester seven, an introductory meeting was held for the students about the new program. Then, the training classes were held for them, including “how to do drug administration and its nursing care”, “how to handover patients between two shifts”, “how to write the nurse’s note”, “how to perform cardiopulmonary resuscitation”, and “how to work with the DC shock machine”. Moreover, an electronic system was used to register the students’ entry and exit, and the students worked as staff nurses in the department. They were present in a clinical department for a longer period compared to group A. All students were covered by an insurance company for professional services insurance. The following people played an active role in the planning and management of the internship model B:

Manager, vice-chancellors, and the directors of the nursing groups (medical/surgical, critical care, pediatric and community health nursing) in the school of Nursing and Midwifery of SUMS.

Fars provincial nursing office manager and her vice-chancellors.

Nemazee nurse manager and her educational and clinical supervisors.

Vice-chancellors of SUMS.

Firstly, the students were trained in the full-time presence of the academic professors in emergency, burn, hemodialysis and pediatric departments, and operating and recovery rooms. After that, in the internship period, the students spent morning, evening, and night shifts in emergency, pediatric, hemodialysis, medical, and surgical departments. In the eighth academic semester, this program was applied for “maternal and newborn diseases” clinical course, emergency, and “advanced children nursing” departments. During the internship period, the students attended these clinical courses without the direct presence of an academic professor and under the direct supervision of NUMs. As to ICU and CCU, the students spent 12 days with their academic professor and then attended their internship period for 4 weeks. In addition, students spent their morning shifts in the community-based health services department.

During this period, for the first 2 weeks of the shifts, one of the supervising professors, one of the experienced professors, and an expert in diseases and care processes referred to the students’ department and taught the necessary contents based on the patient or patients assigned to the students every day. In the third and fourth weeks, the supervising professors visited the departments 3 times a week and from the 5th week of shifts, two times a week. In these supervisory sessions, in addition to teaching the characteristics of each disease, the patient’s drugs and their specific nursing care, general nursing care such as the principles of dressing, urinary catheterization, tracheostomy suction, prescribing blood products and their complications, and nursing care by the professors, the students were also taught to prescribe high-risk drugs such as KCL, etc.

To consolidate learning, we asked the students to complete assignments related to these trainings and sent them to the professors on social media. Moreover, the supervising professors provided a report on the status and progress of each student on social media and in face-to-face meetings to other professors and those in charge of clinical education that were held monthly in order to facilitate coordination in the education of students. Additionally, the specific patients and their nursing care as “case study” were identified and informed to the head nurse of the clinical education of this course, so that these case studies could be analyzed and presented in the form of clinical and medical grand rounds and workshops. The evaluation of students was done by the academic professors and NUMs using evaluation designed form.

It should be noted that at the end of this study, the contents of training classes were provided for internship model A in the form of MP3 and MP4 files.

Ethical considerations

Research Ethics Committees of Schools of Nursing and Midwifery, Management and Medical Information Science in Shiraz University of Medical Sciences approved this study (IR.SUMS.NUMIMG.REC.1402.027, approval date: 2023-05-28). Participation/non-participation of this study was voluntary. The permission to apply “The Competency Inventory for Registered Nurses” was obtained from Ming Liu by the fourth author of our study. The questionnaires were anonymous. Our study was conducted in accordance with the Declaration of Helsinki. The study purpose, procedure, probable complications and the ways of compensation and the person responsible for these possible complications in this study were explained in a consent form. The consent to participate was obtained from the nursing students. All of the nursing students signed the consent form. We confirmed that this consent was informed. The results of this study were reported to Nursing and Midwifery School of SUMS.

Data analysis

Data analysis of this study was conducted using SPSS version 24. Mean, standard deviation, frequency, and percentage were reported. The Independent Samples t-test was used to compare the means of two independent groups in order to determine whether there is statistical evidence that the associated population means are significantly different. Moreover, multivariate analysis of variance (MANOVA) was used for comparing multivariate sample means. As a multivariate procedure, it is used when there are two or more dependent variables, and is often followed by significance tests involving individual dependent variables separately. In this study, to assess how large the effect of the intervention was on the professional competency and anxiety of nursing students, we measured partial eta squared (η2). According to Cohen 1988, an η2 equal to 0.00-0.01, 0.01–0.06, 0.06–0.14, and 0.14-1 means negligible, small, medium, and large, respectively [ 23 ]. p  < 0.05 was considered as significant.

50% of the nursing students in both groups were female. The mean age of the students was 23.48 (SD = 1.77) and 23.64 (SD = 2.70) in the internship model groups A and B, respectively. No significant difference was observed between the groups regarding gender (χ 2  = 1.00, p  = 0.00) and age (t= -0.34, p  = 0.72) of the students who participated in this study.

As Table  1 ; Fig.  1 show, the mean scores of professional competency were 134.56 (SD = 43.23) and 160.19 (SD = 35.81) for the internship model groups A and B, respectively. Based on these mean scores, nursing students in the internship model groups A and B reported a medium level of professional competency. As displayed in Table  1 , independent sample t-test and MANOVA test showed a significant difference between the groups regarding professional competency and its dimensions ( p  < 0.05). Based on the professional competency η2 that was 0.1, a medium effect size was reported. The highest and lowest η2 among the dimensions of professional competency were related to clinical care and critical thinking/research aptitude, respectively (Table  1 ). Moreover, as Table  1 shows, all the dimensions of professional competency were significantly higher in the internship model group B compared to group A ( p  < 0.05). Moreover, based on the η2 in Table  1 , all professional competency dimensions had medium η2 except for critical thinking/research aptitude that was low.

As Table  4 ; Fig.  1 show, the mean scores of nursing students’ total anxiety were 92.14 (SD = 15.36) and 80.44 (SD = 18.16) in the internship model groups A and B, respectively. Independent sample t-test and MANOVA test showed a significant difference between the groups regarding total anxiety ( p  = 0.001). Based on the anxiety η2 that was 0.11, a medium effect size was indicated (Table  4 ).

Moreover, as shown in Table  4 , the mean scores of state anxiety were 47.43 (SD = 7.27) and 41.32 (SD = 8.62) in the internship model groups A and B, respectively. Based on these mean scores, the nursing students experienced moderate and mild state anxiety in the internship models groups A and B, respectively. Independent sample t-test and MANOVA test indicated a significant difference between the groups regarding the mean scores of state anxiety ( p  < 0.001). Based on the state anxiety η2 that was 0.12, a medium effect size was found.

In addition, as Table  4 shows, the mean scores of trait anxiety were 44.80 (SD = 9.44) and 39.11 (SD = 10.92) in the internship model groups A and B, respectively. Based on these mean scores, both groups of nursing students experienced mild trait anxiety. However, independent sample t-test and MANOVA test showed that the mean score of trait anxiety was significantly lower in the internship model B compared to model A ( p  < 0.05). Based on the trait anxiety η2 that was 0.07, a medium effect size was indicated.

Comparison of the nursing students’ anxiety and professional competency between internship model groups A and B

This study aimed to compare the professional competency and anxiety of nursing students trained based on the two internship models. The nursing students in the internship model group B significantly reported higher mean scores of professional competency and experienced lower mean scores of anxiety compared to the internship model group A.

Our findings revealed that nursing students in the internship model groups A and B reported medium levels of professional competency. A study reported that internship program helped the students achieve clinical competency, and increased academic and professional skills [ 2 ]. Our results indicated that the internship model group B significantly reported higher mean scores of professional competence compared to group A. In a study, it was reported that clinical supervision model in internship nursing students improved the nursing process-based performance [ 9 ]. In the internship model group B, the students had the support of the professor. Their needs were considered by managers, supervisors, professors, etc. The detailed planning of educational and clinical managers reduced the gap between theory and practice and had a positive effect on the internship students. In addition, interactions between professors and students; professors and supervisors, nurses, and patients; students and educational managers; and educational and clinical managers were extensively carried out. The challenges of the students were identified and solved by the team quickly. Possibly, above-mentioned reasons led to improvement of professional competency in the internship group B compared to the internship model A.

Our study showed nursing students in the internship model group B reported higher clinical care and professional development competency compared to the group A. In addition, the group B had higher mean scores of teaching and coaching compared to the group A. Moreover, the highest effect size was related to clinical care competency. A qualitative study reported that the internship program in nursing students improved their clinical skills and “professional self-efficacy”. In addition, these nursing students had professional identity development. They indicated that internship program led to “accepting professional roles” [ 6 ]. In a study on the attitude of nursing students “community-based training and internship”, it was reported that nursing students had a teaching role and provided some of the clients and patients with information regarding lifestyle, mental health, hygiene, etc. [ 3 ]. It seems that in the internship model group B, the full presence of the nursing students in each work shift provided the opportunity to deliver clinical care and educate the patient and colleagues. In addition, because students are still studying, when they encounter new topics, they try to learn them by reading reliable books and Internet sources, asking their peers or supervisors, and providing the nursing staff and the healthcare team with this information. Since there was a lot of emphasis on students’ clinical care in the internship model group B, their supervisors evaluated and taught the skills daily, and the nurses emphasized the students’ education; there was a possibility that this group had better mean scores of clinical care and professional development competency as compared to group A.

This study indicated that interpersonal relations and leadership competency were higher in the internship model group B compared to group A. Researchers believed that in the learning process, interpersonal relationships linked the patients, students, and supervisors to each other [ 24 ]. They suggested that we should respect each other and provide supportive interaction, leading to improvement in learning outcomes [ 24 ]. In clinical setting, interpersonal relationship is crucial for the nurses because it improves the nursing students’ learning and their outcomes [ 25 ]. It seems that better and more frequent interpersonal relations between supervisors, students, and nurses in the internship model group B compared to the group A further improved the nursing students’ competency. In the internship model group B, nursing students worked as staff nurses. They became familiar with facts, documents, etc. Therefore, as they probably knew each other’s strengths and weaknesses and the setting atmosphere and climate, they cooperated better, conducted teamwork, and communicated with other health team members, compared to group A.

Our study showed nursing students in the internship model group B reported higher critical thinking/research aptitude competency compared to group A. However, the smallest difference between the two groups was in this variable. A qualitative study showed the “lack of scientific research training” as a barrier to nursing internship [ 26 ]. A study indicated that critical thinking subscale of performance competence in nursing students’ internship model was in the lowest level [ 18 ]. Therefore, using knowledge and reflecting on it to solve the clinical problems in nursing students needs more attention in both groups.

Our findings showed legal/ethical practice competency had a higher mean score in the internship model group B, compared to group A. Intern nursing students’ moral sensitivity was associated to “ethical decision-making ability” [ 27 ]. It was mentioned that ethical issues would happen in clinical setting among healthcare workers, supervisors, teachers, and patients [ 28 ]. As in the internship model group B, nursing students worked as staff nurses for a long time in a ward/department, it seems that they paid more attention to the security of the patients’ information. Moreover, because they worked as staff nurses, they might have more respect to the patients’ privacy, be more familiar to advocating the rights of the patients, and take more responsibility for their performance compared to group A.

The nursing students experienced moderate and mild state anxiety in the internship models groups A and B, respectively. Moreover, both groups experienced mild trait anxiety. This study indicated that state-trait anxiety was lower in the internship model group B compared to group A. In the same line with the present study, the results of a study in China showed that the anxiety level of nursing students after experiencing the internship program was moderate. Because nursing students are still in the transition phase during internship, their psychological defense mechanisms seem to be incomplete [ 29 ], resulting in experiencing mild to moderate anxiety by them. A study showed that painful experiences during the internship period, feedback and suggestions of trainers, and hard work in the evening and night shifts were the factors that caused anxiety during the internship period [ 11 ]. Of course, researchers believe that moderate anxiety has a protective role and could lead to the improvement of individual ability in response to environmental stimuli [ 11 ]. In group B, holding preparatory workshops for the students before the start of the internship period, close communication between students and academic supervisors, as well as frequent communication and meetings between the hospital nurse managers and educational supervisors with educational and clinical vice-chancellors and academic supervisors probably led to experiencing lower anxiety by nursing students.

This study had some limitations. Since there was no exact control group in this study, it was not possible to compare nursing students who had not experienced these two interventional models and had passed the 7th and 8th semester traditionally, in terms of professional competence and anxiety. Moreover, without a control group, it is impossible to exactly conclude which outcomes were the result of the internship model groups A/B rather than the other variables. Therefore, it is suggested that these interventions should be compared with the control group in other studies and should measure the outcomes before and after the interventions. Given that the study was conducted in only one center (school of Nursing and Midwifery in Shiraz), the generalizability of the findings is not possible. Therefore, it is suggested that the study should be repeated in other schools of nursing in our country and other parts of the world. The fact that the practice was made in different semesters might have an impact on the results; clinical functioning, etc. might be different in that period. There were actually many uncontrollable variables in our study. Therefore, it is suggested to a study in two groups in one semester.

Since the least difference between the two groups was related to the dimension of critical thinking and research aptitude competency, it is suggested that this issue should be given more attention in future internship programs.

This study showed that the nursing students in the internship model group B had a higher mean score of professional competency and lower mean score of anxiety compared to the internship model group A. Given that the internship model group B as a precise and regular program could improve the professional competency of nursing students to a great extent and they experienced mild anxiety during the program, it is suggested that this intervention should be carried out for nursing students and other students who have clinical functions. It is recommended that the internship model group B should be added to the nursing program and curriculum in our country. Since the internship model group B only required detailed planning and we explained it in the intervention section, the model could easily be implemented in different universities.

Data availability

The data of this study would be available by email to Masoume Rambod.

Liu M, Yin L, Ma E, Lo S, Zeng L. Competency inventory for registered nurses in Macao: instrument validation. J Adv Nurs. 2009;65(4):893–900.

Article   Google Scholar  

Babamohamadi H, Aghaei N, Asgari MR, Dehghan-Nayeri N. Strategies used by Iranian nursing students for adjusting to internship: a qualitative study. BMC Med Educ. 2023;23(1):454.

Fereidouni Z, Hatami M, Jeihooni AK, Kashfi H. Attitudes toward community-based training and internship of nursing students and professors: a qualitative study. Investigación Y educación en enfermería. 2017;35(2):243–51.

Suresh H. Perception of nursing students towards internship. Nurs J India. 2012;103(2):59.

Esteves LS, Cunha IC, Bohomol E, Negri EC. Supervised internship in undergraduate education in nursing: integrative review. Revista Brasileira De Enfermagem. 2018;71:1740–50.

Karimyar Jahromi M, Momennasab M, Yektatalab S, Pasyar N, Rivaz M. Live experience of nursing students with internship program: a phenomenological study. J Educ Health Promotion. 2023;12(1):124.

Google Scholar  

Ahmadi S, Abdi A, Nazarianpirdosti M, Rajati F, Rahmati M, Abdi A. Challenges of clinical nursing training through internship approach: a qualitative study. J Multidisciplinary Healthc 2020 Sep 7:891–900.

Nematollahi M, Bagherian B, Mehdipour-Rabori R, Farokhzadian J, Khoshnood Z, Navidi Z. Implementing the internship educational method, a step to reduce the gap between theory and practice, experience of undergraduate nursing students: a qualitative content analysis study. J Qualitative Res Health Sci. 2022;11(4):253–9.

Shahzeydi A, Farzi S, Tarrahi MJ, Sabouhi F, Babaei S, Yazdannik A. The effect of the clinical supervision model on nursing internship students’ nursing process-based performance: an experimental study. BMC Nurs. 2024;23(1):166.

Emrani M, Khoshnood Z, Farokhzadian J, Sadeghi M. The effect of service-based learning on health education competencies of students in community health nursing internships. BMC Nurs. 2024;23(1):138.

Yi QF, Yan J, Zhang CJ, Yang GL, Huang H, Yang Y. The experience of anxiety among Chinese undergraduate nursing students in the later period of their internships: findings from a qualitative study. BMC Nurs. 2022;21(1):70.

Bahari G, Alharbi F, Alharbi O. Facilitators of and barriers to success in nursing internship programs: a qualitative study of interns’ and faculty members’ perspectives. Nurse Educ Today. 2022;109:105257.

Aghaei N, Babamohamadi H, Asgari MR, Dehghan-Nayeri N. Barriers to and facilitators of nursing students’ adjustment to internship: a qualitative content analysis. Nurse Educ Today. 2021;99:104825.

Rizany I, Hariyati RT, Handayani H. Factors that affect the development of nurses’ competencies: a systematic review. Enfermeria Clin. 2018;28:154–7.

El-Sayed AA, Abdelaliem SM. Application of Kano model for optimizing the training system among nursing internship students: a mixed-method Egyptian study. BMC Nurs. 2023;22(1):316.

Leyva-Moral JM, Aguayo‐González M, San Rafael Gutiérrez S, Jiménez Pera M, Mestres‐Soler O. Understanding the expectations of nursing students following the first clinical internship: a qualitative study. Nurs Health Sci. 2022;24(1):93–100.

Nash J, Kamel TC, Sherer J, Nauer K. Implementing a perioperative nursing student summer internship. AORN J. 2018;107(1):83–90.

Liou SR, Liu HC, Tsai SL, Chu TP, Cheng CY. Performance competence of pregraduate nursing students and hospital nurses: a comparison study. J Clin Nurs. 2020;29(13–14):2652–62.

Liu M, Kunaiktikul W, Senaratana W, Tonmukayakul O, Eriksen L. Development of competency inventory for registered nurses in the people’s Republic of China: scale development. Int J Nurs Stud. 2007;44(5):805–13.

Ghasemi E, Janani L, Dehghan NN, Negarandeh R. Psychometric properties of persian version of the competency inventory for registered nurse (CIRN). Iran J Nurs. 2014;27(87):1–13.

Spielberger CD, Sydeman SJ. State-trait anxiety inventory and state-trait anger expression inventory. In: Maruish ME, editor. The use of psychological tests for treatment planning and outcome assessment. Hillsdale, NJ: LEA; 1994. pp. 292–321.

Abdoli N, Farnia V, Salemi S, Davarinejad O, Jouybari TA, Khanegi M, Alikhani M, Behrouz B. Reliability and validity of Persian version of state-trait anxiety inventory among high school students. East Asian Archives Psychiatry. 2020;30(2):44–7.

Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, N.J: L. Erlbaum Associates; 1988.

Holst H, Ozolins LL, Brunt D, Hörberg U. The learning space—interpersonal interactions between nursing students, patients, and supervisors at developing and learning care units. Int J Qualitative Stud Health Well-being. 2017;12(1):1368337.

Rebeiro G, Foster K, Hercelinskyj GJ, Evans A. Enablers of the interpersonal relationship between registered nurses and students on clinical placement: a phenomenological study. Nurse Educ Pract. 2021;57:103253.

Lin H, Yan M, Fang Y, Wang Y. Barriers to the completion of bachelor thesis for bachelor nursing students during their internship: a qualitative study from dual student and faculty perspectives. Nurse Educ Today. 2024;132:105997.

Luo Z, Tao L, Wang CC, Zheng N, Ma X, Quan Y, Zhou J, Zeng Z, Chen L, Chang Y. Correlations between moral courage, moral sensitivity, and ethical decision-making by nurse interns: a cross-sectional study. BMC Nurs. 2023;22(1):260.

Kont KR, Rannula K, Puura K. Professional ethical aspects in the study and internship environment: research in Tallinn health care college. Acta Paedagogica Vilnensia. 2021;46:148–67.

Dong C, Xia L, Zhao C, Zhang X, He J, Zhang G, Zhang J. Prospective association between perceived stress and anxiety among nursing college students: the moderating roles of career adaptability and professional commitment. BMC Psychiatry. 2023;23(1):388.

Download references

Acknowledgements

The authors would like to thank the personnel who collaborated in the implication of the intervention and nursing students’ education in clinical settings and Shiraz University of Medical Sciences. The authors would like to thank Razieh Rasekh, Hamideh Falah, Laila Hashemizadeh, and Fatemeh Azadi for preparing and managing the intervention. The authors would like to thank Shiraz University of Medical Sciences, Shiraz, Iran, and Center for Development of Clinical Research of Nemazee Hospital and Dr Nasrin Shokrpour for English language editorial assistance. We appreciated Ming Liu who gave us the permission to apply “The Competency Inventory for Registered Nurses” in this study.

This study was financially supported by Shiraz University of Medical Sciences (Grant Number = 28249).

Author information

Authors and affiliations.

Community Based Psychiatric Care Research Center, Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran

Roya Dokoohaki, Masoume Rambod, Nilofar Pasyar, Maryam Shaygan, Majid Najafi Kalyani, Zinat Mohebbi & Azita Jaberi

Department of Nursing, School of Nursing, Larestan University of Medical Sciences, Larestan, Iran

Ali Mohammad Parviniannasab

You can also search for this author in PubMed   Google Scholar

Contributions

MR, NP, RD, AP participated in conceptualization of this study. RD participated in data collection. MR and AP conducted the management the data analysis. MSH, ZM, AZ, and MN participated in the intervention management. All authors participated in writing and approving the original draft of the manuscript.

Corresponding author

Correspondence to Masoume Rambod .

Ethics declarations

Ethics approval and consent to participate.

Research Ethics Committees of Schools of Nursing and Midwifery, Management and Medical Information Science-Shiraz University of Medical Sciences approved this study (IR.SUMS.NUMIMG.REC.1402.027, approval date: 2023-05-28). Participation/non-participation of this study was voluntary. The permission to apply “The Competency Inventory for Registered Nurses” was obtained from Ming Liu by the fourth author of our study. The questionnaires were anonymous. Our study was conducted in accordance with the Declaration of Helsinki. The study purpose, procedure, probable complications and the ways of compensation, and the person responsible for these possible complications in this study were explained in the consent form. The consent to participate was obtained from the nursing students. All of the nursing students signed the consent form. We confirmed that this consent was informed. The results of this study were reported to Nursing and Midwifery School of SUMS.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ .

Reprints and permissions

About this article

Cite this article.

Dokoohaki, R., Rambod, M., Pasyar, N. et al. Comparison of professional competency and anxiety of nursing students trained based on two internship models: a comparative study. BMC Med Educ 24 , 968 (2024). https://doi.org/10.1186/s12909-024-05956-4

Download citation

Received : 13 May 2024

Accepted : 26 August 2024

Published : 04 September 2024

DOI : https://doi.org/10.1186/s12909-024-05956-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Clinical competence

BMC Medical Education

ISSN: 1472-6920

• General enquiries: [email protected]

Johdel Cabaluna RN, MAN, PhD, Adamson University, Philippines

Dr. Johdel C. Cabaluna is a Registered Nurse and a Licensed Professional Teacher. He is an Associate Professor at Wesleyan University-Philippines. He is also a reviewer and lecturer in various review centers in the Philippines.

Maria Karmela Del Rosario PhD Candidate, RN, MAN, St. Louis University of Baguio, Philippines

Maria Karmela Del Rosario RN, MAN is a Doctor of Philosophy in Nursing student at St. Louis University-Baguio, Philippines. She is a former nurse manager at St. Luke’s Medical Center and is currently the Academic Coordinator of Wesleyan University, Philippines.

Kyla Christine Antipala Wesleyan University, Philippines

Kyla Christine Antipala is a nursing student enrolled at Wesleyan University, Philippines.

Mariden Claire Alvaran Wesleyan University, Philippines

Mariden Claire Alvaran is a nursing student enrolled at Wesleyan University, Philippines

Camille Faye Candelaria Wesleyan University, Philippines

Camille Faye Candelaria is a nursing student enrolled at Wesleyan University, Philippines.

Vennieve Jane Eder Wesleyan University, Philippines

Vennieve Jane Eder is a nursing student enrolled at Wesleyan University, Philippines.

Ashley Nickole Alexisse Castelo Wesleyan University, Philippines

Ashley Nickole Alexisse Castelo is a nursing student enrolled at Wesleyan University, Philippines.

..................................................

ISSN    2668 - 1056

Issn-l 2568 - 1056, public health journals.

European Journal of Fitness, Nutrition and Sport Medicine Studies

European Journal of Physiotherapy and Rehabilitation Studies

Education Journals

European Journal of Education Studies

European Journal Of Physical Education and Sport Science

European Journal of Foreign Language Teaching

European Journal of English Language Teaching

European Journal of Special Education Research

European Journal of Alternative Education Studies

European Journal of Open Education and E-learning Studies

Social Sciences Journals

European Journal of Social Sciences Studies

European Journal of Economic and Financial Research

European Journal of Management and Marketing Studies

European Journal of Human Resource Management Studies

European Journal of Political Science Studies

Literature, Language and Linguistics Journals

European Journal of Literature, Language and Linguistics Studies

European Journal of Literary Studies

European Journal of Applied Linguistics Studies

European Journal of Multilingualism and Translation Studies

• Other Journals
• ##Editorial Board##
• ##Indexing and Abstracting##
• ##Author's guidelines##
• ##Covered Research Areas##
• ##Related Journals##
• ##Manuscript Submission##

SELECTED NURSING STUDENTS’ ACADEMIC STRESS: COPING AND ACHIEVEMENT STRATEGIES AMIDST COVID-19

Article visualizations:

Adnan, M., & Anwar, K. (2020). Online Learning amid the COVID-19 Pandemic: Students' Perspectives. OnKecojevic, A., Basch, C. H., Sullivan, M., &Davi, N. K. (2020). The impact of the COVID-19 epidemic on mental health of undergraduate students in New Jersey, cross-sectional study. PloS one, 15(9), e0239696. ine Submission, 2(1), 45-51. Retrieved from https://eric.ed.gov

Akhter, S. H. (2014). Privacy concern and online transactions: the impact of internet self-efficacy and internet involvement. Journal of Consumer Marketing. Retrieved from https://doi.org/10.1108/JCM-06-2013-0606

Ala’a, B., Akour, A., & Alfalah, L. (2020). Is It Just About Physical Health? An Online Cross-Sectional Study Exploring the Psychological Distress Among University Students in Jordan in the Midst of COVID-19 Pandemic. Frontiers in Psychology, 11. Retrieved from https://doi.org/10.3389/fpsyg.2020.562213

AlAteeq, D. A., Aljhani, S., & AlEesa, D. (2020). Perceived stress among students in virtual classrooms during the COVID-19 outbreak in KSA. Journal of Taibah University Medical Sciences, 15(5), 398-403. Retrieved from https://doi.org/10.1016/j.jtumed.2020.07.004

Alemany-Arrebola, I., Rojas-Ruiz, G., Granda-Vera, J., &Mingorance-Estrada, Á. C. (2020. Influence of COVID-19 on the Perception of Academic Self-Efficacy, State Anxiety, and Trait Anxiety in College Students. Frontiers in psychology, 11. Retrieved from https://doi.org/10.3389/fpsyg.2020.570017

Al-Hanawi, M. K., Mwale, M. L., Alshareef, N., Qattan, A. M., Angawi, K., Almubark, R., & Alsharqi, O. (2020). Psychological distress amongst health workers and the general public during the COVID-19 pandemic in Saudi Arabia. Risk Management and Healthcare Policy, 13, 733. Retrieved from https://doi.org/10.2147/RMHP.S264037

Almarzooq, Z., Lopes, M., & Kochar, A. (2020). Virtual learning during the COVID-19 pandemic: a disruptive technology in graduate medical education. Retrieved from https://doi.org/10.1016/j.jacc.2020.04.015

Broadbent, J., & Poon, W. L. (2015). Self-regulated learning strategies & academic achievement in online higher education learning environments: A systematic review. The Internet and Higher Education, 27, 1-13. Retrieved from https://doi.org/10.1016/j.iheduc.2015.04.007

Cazan, Ana-Maria (2014). Self-Regulated Learning and Academic Achievement in The Context of Online Learning Environments. The International Scientific Conference eLearning and Software for Education 3: 90-95. Bucharest: "Carol I" National Defence University. Retrieved from https://www.researchgate.net

Cazan, A. M. (2015). Learning motivation, engagement and burnout among university students. Procedia-Social and Behavioral Sciences, 187, 413-417. Retrieved from https://doi.org/10.1016/j.sbspro.2015.03.077

Centers for Disease Control and Prevention. (2020). Considerations for events and gatherings. Retrieved from https://scholarworks.wmich.eduCoronavirus, N. (2019). Situation Report-1 21 January 2020. World Health, 251.

Cullen, W., Gulati, G., & Kelly, B. D. (2020). Mental health in the Covid-19 pandemic. QJM: An International Journal of Medicine, 113(5), 311-312. Retrieved from https://doi.org/10.1093/qjmed/hcaa110

Fawaz, M., & Samaha, A. (2020, January). E‐learning: Depression, anxiety, and stress symptomatology among Lebanese university students during COVID‐19 quarantine. In Nursing Forum. Retrieved from https://doi.org/10.1111/nuf.12521

Garcia, R. S. (2021). Influence of Self-Directed Learning Skills on the Academic Adjustment in an Online Learning Platform Among Level I And II Student Nurse. Retrieved from https://www.researchgate.net

Green, J. K., Burrow, M. S., & Carvalho, L. (2020). Designing for transition: supporting teachers and students cope with emergency remote education. Postdigital Science and Education, 2(3), 906-922. Retrieved from https://link.springer.com/

Gupta, S., & Sahoo, S. (2020). Pandemic and mental health of the front-line healthcare workers: a review and implications in the Indian context amidst COVID- 19. General Psychiatry, 33(5). Retrieved from https://doi.org/10.1136/gpsych-2020-100284

Hasan, N., & Bao, Y. (2020). Impact of “e-Learning crack-up” perception on psychological distress among college students during COVID-19 pandemic: A mediating role of “fear of academic year loss”. Children and Youth Services Review, 118,105355. Retrieved from https://doi.org/10.1016/j.childyouth.2020.105355

Hung, M. L., Chou, C., Chen, C. H., & Own, Z. Y. (2010). Learner readiness for online learning: Scale development and student perceptions. Computers & Education, 55(3),1080-1090.Retrievedfromdoi: https://doi.org/10.1016/j.compedu.2010.05.004

John Hopkins University and Medicine (2020). Coronavirus ressource centre. https://coronavirus.jhu.edu/map.html

Kamaludin, K., Chinna, K., Sundarasen, S., Khoshaim, H. B., Nurunnabi, M., Baloch, G. M., ... & Hossain, S. F. A. (2020). Coping with COVID-19 and movement control order (MCO): experiences of university students in Malaysia. Heliyon, 6(11), e05339. Retrieved from https://doi.org/10.1016/j.heliyon.2020.e05339

Kasi, P. M., Naqvi, H. A., Afghan, A. K., Khawar, T., Khan, F. H., Khan, U. Z., ... & Khan, H. M. (2012). Coping styles in patients with anxiety and depression. ISRN psychiatry, 2012. Retrieved from https://doi.org/10.5402/2012/128672

Krishnamoorthy, Y., Nagarajan, R., Saya, G. K., & Menon, V. (2020). Prevalence of psychological morbidities among general population, healthcare workers and COVID-19 patients amidst the COVID-19 pandemic: A systematic review and meta-analysis. Psychiatry research, 293, 113382. Retrieved from https://doi.org/10.1016/j.psychres.2020.113382

Kutlu, M. O., Yapıcı, A. & Yılmaz, C. (2019). The Use of “Learner Control Strategy” in Courses of Law Faculties in State and Private Universities. Maarif Mektepleri Uluslararası Eğitim Bilimleri Dergisi, 3 (2), 89-102. Retrieved from https://doi.org/10.46762/mamulebd.637573

Lan, H. T. Q., Long, N. T., & Van Hanh, N. (2020). Validation of depression, anxiety and stress scales (DASS-21): Immediate psychological responses of students in the e-learning environment. International Journal of Higher Education, 9(5). Retrieved from https://doi.org/10.5430/ijhe.v9n5p125

Li, L., Liu, X., & Steckelberg, A. L. (2010). Assessor or assessee: How student learning improves by giving and receiving peer feedback. British journal of educational technology, 41(3), 525-536. Retrieved from https://doi.org/10.1111/j.1467-8535.2009.00968.x

Lyons, Z., Wilcox, H., Leung, L., & Dearsley, O. (2020). <? covid19?> COVID-19 and the mental well-being of Australian medical students: impact, concerns and coping strategies used. Australasian Psychiatry, 1039856220947945. Retrieved from https://doi.org/10.1177/1039856220947945

Maddux, J. E., & Volkmann, J. (n.d.). Self-Efficacy. Handbook of Personality and Self-Regulation, 315–331. Retrieved from https://doi.org/10.1002/9781444318111.ch14

Mishra, A., Rani, S., &Bhardwaj, U. D. (2017). Effectiveness of e-learning module on first aid: a study on student nurses. International Journal of Nursing Education, 9(3), 6-10. Retrieved from http://www.indianjournals.com

Nicol, D. (2010). From monologue to dialogue: improving written feedback processes in mass higher education. Assessment & Evaluation in Higher Education, 35(5)501-517.Retrievedfrom https://doi.org/10.1080/02602931003786559

Nurunnabi, M., Hossain, S. F. A. H., Chinna, K., Sundarasen, S., Khoshaim, H. B., Kamaludin, K., ... & Shan, X. (2020). Coping strategies of students for anxiety during the COVID-19 pandemic in China: a cross-sectional study. F1000Research, 9. Retrieved from https://doi.org/10.12688/f1000research.25557.1

Oducado, R. M. F., & Soriano, G. P. (2021). Shifting the Education Paradigm amid the COVID-19 Pandemic: Nursing Students’ Attitude to E-learning. Africa Journal of Nursing and Midwifery, 23(1). Retrieved from https://doi.org/10.25159/2520-5293/8090

Radovan, M. (2011). The Relation between Distance Students' Motivation, Their Use of Learning Strategies, and Academic Success. Turkish Online Journal of Educational Technology-TOJET, 10(1), 216-222. Retrieved from www.eric.ed.gov

Rakes, G. C., & Dunn, K. E. (2010). The Impact of Online Graduate Students' Motivation and Self-Regulation on Academic Procrastination. Journal of Interactive Online Learning, 9(1). Retrieved from http://citeseerx.ist.psu.edu

Remtulla, R. (2020). The present and future applications of technology in adapting medical education amidst the COVID-19 Pandemic. JMIR medical education, 6(2), e20190. Retrieved from https://doi.org/10.2196/20190

Restubog, S. L. D., Ocampo, A. C. G., & Wang, L. (2020). Taking control amidst the chaos: Emotion regulation during the COVID-19 pandemic. Retrieved from https://doi.org/10.1016/j.jvb.2020.103440

Romero-Blanco, C., Rodríguez-Almagro, J., Onieva-Zafra, M. D., Parra-Fernández, M. L., Prado-Laguna, M. D. C., & Hernández-Martínez, A. (2020). Sleep pattern changes in nursing students during the COVID-19 lockdown. International Journal of Environmental Research and Public Health, 17(14), 5222. Retrieved from https://doi.org/10.3390/ijerph17145222

Samat, M. F., Awang, N. A., Hussin, S. N. A., & Nawi, F. A. M. (2020). Online Distance Learning Amidst Covid-19 Pandemic Among University Students. Asian Journal of University Education, 16(3), 220-233. Retrieved from https://doi.org/10.24191/ajue.v16i3.9787.

Shahzad, A., Hassan, R., Aremu, A. Y., Hussain, A., & Lodhi, R. N. (2020). Effects of COVID-19 in E-learning on higher education institution students: the group comparison between male and female. Quality & quantity, 1-22. Retrieved from https://doi.org/10.1007/s11135-020-01028-z

Sharififard, F., Asayesh, H., Hosseini, M. H. M., & Sepahvandi, M. (2020). Motivation, self-efficacy, stress, and academic performance correlation with academic burnout among nursing students. Journal of Nursing and Midwifery Sciences, 7(2), 88. Retrieved from https://doi.org/10.4103/JNMS.JNMS_30_19

Sheroun, D., Wankhar, D., Devrani, A., Lissamma, P. V., & Chatterjee, K. (2020). A Study to Assess the Perceived Stress and Coping Strategies among B. Sc. Nursing Students of Selected Colleges in Pune during COVID-19 Pandemic Lockdown'. International Journal of Science and Healthcare Research, 5(2), 280-288. Retrieved from www.cloudfront.net

Sims, R. (2003). Promises of interactivity: Aligning learner perceptions and expectations with strategies for flexible and online learning. Distance Education, 24(1), 87-103. Retrieved from https://doi.org/10.1080/01587910303050

Song, L., & Hill, J. R. (2007). A conceptual model for understanding self-directed learning in online environments. Journal of Interactive Online Learning, 6(1), 27-42. Retrieved from www.researchgate.net

Surkhali, B., & Garbuja, C. K. (2020). Virtual Learning during COVID-19 Pandemic: Pros and Cons. Journal of Lumbini Medical College, 8(1), 2-pages. Retrieved from https://doi.org/10.22502/jlmc.v8i1.363

Tahir, M., Butt, M. W. U., Sheikh, G. M., Yasmeen, R., & Raza, T. (2020). Factors contributing to stress and anxiety in undergraduate medical students. The Professional Medical Journal, 27(12), 2769-2774. Retrieved from https://doi.org/10.29309/TPMJ/2020.27.12.4598

Yang, H., Bin, P., & He, A. J. (2020). Opinions from the epicenter: An online survey of university students in Wuhan amidst the COVID-19 outbreak. Journal of Chinese Governance, 5(2), 234-248. Retrieved from https://doi.org/10.1080/23812346.2020.1745411

Ye, Z., Yang, X., Zeng, C., Wang, Y., Shen, Z., Li, X., & Lin, D. (2020). Resilience, social support, and coping as mediators between COVID‐19‐related stressful experiences and acute stress disorder among college students in China. Applied Psychology: Health and Well‐Being, 12(4), 1074-1094. Retrieved from https://doi.org/10.1111/aphw.12211

• There are currently no refbacks.

Copyright © 2019 - 2023.  European Journal of Public Health Studies (ISSN 2668-1056/ISSN-L 2668-1056) is a registered trademark of Open Access Publishing Group . All rights reserved.

This journal is a serial publication uniquely identified by an International Standard Serial Number ( ISSN ) serial number certificate issued by Romanian National Library. All the research works are uniquely identified by a CrossRef DOI digital object identifier supplied by indexing and repository platforms. All the research works published on this journal are meeting the Open Access Publishing requirements and standards formulated by Budapest Open Access Initiative (2002), the Bethesda Statement on Open Access Publishing (2003) and Berlin Declaration on Open Access to Knowledge in the Sciences and Humanities (2003) and can be freely accessed, shared, modified, distributed and used in educational, commercial and non-commercial purposes under a Creative Commons Attribution 4.0 International License . Copyrights of the published research works are retained by authors.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Electron Physician
• v.9(12); 2017 Dec

Coping strategies of nursing students for dealing with stress in clinical setting: A qualitative study

Foozieh rafati.

1 Ph.D. of Nursing, Faculty Member, Nursing and Midwifery School, Jiroft University of Medical Sciences, Jiroft, Iran

Esmat Nouhi

2 Ph.D. of Nursing Education, Associate Professor, Department of Medical Surgical Nursing, Physiology Research Center, Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran

Sakineh Sabzevari

Nahid dehghan-nayeri.

3 Ph.D. of Nursing Education, Professor, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

Nursing students in the clinical setting experience a high level of stress. The understanding of people involved in nursing education, from coping strategies of nursing students with clinical stress, is highly important for any kind of planning in this field

To explore the coping strategies of Iranian nursing students with stress in a clinical setting.

This qualitative content analysis study was carried out with twenty nursing students who were selected using purposive sampling at the Razi nursing and midwifery school in Kerman, in Iran during a ten-month period in 2016. Data were collected using semi-structured face to face interviews, and analyzed through Graneheim and Lundman’s qualitative content analysis method.

“Seeking well-being” as the main theme and three categories of “Active confrontation with stress”, “mastering the mind and body” and “avoidance” were obtained from data analysis.

The exploration of nursing students’ experiences of coping with clinical stressors, increases students’ awareness of their coping strategy. The academic authorities in recognizing the coping strategies of students with stress in clinical setting, can provide necessary training on effective coping strategies for students.

1. Introduction

Nursing students experience higher levels of stress than students in other health sciences. The clinical part of nursing education is more stressful than the theoretical part ( 1 ). A study in Bahrain found that all nursing students experienced moderate to severe stress in the clinical setting ( 2 ). Also, a conducted study in Iran revealed that 99.3 percent of nursing students reported the level of perceived stress as moderate to high ( 3 ). The common causes of clinical stress in nursing students included the fear of unknown events, working with equipment ( 4 ), staff and faculty incivility ( 5 , 6 ), theory and practice gap ( 7 ), the fear of making a mistake ( 8 ) and communication with staff, peers and patients ( 9 ). Stress can lead to disease, changes in health, poor academic performance, students withdrawal from the program ( 10 ), and can ultimately affect the quality of patient care ( 11 ). Because nursing students are not able to avoid these stressors, it is necessary for students to cope with them, if they are not able to manage their stress, it will affect their performance, health, attitude and role satisfaction as a nurse ( 12 ). In a stress-adaptive strategy, the individual’s ability to coping with stress is more important than the stress itself, Suitable coping methods reduce stress-induced injuries ( 13 ). Coping is a dynamic, behavioral and cognitive effort in controlling internal and external stress. There are at least two types of coping strategies; problem-focused and emotion-focused. Each individual uses one of the strategies depending on the type of threat, previous beliefs or impermanent factors such as changing strategy based on type of feedback ( 14 ). Research has demonstrated that, nursing students employ a variety of coping strategies ( 15 ) such as; talking to friends, sports, crying, ignoring stress, feelings of sadness/misery and the use of alcohol, which may be adaptive or maladaptive ( 16 ). Some studies have pointed to problem solving as the most utilized strategy in nursing students ( 11 ). Others refer to emotion-focused coping methods, ( 17 ) while some believe that transference, optimism and problem solving are the most used strategies among nursing students ( 12 ). Since, coping strategies of nursing students affect their physical and mental health as well as the quality of care provided by them, identifying coping strategies of nursing students is important for early interventions ( 18 ). Coping must be examined in the context of dealing with a particular stress ( 19 ). Glazer and Gyuark recommend that qualitative studies be used to deeper and better understanding of coping strategies ( 20 ). Even though coping is a context-dependent phenomenon, studies on coping with stress by nursing students in clinical settings in Iran have been mostly quantitative, which used general questionnaires from other cultures, this methodology does not lead to a deep understanding of nursing students coping strategies. Besides, the researcher’s experience, as a faculty member, indicate that some students experience a lot of stress in the clinical setting that limits their learning, this problem in addition to the literature gap in this field, motivated researchers to carry out a qualitative study in order to explore nursing students’ coping strategies with clinical setting stresses in Iran. The nursing undergraduate program in Iran is a four-year-long nursing education, of which graduates will be awarded with a Bachelor’s degree (BSc) certificate in nursing. During the first semester, students learn about the theoretical principles of basic nursing skills and practice clinical skills in a skill lab. Clinical training (practice placement) starts in the first year together with theoretical education, and continues until the end of the third year. In the fourth year, students spend internship in clinical setting, and work with nurses under head nurses and faculty supervision ( 21 , 22 ). Nursing students in Iran are recruited according to ranking in the National Higher Education Entrance Examination, thus, students who have little or no information about nursing may be recruited. Often, they are not happy for not entering the nursing program.

2. Material and Methods

2.1. study design.

This qualitative study was carried out using a content analysis method to investigate nursing students’ coping strategies with clinical stresses. Qualitative studies are utilized to increase understanding and describe the world of human experience ( 23 ). Content analysis is a systematic coding and categorizing approach which includes a process of understanding, interpreting and conceptualizing the essential meanings of qualitative data ( 24 ).

2.2. Setting and Participants

Study setting was Razi Nursing and Midwifery College and relevant settings as hospitals and dormitories in Kerman University of Medical Sciences in Iran that lasted ten months in 2016. The main study population comprised of undergraduate nursing students. Purposeful sampling was employed to recruit the participants. Inclusion criteria were: having at least a semester of clinical experience, the willingness to participate in the research and absence of previous clinical work experience. Participants with maximum variation in terms of gender, age, marital status, semester, and students’ living condition (living in dormitory, with family or rented home) were selected. Data collection continued until data saturation was attained, which means, further interviews could not provide new information about the target concept. Data saturation was accrued after 18 interviews. Furthermore, two additional interviews were carried out to ensure data saturation.

2.3. Ethical Consideration

The Ethics Committee of Kerman University of Medical Sciences approved the study (ethics code: ir.kmu.rec.1394.575). All participants were informed about the aim and method of the research. Written informed consent was obtained from all participants prior to each interview. They were told that participation in the study and withdrawal from the study at any time was voluntary. They were assured of the anonymity and confidentiality of the study.

2.4. Data Collection

Initially, participants were visited or called and after explaining the aim of the study, the time and place of each interview was set. All interviews were carried out with participants’ agreement at the Razi Nursing & Midwifery School, in Kerman University of Medical Sciences. Data were gathered via face-to-face, in-depth interviews with semi-structured questions. Interviews explored issues surrounding clinical stressors, as well as coping strategies employed to deal with them. At the start of the interviews, the interviewer (first author who was not involved in teaching or evaluation of participants) started with general questions, and moved to more specific issues, such as; Tell me about your clinical experience, what are your experiences of clinical stressors? How do you deal with them? Proportional to the answers, probing questions were put forward, like “Could you explain more?” Interviews lasted between 45to 75 minutes and were audio taped by a voice recorder device with participants’ consent.

2.5. Data Analysis

Data was analyzed using qualitative content analysis method described by Graneheim and Lundman ( 25 ). Interviews were transcribed immediately after each interview. Initially, each text was read several times until a general impression was conceptualized. Thereafter, all texts were read line-by-line and were broken down into meaningful units which were key phrases in the text. Subsequently, the meaningful units were condensed and labeled with codes. Thereafter, the codes, according to similarities and differences, were allocated into subcategories. Similar subcategories were grouped into categories. Finally, the theme was determined as the expression of the latent meaning of the text. A sample of the process of analysis is shown in Table 1 . MAXQDA12 software was employed for data analysis. Trustworthiness was assured via the use of Lincoln and Guba’s criteria ( 26 ). To ensure credibility, long term involvement with participants was utilized, member check was used, which means, analyzed and interpreted data was shown to the participants to evaluate the interpretations made by the researcher and to make suggestions if they did not agree with them; however, they did agree with them. For conformability, two faculty members who had experience in performing qualitative research, confirmed data analysis. From the first interview, field notes were taken. To control dependability, supervisors revised the codes and categories in order to reach a consensus. For transferability, participants were selected with maximum variation, initial findings were given to several students who did not participate in the study, and they confirmed fitness of results with their experience. Also, thick description of data was carried out.

Example of qualitative content analysis process

Twelve females and 8 males that ranged in age between 18 to 35 years with mean 23 (SD ± 3.5) participated in this study. Six of them were married and 14 were single. One main theme, three categories (“Active confrontation with stress”, “mastering the mind and body” and “avoidance”) and 15 subcategories emerged from data analysis ( Table 2 ). “Seeking well-being” as the main theme was extracted from data analysis, this implies that participants employed varieties of coping strategies for approach to well-being. All participants’ coping strategies were along the lines of reducing physical and mental symptoms of stress and attaining well-being. This theme included three categories: Active confrontation with stress, Mastering the mind and body and Avoidance.

Emerged theme, categories and subcategories from data analysis

3.1. Active Confrontation with Stress

To control stress, some of the participants actively confronted the stressful situation and tried to deal with the situation this way.

3.1.1. Developing Professional Competency

Given that one of the main causes of stress for the participants was their feeling on the lack of professional knowledge and skills, participants were trying to develop their knowledge and skills through various methods. Participants were developing their knowledge and skills via direct experience, observation of others, consultation with educators, staff, higher grade students and older classmates to become proficient in the procedures and patient care. In this regard, a male participant in the second semester (Participant No. 3) stated; “…I ask my practical questions from the nurses and theoretical questions from university teacher…” some participants were also using peer learning to develop their skills.”…When classmates go to perform a procedure, I follow them to see how they do it…” said a female participant in the sixth semester (Participant No. 7). In order to cope better with environmental stress as well as upgrading their practical skills, the participants were developing their theoretical knowledge as well. One participant stated; “…I do not know many things, that is why when I go to a new ward, I study common clinical cases of the ward…” (A female participant in the eighth semester; Participant No. 4).

3.1.2. Correcting a Wrong Intervention

When the source of stress was a wrong intervention for patients, the participants tried to prevent any harm to patients by quickly correcting their mistake, so as to be relaxed and have peace of mind. One of the female participants in the seventh semester said: “…While inserting a cannula, I entered into the artery by mistake. In this situation, you should do the best and fastest intervention. I took out the cannula and put a sterile pad on the spot and applied pressure on it. Literally, correcting the mistake reduced my stress…” (Participant No. 10).

3.1.3. Facing Stressful Situations Purposefully

Some of the participants while facing stressful situations were trying to break the vicious cycle of avoidance-stress. One participant said: “…I tried to face the situation that I was escaping from. For instance, by standing next to my friend who was dealing with the same situation, I gradually tried to do it myself…” (A male participant in the fifth semester No 12). Another female student in sixth semester (Participant No. 7) said: “…I assessed it first (the patient’s vein) then I faced my fear and entered the needle. I knew the more I hesitated, the more my stress would continue…”

3.1.4. Reflection on Stressful Situations

This sub-category that was being used mostly by male participants refers to the analysis of stressful situations, thinking and mental rehearsal of the measures taken in the stressful situations. Students were reflecting on the stressful situations for two reasons; for analysis of the stressful situation and for mental rehearsal of the correct nursing care process to prevent the error. A male participant in this regard stated; “...I like to be alone and think about the subject (stressful situation), why this happened? Why was I treated like that? So that I can calm myself…” (Participant No. 13). Another male participant in the second semester who was stressed during clinical activities said: “…I do go and sit somewhere quiet and analyze the situation. I identify things that I should have done but didn’t, thus subsequently, I would have a better performance if faced with similar situation…” (Participant No. 3).

3.1.5. The Use of Communication Skills in Controlling Stressful Interactions

When interacting with others (patients, staff, mentor, and peers) who could be stressful, participants employed their communication skills so as to control or prevent the stress. A male participant (No. 2) in this regard said: “…a patient might be angry and say something, I try to calm them down through a favorable eye contact or an appropriate verbal communication, and I don’t allow patients to control my emotions…”Students stated that, they tried different ways to win the patients and families’ trust so that they can allow the student to deliver care for them. “…I spoke to him (patient) and said that I am a nursing student, I am on my last semester and know what I am doing, then he allowed me collect his blood sample…” (Male participant in the eighth semester, No. 18).

3.2. Mastering the Mind and Body

To cope with stress alongside the use of mental activities such as; deviation and stop thinking, realism, and positive thinking, participants used strategies such as: performing favorite activities, taking drugs and medicines. They were also using techniques to decrease the physiological symptoms, releasing emotions, and praying to control their body and mind.

3.2.1. Deviation and Stop Thinking

Some students using various methods such as “…engaging thought with something else…” (A male participant in the third semester, No. 20), diverted their mind from the stressful subject, or stopped stressful thoughts. One participant said: “…I said, it’s enough, I will stop thinking about you (stressful thoughts) …” (A female participant in the third semester, No 11).

3.2.2. Realism

Some participants, by relying on existing realities, were coping with clinical setting stresses. They knew that, perfectionism can be highly maladaptive. One of the male participants in first semester said: “…I was stressed when checking patients’ blood pressure, but then I said to myself, I am not supposed to know everything, this is my first semester and it is normal that I do not know many things. This way, I coped with the stress…” (Male participant in the first semester, No. 8).

3.2.3. Positive Thinking

Positive thinking or repeating positive sentences were among methods used to cope with stresses. One of the male participants in this regard said: “…I repeated to myself that I could do it better than everybody else, and that was very helpful (in reducing the stress) …” (Participant No. 8).

3.2.4. Relieving Stress by Doing Favorite Activities

Most students were trying to distract their thoughts from stressful subjects by doing their favorite activities. “…We go out with our friends and have fun, in this way, we reduced our stress” (Female participant No. 14). Even one of the male participants in the first semester was using “cooking” to relieve the stress. “…I love cooking, when I get to the dormitory, in order to relieve the stress, I start cocking…” (Participant No. 3).

3.2.5. The Use of Herbal and Chemical Medicines

A small number of participants used herbal or chemical medicines to deal with stress of the clinical environment. One female participant in the seventh semester said: “…When I have a presentation the next day, and the teacher is strict, I make myself a glass of milk with cinnamon or brew borage, then I feel much better…” (Participant No 10). Another male participant in the fifth semester said: “…In the morning, I will say another day has begun, patients, professors and peers’ demand again, so I take an Inderal pill to calm myself down a bit and then go to work in the clinical setting” (Participant No. 1). The same student also said: “…When one of my friends comes to the dormitory from practicum, he smokes to lower his stress, and when I object to his attitude, he says, smoking to me is like chewing gum for you…”

3.2.6. Reducing Physiological Symptoms

Few of the participants were using techniques such as; deep breathing, drinking water or resting to reduce the physiological symptoms of stress. “...My heart was palpitating and I was also breathing fast, I said to the patient that I needed to go out of the room to wash my hands, thereafter I came out and took a couple of deep breaths to normalize my breathing rhythm” (Male participant in the first semester, No 8).

3.2.7. Releasing Emotions

Some of the participants were relaxing themselves by talking to others about stressful events. Most of the participants were talking to peers, family members and even mentors for catharsis of their emotions. One female participant in the fifth semester talked about her experience of peace by talking to her husband and said: “…Basically, when I have a stressful situation at my practicum, I go home and talk to my husband and that makes me relaxed and calm” (Participant No. 9).

3.2.8. Praying

Strategy used by few participants was praying. Praying impacted on participants’ perceptions of stressful situations, rather than reduce stress symptoms. “…I pray and say to myself that God willing, I’ll succeed (in patient care)” (Female participant in the third semester, No 19).

3.3 Avoidance

As seen from all the statements of the participants, avoidance was the most used strategy.

3.3.1. Avoiding Stressful Situations

Participants believed that this strategy was effective in some stressful situations and they were trying to avoid stressful people and situations. “…I'm stressed while taking blood samples, I'm afraid, so I ask others to do it for me…” (Male participant in the 5th semester, No 12). Another female participant in the sixth semester talked about avoidance of individuals: “…I picked up some gloves to take blood samples with a nurse, but she said: one glove is enough. She wanted to take blood samples with only one glove. It was hard and unbearable for me; but I could not protest. I was just a student; so, I did not argue with him… “(Participant No. 17).

3.3.2. Giving up

In cases where the stressful situation was outside the control of students, they give up to prevent stress. They avoid mentally stressful situations with these manners. One female student in the fourth semester said: “…She (head nurse) told me to check the vital signs of 40 patients on the ward, it was tiring but I didn’t have a choice, I did it because she was the evaluator of my practice…” (Participant No. 15).

4. Discussion

The results of this study showed that, nursing students were using a variety of strategies to cope with work-related stress in the clinical setting. To actively deal with the clinical setting’s stress, participants used strategies to develop their professional competency, correct their mistakes, confront stressful situations, and reflect on stressful issues. Development of professional competency was one of their most important strategies for coping with the stress of the clinical environment. Due to lack of knowledge or confidence in their professional skills, participants were faced with stress throughout their entire academic education; hence they recognized the development of professional competency as a problem-based solution in dealing with their stress. Therefore, clinical instructors should create an atmosphere in which nursing students express their skill in conducting procedures without fear of instructors’ judgment, and in which instructor’s support students in the process of gaining professional competency. Also in a study by Dadgaran et al, the development of practical skills was recognized as one of the ways of gaining professional competency by Iranian nursing students ( 27 ). Rapid correction of incorrect action by students, showed the importance of patient safety for them. Therefore, nursing students need to be trained on patient safety and risk management as a preventive coping, before entering to the clinical setting. Researchers in this regard state that to identify threats of patient safety, incorrect reports and understanding of errors’ consequences in Iran’s nursing education, there is need for a fundamental change in educational philosophy towards empirical and reflective learning ( 28 ) and also in curriculum content. Furthermore, to achieve professional maturity, some students were facing stress purposefully in stressful interventions. They state that they can never deal with stressful situations by running away from them. This finding is consistent with the theme “Struggle for clinical independency” in the study by Dadgaran et al. ( 27 ). Nursing students knew that direct participation in activities and techniques of nursing practice can lead to a more stable learning ( 29 ).

The participants of this study, by reflecting and thinking carefully on their behavior and behavior of others in stressful situations with careful analysis of the situation, learned to deal with the situation or increase their knowledge and skills. A detailed analysis of stressful situation was carried out alone or with the help of peers. This finding is consistent with the findings of Reev et al. ( 16 ) and Sun et al. ( 6 ) studies. Ganzer and Zauderer also stated that, reflection enhanced students’ self-awareness and ability to adapt mentally with the experiences of the psychiatric ward ( 30 ). Since reflection helps students better understand the stressful situation, gain self-awareness, and improve the ability to solve a problem, so it can be taught to them as an effective coping strategy by instructors. Moreover, participants were managing stressful interactions to reduce their stress. Also, by using this technique, they were trying to win patients and their family’s trust. Due to staff shortages, students in Iran undertake almost all nursing procedures, they know that winning a patients’ trust is the key in caring for them. Particularly, after enacting a general health insurance by Iran’s previous government, hospital admission has not been proportionate to the increase of nursing staff, and this resulted in nursing students undertaking most procedures. Also in Hartman’s study, most participants believed that good interpersonal communication is needed to resolve the conflict in the clinical setting ( 31 ). Also, the emerged theme in the study by O’Mara et al. was “rebuilding relationship” to face communication challenges ( 32 ). Having control over the body and mind was another category mentioned by the participants. To control their mental and physiological functions, students undertook a series of actions. Findings regarding the use of thought’s distraction techniques are consistent with the findings of Phillips ( 33 ) and Al-Zayyat and Al-Gamal ( 34 ). To better cope with environmental stress, some of the students chose to be realists and set realistic professional goals. They were also avoiding unrealistic perfectionism. Maladaptive perfectionism is related to unhealthy work and psychological consequences. Moreover, nurses who have maladaptive perfectionism may feel depressed and not supported, which could lead to their inability to learn from mistakes ( 35 ). Results of this study regarding the use of positive thinking is consistent with the findings of Wolf’s study ( 36 ). Positive thinking does not change the actual situation of a stressful situation but changes the person’s interpretation of the position. Students also, by doing their favorite activities, reduced their stress. In a study by Sun, students listened to music and watched TV to free their minds from anxiety ( 6 ).

The use of herbal and chemical medicines was another way some students used to manage stress-induced physiological and psychological symptoms. In this study, only two students referred to smoking marijuana and cigarettes, and no student used alcohol. In the study of Seyedfatemi et al. in Iran, over 90% of the participants declared that, they avoided strategies such as; smoking or drinking beer or wine to reduce stress ( 37 ). Avoiding the consumption of alcohol by the participants of this study could be related to religious and legal barriers, regarding the use of alcohol in Iran. Results of this study on alcohol consumption are against the findings in the study of Reev et al. ( 16 ). This difference might be related to religious and cultural differences. The use of herbal medicines by some participants in reducing stress is related to the view of Iranian society that believes in low toxicity and side effects of herbal medicines. Khorasgani and Moghtadaie’s study showed that the view of Iranian nursing students on Iranian traditional medicine is positive ( 38 ). In this study, few of the students used procedures such as; deep breathing, relaxation and drinking water to reduce the physiological symptoms of stress. Which indicates that they are not familiar with such techniques, therefor, teaching non-pharmacological techniques to nursing students for reducing their stress symptoms is necessary. Literature indicates that special breathing exercises are effective in reducing symptoms of stress, anxiety and insomnia ( 39 ). Releasing emotions associated with stress by talking to others is a strategy that has also been confirmed by other studies ( 6 , 15 , 33 ). Peers and instructors as available social support resources, can play a more active role in nursing students’ coping of stress. The results of the study revealed that few participants benefit from praying when encountering stressful situations, perhaps their experience is not as intense as to require prayer and spirituality. Paying attention to prayer has been confirmed in other Asian countries ( 12 , 15 ). Avoiding and escaping from stressful situations, was the most widely utilized strategy in coping with the stress of the clinical environment. This finding has been confirmed by O’Mara et al. ( 32 ). Studies by Shaban et al. ( 11 ) and Zhao et al. ( 12 ), showed that avoidance was the least used strategy among students for coping. The differences in these findings could be attributed to the differences in participants, culture or method of research. Unfortunately, avoidance reduces stress temporarily, therefore, instructors should be careful about avoiding adaptive strategy in nursing students. In cases where students cannot find any solution for their problem, they give up and accept it. Probably, lack of meaningful personal relationships in the clinical environment leads to increased dependency behaviors such as, incontestable agreement with the decision made by others and surrendering. Generalizability due to the low number of participants, selecting them from one university, and the nature of the study may be the limitations.

5. Conclusions

According to this qualitative study, nursing students apply different coping strategies, depending on the contextual condition. In order to solve stressors, they tried to confront stressful sources actively, sometimes they were looking for a way to reduce their physical, psychological, and cognitive symptoms caused by stress, other times, when they felt the stressful situation was beyond their control, they avoided or accepted it. According to the findings, planning and adoption measures to nursing students training for active coping strategies, improving positive methods for reducing stress symptoms and helping to eliminate maladaptive coping strategies as drug consumption and avoidance by instructors and authorities is probably effective in nursing students coping with clinical stresses. Action research and quantitative studies in this field are a good route for future research.

Acknowledgments

The authors would like to thank nursing student participants and research and ethic board members of Kerman University of Medical Sciences. This study was part of a nursing PhD dissertation and was supported financially by Kerman University of Medical Sciences. It was coded as 94/518.

iThenticate screening: August 21, 2017, English editing: September 25, 2017, Quality control: October 27, 2017

This article has been reviewed / commented by three experts

Conflict of Interest:

There is no conflict of interest to be declared.

Authors’ contributions:

All authors contributed to this project and article equally. All authors read and approved the final manuscript.

Login to your account

If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password

If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password

• AACP Member Login      Submit

Identification of Risk Factors for Imposter Syndrome Among Healthcare Professional Students

• Add to Mendeley

Get full text access

Log in, subscribe or purchase for full access.

Article metrics

Related articles.

• Download Hi-res image
• Download .PPT
• Access for Developing Countries
• Articles & Issues
• Articles In Press
• Current Issue
• Past Issues
• Journal Information
• About Open Access
• Aims & Scope
• Editorial Board
• Editorial Team
• History of AJPE
• Contact Information
• For Authors
• Guide for Authors
• Researcher Academy
• Rights & Permissions
• Submission Process
• Submit Article
• For Reviewers
• Reviewer Instructions
• Reviewer Frequently Asked Questions

The content on this site is intended for healthcare professionals.

• Privacy Policy   
• Terms and Conditions   
• Accessibility   
• Help & Contact

Society Member Access

AACP Members, full access to the journal is a member benefit. Login via the AACP Website to access all journal content and features.

• Institutional Access: Log in to ScienceDirect
• Existing Subscriber: Log in
• New Subscriber: Claim access with activation code. New subscribers select Claim to enter your activation code.

Academic & Personal

Corporate r&d professionals.

• Full online access to your subscription and archive of back issues
• Table of Contents alerts
• Access to all multimedia content, e.g. podcasts, videos, slides

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Lifestyles and academic stress among health sciences students at the National University of Chimborazo, Ecuador: a longitudinal study

Affiliations.

• 1 Doctorate Program in Clinical Medicine and Public Health, University of Granada, Granada, Spain.
• 2 Instituto de Investigación Biosanitaria (ibs-GRANADA), Granada, Spain.
• 3 Department of Nursing, Faculty of Health Sciences, National University of Chimborazo, Riobamba, Ecuador.
• 4 Department of Nursing, Faculty of Health Sciences, University of Jaén, Jaén, Spain.
• 5 Center for Mind, Brain, and Behavior Research (CIMCYC), Granada, Spain.
• 6 Department of Nursing, Faculty of Health Sciences, University of Granada, Granada, Spain.
• PMID: 39188803
• PMCID: PMC11345227
• DOI: 10.3389/fpubh.2024.1447649

Background: The significant changes experienced by university students in their training are inherent to educational processes. Social isolation caused by the COVID-19 pandemic, online education and the reopening of higher-education institutions produced substantial variations in the lifestyle of university students in health sciences and generated academic stress and perceived stress. This study was conducted at the National University of Chimborazo (UNACH), a public institution located in Riobamba, central Ecuador, the diverse student's population provided an ideal setting for examining the interplay between academic and perceived stress, lifestyle factors, and learning modalities. The research focused on health sciences students across six academic programs. The university's geographical position and demographic characteristics offered a representative sample for investigating these factors within the context changing.

Aim: To compare academic and perceived stress and university students' lifestyles at two different periods: (1) during the mandatory social confinement caused by the COVID-19 pandemic with an online learning modality (T1); (2) in the post-pandemic period with a return to face-to-face activities (T2).

Design: An observational, analytical, quantitative, and longitudinal study.

Participants: Students from six programs (Nursing, Physiotherapy, Clinical Laboratory, Medicine, Dentistry, and Clinical Psychology) from the Faculty of Health of the National University of Chimborazo-Ecuador ( n = 2,237) participated voluntarily, the students had one mean age of M = 21.31 (SD = 2.36) at T1 and M = 22.94 (SD = 2.40) at T2. Non-probability convenience sampling was employed due to the accessibility of the student population and the importance of including the maximum number of relevant individuals within the study population.

Methods: The following instruments were used: Nola Pender's Lifestyle Profile Questionnaire, Cognitive Systemic Inventory for the study of academic stress, and Cohen's Perceived Stress Scale.

Results: In T1 and T2, students reported high levels of stress, and increased unhealthy lifestyle increased with the return to classrooms. Additionally, upon returning to face-to-face activities (T2), the mean score applied to the responses of Nola Pender's Lifestyle Profile Questionnaire decreased from M = 113.34 (SD = 23.02) to M = 107.2 (SD = 29.70; p < 0.001). There was significant difference ( p < 0.001) in academic stress in T1 [M = 66.25 (SD = 15.66)] and T2 [M = 64.00 (SD = 17.91)].

Conclusions: Upon returning to university classrooms (T2), the number of students who reported an "unhealthy" lifestyle increased. Academic stress was high in T1 and T2 and was reported higher in online activities during social isolation.

Keywords: health students; lifestyle; online education; social isolation; stress.

Copyright © 2024 Salazar-Granizo, Hueso-Montoro and Caparros-Gonzalez.

PubMed Disclaimer

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Student engagement flow. T1 academic…

Student engagement flow. T1 academic period characterized by the online-learning modality owing to…

Longitudinal design, study sample, and…

Longitudinal design, study sample, and procedure.

Lifestyle dimensions T1–T2 ( n…

Lifestyle dimensions T1–T2 ( n = 2,237).

Academic stress dimensions T1–T2 (…

Academic stress dimensions T1–T2 ( n = 2,237).

• Cuijpers P, Auerbach RP, Benjet C, Bruffaerts R, Ebert DD, Karyotaki E, et al. . The World Health Organization World Mental Health International College student initiative: an overview. Int J Methods Psychiatr Res. (2019) 28:e1761. 10.1002/mpr.1761 - DOI - PMC - PubMed
• Spinazze P, Kasteleyn MJ, Aardoom JJ, Car J, Chavannes NH. Cross-sectional analysis of university students' health using a digitised health survey. Int J Environ Res Public Health. (2020) 17:3009. 10.3390/ijerph17093009 - DOI - PMC - PubMed
• Andraus GS, Vieira FM, De Mello Candido G, Patino GP, Bernardelli RS, De Palma HLA. Associations between lifestyle and sociodemographic factors in medical students: a cross sectional study. J Lifestyle Med. (2023) 13:73–82. 10.15280/jlm.2023.13.1.73 - DOI - PMC - PubMed
• Abdulrahman KaB, Khalaf AM, Abbas FBB, Alanezi OT. The lifestyle of Saudi medical students. Int J Environ Res Publ Health. (2021) 18:7869. 10.3390/ijerph18157869 - DOI - PMC - PubMed
• Tahir S, Imran N, Haider I, Mustafa A, Rehman AU, Azeem MW, et al. . A study to evaluate the impact of COVID-19 on Lifestyle of Medical students. Pak J Med Sci. (2022) 38:6031. 10.12669/pjms.38.7.6031 - DOI - PMC - PubMed

Publication types

• Search in MeSH

Related information

Grants and funding, linkout - more resources, full text sources.

• Frontiers Media SA
• PubMed Central
• MedlinePlus Health Information

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.