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International Journal of Nursing Studies 45 (2008) 15341542

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A study of stress and burnout in nursing students in Hong Kong:

A questionnaire survey
Roger Watson a,*, Ian Deary b, David Thompson c, Gloria Li c
a
School of Nursing & Midwifery, The University of Sheffield, Sheffield S10 2TN, UK
b
The School of Philosophy Psychology and Language Sciences, The University of Edinburgh, Edinburgh EH8 9JZ, UK
c
Nethersole School of Nursing, Chinese University of Hong Kong, Hong Kong SAR, China
Received 4 June 2007; received in revised form 8 November 2007; accepted 16 November 2007

Abstract

Background: Stress in nursing students may be related to attrition from nursing programmes and lead to a shortage of nurses
entering clinical careers. In addition, stress leads to psychological morbidity which may have profound adverse consequences
for individual nursing students.
Objectives: To follow a cohort of nursing students from entry to their programme to the end of the first year and to study the
interrelationship between a range of psychological variables including personality, stress, coping and burnout.
Design: Prospective, repeated measures survey using self-administered questionnaires.
Setting: A university school of nursing in Hong Kong.
Participants: Students were selected on the basis of entry to their nursing programme in 2004; 158 students entered the study
and 147 completed; 37 were male and 121 were female at entry. The mean age of the cohort at entry was 19.1 (S.D. 0.85); ages
ranged from 18 to 26.
Methods: The questionnaires administered at wave 1 were: the NEO Five Factor Inventory, the Coping in Stressful Situations
questionnaire, the 12-item General Health Questionnaire, the Maslach Burnout Inventory and the Stress in Nursing Students
questionnaire. At wave 2 the 12-item General Health Questionnaire, the Maslach Burnout Inventory and the Stress in Nursing
Students questionnaire were administered.
Results: Students suffered greater levels of psychological morbidity and burnout at the second time wave and this was largely
explained by the personality trait of neuroticism. Stress also increased and this was largely explained by emotion-oriented
coping.
Conclusions: Undertaking a nursing programme leads to increased level of stress, burnout and psychological morbidity and this
is largely related to individual personality and coping traits.
# 2007 Elsevier Ltd. All rights reserved.

Keywords: Burnout; Coping; General health; Nurses; Stress; Students

What is already known about the topic?

 Nursing students suffer from stress and psychological

* Corresponding author. Tel.: +44 1142229848; morbidity.
fax: +44 1142229712.  Stress and psychological morbidity have adverse effects
E-mail address: roger.watson@sheffield.ac.uk (R. Watson). such as burnout and attrition.

0020-7489/$ see front matter # 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2007.11.003

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 R. Watson et al. / International Journal of Nursing Studies 45 (2008) 15341542 1535

What this paper adds sources such as separation from home, financial worries,
regular clinical and educational assessment and frequently
 Psychological morbidity in nursing students in Hong changing clinical environments (Deary et al., 2003). Deary
Kong is largely explained by individual personality traits. et al. (2003) showed that nursing students experience
 Stress in nursing students in Hong Kong is largely increasing levels of stress and psychological morbidity
explained by individual coping strategies. throughout their nursing programme and that the personality
trait of neuroticism was initially associated with the emo-
1. Introduction tional exhaustion aspect of burnout and that conscientious-
ness was associated with a greater sense of achievement
There is now a global shortage of nurses (Buchan and from work. This relationship between personality factors
Calman, 2004) and a major contributory factor to this is the and burnout has previously been demonstrated in nurses by
high attrition rates of nurses and nursing students, which are Zellars et al. (2000).
linked to stress and burnout. Recent and extensive coverage Stress in nursing students does not just have negative
has been given to stress in nurses (Chang et al., 2005) and an effects on them; ultimately it will have a negative effect on
increasing amount of research has focused on stress in the nursing workforce. These deleterious effects of stress on
nursing students (Jones and Johnson, 1997, 1999, 2000). the workforce include leaving it periodically or permanently
through stress-related illness (Ryan et al., 2005). The
1.1. Stress remaining workforce has to compensate for stress-related
absence and increasing their workload further increases their
Stress is intrinsic to nursing and a highly demanding job stress and leads to poor patient care.
with poor support, rapidly changing circumstances, shortage
of resources and staff, and dealing with death and dying all 1.2.1. Attrition
contribute (Chang et al., 2005). Nursing is emotionally Attrition is also a recognised problem among nursing
demanding and this interactive stress contributes to the daily students (Deary et al., 2003) which increases the costs of
stress of nurses (Mann and Cowburn, 2005). Environmental those who fund nurse education. For example, in response to
factors compound these intrinsic factors and these include increased government targets in the UK for recruiting nur-
difficult patients and their families, relationships with physi- sing students, admission to the nursing register increased by
cians and low institutional commitment to nursing (Chang nearly 8000 between 1998 and 2005 (Nursing and Midwif-
et al., 2005). In addition to the daily stresses of nursing, nurses ery Council, 2005), representing a 65% increase in nurses
are required to undertake continuing professional develop- entering the register in England alone. However, the average
ment (Hogston, 1995) and part-time education (Timmins and level of attrition in UK universities providing nursing edu-
Nicholl, 2005). High levels of stress seem to afflict newly cation is 13% representing an annual loss of over 2500
qualified nurses and this is associated with entering the clinical students. There is, therefore, a robust business case for
setting for the first time whereby they seem to experience lack studying factors related to attrition among nursing students.
of confidence through exposure to unfamiliar circumstances The UK national workforce projects/workforce review team
(Chang et al., 2005; Chang and Hancock, 2003). (Buchan, 2005) reckoned that by 2014 the UK would need
twice as many new entrants as it has now just to keep the
workforce constant. Identifying the antecedent and conse-
1.1.1. Outcomes of stress quent correlates of stress, which is a known factor in the
Stress leads people to cope poorly with situations, such as attrition of nurses and student nurses (Jones and Johnson,
using more emotion-focused coping (Deary et al., 1996). 2000), may illuminate strategies for alleviating it. This
Despite stress leading nurses to seek social support (LeSar- could, possibly, lead to strategies for increasing retention
gent and Hanley, 2005), a recent study by Wu et al. (2007) of nursing students.
demonstrated that burnout amongst nursing staff was related,
amongst other things, to increased level of occupational 1.3. Hong Kong
stress. Although stress is normal in a range of circumstances
(Smith and Fawcett, 2006) the negative consequences aris- In contrast to the UK, few data exist on issues such as
ing from workload factors associated with stress, such as stress and attrition in nurses and nursing students, which
increasing patient load, can lead to emotional exhaustion, or are important factors pertaining to workforce forecasting
burnout (Maslach and Jackson, 1986), a concept that will be and planning, in Hong Kong. Hong Kong, a special admin-
described below. istrative region of the Peoples Republic of China, with a
population of 6.8 million people, has around 35,000 practi-
1.2. Nursing students cing nurses (Chan et al., 2006). All nurses in Hong Kong
are required to have a practice qualification at bachelors
In addition to the above, nursing students not only degree level. Hong Kong started its first nursing degree
experience such stress in clinical practice but also from programme in 1990 and now three of its eight universities

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1536 R. Watson et al. / International Journal of Nursing Studies 45 (2008) 15341542

offer 4-year Bachelor of Nursing honours programmes, 1.4.1. Burnout

with a total intake of around 600 per annum (Thompson, Stress is not an isolated outcome of the transaction
2006). Until recently, there has been no nursing shortage between stimuli and responses and the concept of profes-
in Hong Kong; however, this is changing and in the sional burnout is closely related to it (Schaufeli et al., 1993).
very recent past nursing shortages are being reported Burnout, a phenomenon that is probably unique to people
(http://www.medill.northwestern.edu/medill/grad/spe- working in human caring services (Cox et al., 1993), leads to
cial_programs/global/filed_from_residency/hong_kong_- emotional exhaustion and a tendency to depersonalise those
suffers_nursing_shortage_baptist_hospital_ceo_- who are being cared for; it also reduces a sense of achieve-
says.html; accessed 17 August 2007) and this is predicted ment. According to Cox et al. (1993) the transactional model
to become much worse in the near future. Therefore, the of stress is closely related to burnout and maps on to several
case for studying factors that possibly relate to attrition in aspects of occupational stress. In the same way as response-
nursing students in Hong Kong is increasing and this, in based factors contribute to stress, individual characteristics
part, justifies the study reported here. also influence burnout, and the relationship between person-
Of additional, and specific, relevance to Hong Kong is ality factors and burnout has also been studied (Cox et al.,
the issue of suicide, in which there was a 50% increase 1993).
between 19972003 (http://csrp.hku.hk/WEB/eng/statis-
tics.asp accessed 1 December 2006). In fact, suicide is 1.5. The present study
the leading cause of death in Hong Kong for those aged
1524 (Yip et al., 2004), and the majority of the nursing The theoretical perspective of the present study is trans-
students in this study were in that age group. Academic self- actional and the aim was to study the relationship between
concept and parental dissatisfaction with academic perfor- personality, stress, burnout and psychological morbidity in
mance have been significantly associated with suicidal nursing students in Hong Kong. Such a study has not
ideation amongst Hong Kong adolescents (Lee et al., previously been conducted in Hong Kong and it will serve
2006). It is common, in Hong Kong, for parents to make to inform nursing educators in Hong Kong and it will also
significant financial sacrifice for their childrens education, provide an international comparison with other, similar,
and stress in students could be partly due to Chinese cultural studies. The research question guiding this study was: is
and Confucian concepts of collectivism versus individual- there a relationship between individual traits and a range of
ism, self-control, familial piety, good relationships with psychological outcomes in nursing students?
others and a sense of fulfilling obligations (Graham, 1991;
Bond, 1992).
2. Methods
1.4. Theoretical perspectives on stress
2.1. Design
Stress can be viewed as response-based, i.e. emanating
from individuals reactions to events and circumstances, The design of this study was prospective using repeated
stimulus-based, i.e. the result of events and circumstances, measures in a cohort sample and self-administered ques-
or as interactive and resulting from interplay between stimuli tionnaires for data collection. The data were collected in
and responses (Furnham, 2005). The interactive or transac- 2004 and 2005. Participants were nursing students in one
tional model of stress proposed by Lazarus (1966) is entirely university department of nursing in Hong Kong who
applicable to the circumstances of nursing students and is the entered their nursing programme in 2004. Data were
framework adopted for the present study. Nursing students collected in two waves: at the start of the programme
encounter an array of new and sometimes difficult circum- (wave 1) and after 7 months (wave 2), when the students
stances when they enter their programme of education and were together for the last time prior to undertaking clinical
this provides the stimulus for stress. These nursing students practice. Access to the students was gained through the
will all be individuals taking into their programmes a range head of department and the proposal for the study was
of personality types and coping strategies providing subject to ethical approval by the Universitys review
responses to stressful situations; therefore, the interaction procedure. The voluntary nature of participation in the
between their circumstances and their responses is of inter- study was explained to students in a letter of introduction
est. In the case of nursing students, the kind of stress to the study. Therefore, students could decide to participate
resulting from this transaction between stimuli and or not and time was allocated twice (waves 1 and 2) within
responses is classified as occupational or work-related stress the curriculum for distribution of the questionnaires. There
(Jones and Johnson, 2000) and specific instruments, one of was no remuneration for participating. Questionnanires
which will be described in the methods section below, have were taken home by the students, completed and returned
been developed to measure this kind of stress and some of the following day; it is estimated that completion of the
these are specific to nursing students (Jones and Johnson, questionnaires (185 items) took approximately 1 h for
1999; Deary et al., 2003). wave 1 and 30 min for wave 2.

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2.2. Sample from the job). The validity of the MBI is well established
(Cox et al., 1993) and the internal consistency of the
The sample consisted of all nursing students entering a dimensions of the MBI, using Cronbachs alpha, are: emo-
programme of education towards general (adult) registration tional exhaustion = 0.09; depersonalisation = 0.71; personal
at one university department of nursing in Hong Kong. At accomplishment = 0.71.
the start of the study, 158 students participated of which 37 In addition, the following two instruments were used.
were male and 121 were female. No students declined to
participate. The mean age of the cohort was 19.1 (S.D. 0.85); 2.3.4. The coping inventory for stressful situations
ages ranged from 18 to 26. Dropout from the programme of (CISS) (Cosway et al., 2002)
study was minimal between wave 1 and wave 2 and is not This assesses the extent to which respondents use the
considered as a dependent variable in this study. The instru- following coping strategies: emotion oriented (becoming
ments administered in this study were not used diagnosti- emotionally upset in the face of stress), task oriented
cally with individual students. Therefore, students were not (addressing the causes of stress) and avoidance oriented
referred to support services as a result of outcomes measured (doing something to avoid facing stress: divided into dis-
in this study. However, all normal student support services traction oriented and social diversion oriented). The instru-
were available to students throughout the study. ment has 48 items. The factorial validity of the CISS has
been reported and the high internal consistency of the
2.3. Self-administered instruments inventory (Cronbachs alpha > 0.8) in several professional
groups indicates the reliability of the instrument.
Three widely used and commercially available, reliable
and validated psychometric instruments considered to be 2.3.5. Stress in nursing students (SINS) (Deary et al.,
gold standards in this field were used to gather data in the 2003)
present study to measure personality, psychological morbid- This 43-item instrument assesses stress related to the
ity and burnout, respectively. student nurse experience under the following dimensions:
clinical work, confidence, education and finance. The SINS
2.3.1. NEO Five Factor Inventory (NEOFFI) (Costa has a robust factor structure related to the above four
and McRae, 1992) dimensions. This instrument, which is content valid, has
This assesses five personality traits: neuroticism (a only been reported once previously and the internal con-
greater tendency towards feelings of worry), extraversion sistency of the dimension of stress are reported in this paper
(a tendency towards sociability), openness (being open to under Section 3.
new experiences) and agreeableness (a tendency to be
pleasant), and conscientiousness (being careful and reli- 2.4. Procedure
able). Each trait is assessed by 12 questions. The content
validity of the NEOFFI has been extensively tested and the Instruments were administered and data collected as
internal consistency, measured using Cronbachs alpha, of follows:
the five dimensions are: neuroticism = 0.86; extraver-
sion = 0.77; openness = 0.73; agreeableness = 0.68; con-  Wave 1: NEOFFI, CISS, GHQ12, MBI, SINS
scientiousness = 0.81.  Wave 2: GHQ12, MBI, SINS

2.3.2. General Health Questionnnaire-12 (GHQ12) The number of questionnaires the students had to com-
(Goldberg and Williams, 1988) plete at any wave was minimized by avoiding repetition of
The total score of this 12-item instrument was used to the NEOFFI and CISS, and the above strategy also reflects
measure psychological morbidity (minor, non-psychotic, that personality and coping strategies are more trait-like, and
psychiatric disorder). The scoring system used the 04 that individual differences were unlikely to change over the
Likert scoring system giving a possible range of GHQ12 time of the study. To measure the impact of the programme
scores from 0 to 36. The validity of the original GHQ30, on more state-like factors such as psychological morbidity,
from which the GHQ12 is derived, is well established and burnout and stress, these were measured at waves 1 and 2.
the internal consistency of the GHQ12, using Cronbachs
alpha, is 0.85. 2.5. Analysis

2.3.3. Maslach Burnout Inventory (MBI) (Maslach and Data were entered into an SPSS for Windows 14.0
Jackson, 1986) database (http://www.spss.com/uk/; accessed 17 August
This 22-item instrument measures the following aspects 2007) for analysis including: t-testing, Pearsons correlation
of professional burnout: emotional exhaustion (feeling and partial correlation, stepwise multiple regression and
unable to carry on), depersonalisation (treating people as Cronbachs alpha. The response rates for each of the ques-
objects) and personal accomplishment (gaining satisfaction tionnaires was different as not all students at the second

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1538 R. Watson et al. / International Journal of Nursing Studies 45 (2008) 15341542

wave answered every question on every questionnaire, there- depersonalisation dimensions of the MBI, and with the
fore, analysis was carried out using list wise deletion. GHQ12. Extraversion correlates negatively with SINS-E,
MBI emotional exhaustion and GHQ12. When neuroticism
is controlled for, the associations between extraversion and
3. Results personal accomplishment and GHQ12 are much reduced
and, in the case of GHQ12, non-significant. Conscientious-
3.1. Participation and sample characteristics ness shows a similar pattern of correlations to neuroticism,
though they are in the negative direction and often smaller,
At wave 1, 158 students participated as described earlier and it also correlates positively with the personal accom-
and 147 participated at wave 2 representing response rates of plishment dimension of the MBI. When neuroticism is
100% and a maximum of 93% (not all questions were controlled for, the associations between conscientiousness
answered), respectively. and all SINS dimensions MBI-EE, MBI-DP and GHQ12
are much reduced and the majority non-significant. On the
3.2. Relationship between personality and coping other hand, after controlling for neuroticism, the correla-
strategies tion between conscientiousness and MBI-PA increases.
The openness dimension of NEOFFI correlates negatively
The principal associations between dimensions of the with the depersonalisation and personal accomplishment
NEOFFI and CISS at wave 1 were as follows: positive dimensions of the MBI and the correlations between the
correlations between neuroticism and emotion-oriented cop- remaining dimensions of NEOFFI (i.e. controlling for
ing (r = .59; p < .01); conscientiousness (r = .37; p < .01), neuroticism) and GHQ12 are not significant, supporting
extraversion (r = .31; p < .01) and openness (r = .25; the view that neuroticism explains most of the variance in
p < .01) and task-oriented coping; and extraversion and GHQ12.
social diversion-oriented coping (r = .29; p < .01). Because Higher scores in the emotion-oriented coping dimension
there were significant negative correlations between neuro- of CISS are correlated with higher scores in all dimensions
ticism and extraversion and conscientiousness, the correla- of SINS and MBI (except personal accomplishment) and
tions were re-run, controlling for neuroticism but the with the GHQ12. Task-oriented coping correlates signifi-
subsequent size and directions of the correlation between cantly and positively with MBI Personal accomplishment.
dimensions of the NEOFFI and CISS were very similar.

3.3. Relationship between personality and coping 4. SINS

strategies with stress, burnout and psychological
morbidity: contemporaneous The internal consistency using Cronbachs alpha of
SINS, which has only been reported previously once (Deary
Correlations between dimensions of the NEOFFI and et al., 2003), was examined in this study. The internal
the CISS and SINS, MBI and GHQ12 are shown in Table 1. consistency of all dimensions was acceptable (Cronbachs
Higher neuroticism is correlated with higher scores in all alpha > 0.7), with even the lowest value, for the financial
dimensions of SINS, with the emotional exhaustion and dimension of SINS at wave 2, at an acceptable 0.67.

Table 1
Correlations between wave 1 personality traits and coping styles with wave 1 dimensions of stress and burnout and general health
SINS Clin SINS Conf SINS E SINS F MBI EE MBI DP MBI PA GHQ
NEO-FFI N .33 ** .30 ** .44**,y .24 ** .52** .28** .12 .60 **
NEO-FFI E .12 .15 .23 ** .08 .32** .19** .28 ** .25**,y
NEO-FFI O .09 .10 .09 .01 .13 .23** .19y,* .08
NEO-FFI A .11 .22**,y .00 .18 * .15 .17*,y .06 .09
NEO-FFI C .23 ** .26 ** .30 ** .25**,y .21**,y .21**,y .18 * .24**,y
CISS T .10 .07 .18 * .01 .05 .07 .40 ** .03
CISS E .18 ** .21 ** .28 ** .23 ** .42** .41** .09 .45 **
CISS A .08 .11 .03 .19 .07 .00 .05 .17 *
CISS D .01 .16 * .04 .21 ** .01 .03 .02 .15
CISS S .16 .05 .04 .21 ** .08 .03 .07 .01
*
p < .05.
**
p < .01.
y
Indicates correlations that become non-significant when neuroticism is controlled for; see text and Table 2 for abbreviations; MBI EE:
emotional exhaustion; MBI DP: depersonalisation; MBI PA: personal accomplishment; SINS Clin: SINS clinical; SINS Conf: SINS confidence;
SINS E: SINS education; SINS F: SINS finance; 139  n  146.

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 R. Watson et al. / International Journal of Nursing Studies 45 (2008) 15341542 1539

4.1. Stability of instruments used at both waves 1 and 2 p < .01). At wave 1 the emotional exhaustion dimension of
the MBI has positive and mostly significant associations
The stability of GHQ12, SINS and MBI are shown in with all dimensions of the SINS (.10  r  .31), all of which
Table 2. All instruments show significant stability of indi- are significant and larger in effect size at wave 2
vidual differences based on the correlation of the measures (.33  r  .50). The depersonalisation dimension of the
across time. Absolute stability examined whether mean MBI shows positive and mostly significant correlations with
scores change across time. GHQ12 score increased. SINS all dimensions of the SINS at wave 2 (.16  r  .33), though
education and MBI emotional exhaustion and depersonali- there are no significant associations at wave 1. MBI personal
sation increased between wave 1 and wave 2; SINS clinical accomplishment shows little association with SINS dimen-
and MBI personal accomplishment both decreased between sions at either waves 1 or 2. Examining correlations across
waves 1 and 2. time waves does not add anything to the contemporaneous
correlations.
4.2. Relationship between personality and coping styles
with stress, burnout and psychological morbidity: across 4.4. Determinants, across time, of psychological
time morbidity and burnout

Correlations between dimensions of the NEOFFI and GHQ12, emotional exhaustion, depersonalisation and
CISS at wave 1 with SINS, MBI and GHQ12 at wave 2 were personal accomplishment were entered as dependent vari-
studied. Higher neuroticism at wave 1 is correlated signifi- ables into a series of stepwise multiple linear regression
cantly and positively with all SINS dimensions (.29  analyses using GHQ12 and all dimensions of NEOFFI,
r  .47; p < .01), MBI emotional exhaustion (r = .52; CISS, SINS and MBI at wave 1. The clinical, confidence,
p < .01) and depersonalisation (r = .19; p < .01) and educational and financial dimensions of SINS at wave 2
GHQ12 at wave 2 (r = .47; p < .01). There is a negative were entered as dependent variables into a series of stepwise
correlation between neuroticism at wave 1 and MBI personal multiple linear regression analyses using all dimensions of
accomplishment at wave 2 (r = .32; p < .01). CISS emo- NEOFFI and CISS at wave 1. Table 3 shows that neuroticism
tion-oriented coping shows a very similar pattern and size of is retained in the regression equation for wave 2 GHQ12,
correlations to neuroticism. The other notable across-wave emotional exhaustion and personal accomplishment and, in
associations are the positive associations between wave 1 each case, is the most important predictor variable. Neuroti-
conscientiousness (r = .23; p < .01) and task-oriented coop- cism is positively associated with GHQ12 and emotional
ing (r = .23; p < .01) with wave 2 personal accomplishment. exhaustion and negatively associated with personal accom-
plishment. Emotion-oriented coping and personal accom-
4.3. Relationship between stress and burnout plishment (at wave 1) are also retained in the regression
equations for emotional exhaustion and personal accom-
Correlations of the dimensions within the SINS and the plishment, respectively, and are positively associated with
dimensions within the MBI and between these two instru- both. For depersonalisation, the most important independent
ments dimensions at waves 1 and 2 were studied as were variable is emotion-oriented coping (positive association)
correlations of the SINS and MBI with the GHQ. At both which is retained in the regression equation with agreeable-
waves all dimensions of SINS correlate positively. The ness (negative association). The respective dimensions of
personal accomplishment dimension of the MBI does not SINS at wave 1 are retained in the regression equations for
correlate significantly with the emotional exhaustion and all dimensions of SINS at wave 2, and emotion-oriented
depersonalisation dimensions but these both correlate coping at wave 1 is retained for all dimensions of SINS at
strongly at wave 1 (r = .65; p < .01) and wave 2 (r = .58; wave 2. All of these relationships are positive. Task-oriented

Table 2
Mean (S.D.) and stability data for psychological morbidity, dimensions of stress and burnout in nursing students at wave 1 and wave 2
Wave 1 Wave 2 p-Value for wave 2wave 1 a Stability coefficientb n
GHQ total score 11.7 (3.9) 13.1 (5.3) .01 .41 99
SINS clinical 3.0 (5.3) 27.7 (4.8) <.001 .33 98
SINS confidence 27.9 (5.3) 27.9 (5.3) .214 .32 99
SINS education 28.0 (5.0) 29.4 (4.5) .001 .65 101
SINS finances 13.1 (3.6) 13.8 (4.4) .102 .39 103
MBI emotional exhaustion 22.6 (7.7) 24.5 (9.2) .045 .40 100
MBI depersonalisation 10.4 (4.3) 11.5 (4.1) .027 .26 101
MBI personal accomplishment 29.1 (6.2) 27.0 (6.1) .004 .32 100
a
All comparisons were based on t-tests.
b
All stability coefficient were significant at p  .01; see text and Table 1 for abbreviations.

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Table 3
Stepwise multiple regression
Dependent variable Independent variable(s) Adjusted R 2 Standardised b p
GHQ Neuroticism .261 .520 <.001
Emotional exhaustion Neuroticism .319 .443 <.001
Emotion-oriented coping .344 .224 .049
Depersonalisation Emotion-oriented coping .086 .269 .014
Agreeableness .127 .230 .035
Personal accomplishment Neuroticism .075 .273 .012
Personal accomplishment .110 .217 .045
Clinical stress Emotion-oriented coping .178 .372 <.001
Clinical .236 .266 <.001
Confidence stress Emotion-oriented coping .165 .393 <.001
Confidence .235 .266 <.001
Task-oriented coping .272 .214 <.001
Educational stress Educational .433 .570 <.001
Emotion-oriented coping .508 .290 <.001
Financial stress Emotion-oriented coping .162 .321 <.001
Financial .231 .293 <.001

coping is retained on the regression equation for stress the first year of study. In terms of the theoretical foundation
related to confidence and is negatively associated with it. for the study, the transactional model of stress and burnout is
clearly supported (Lazarus, 1966). Specific aspects of this
will be examined below.
5. Discussion
5.1. Personality
Broadly, in the cross-sectional data, there are two com-
plexes of associations that encompass personality traits, The importance of the personality trait neuroticism is
coping strategies and stress and burnout. The first includes demonstrated by its strong contemporaneous correlation
the personality trait of neuroticism, emotion-oriented cop- with emotion-oriented coping, emotional exhaustion and
ing, all self-reported stress scales and the emotional exhaus- psychological morbidity. Across time, in the present study,
tion and depersonalisation aspects of burnout. The second neuroticism was correlated with all the dimensions of stress
includes the personality trait of conscientiousness, task- measured by SINS, with the negative aspects of burnout and
oriented coping, and the personal accomplishment aspect with psychological morbidity. When the predictive ability of
of (non-) burnout. There are additional findings in the neuroticism was modelled across time in the presence of
longitudinal data. These closely agree with the complexes other possible predictors it remained a strong predictor of
of association among similar variables tested in consultant psychological morbidity and emotion-oriented coping. In
doctors (Deary et al., 1996) and nurses (Zellars et al., 2000). addition, wave 1 conscientiousness was strongly correlated
Stress, burnout and psychological morbidity increase over with wave 1 task-oriented coping and both of these were
time in these nursing students. Higher trait neuroticism and positively correlated with personal accomplishment at wave
emotion-oriented coping are strong, and correlated, predic- 2. Modelling across time demonstrated that higher personal
tors of psychological morbidity, emotional exhaustion; accomplishment at wave 2 was predicted by lower neuroti-
lower neuroticism predicts higher personal accomplishment. cism. Higher neuroticism remained the sole predictor of
Stress in nursing students is strongly predicted by emotion- psychological morbidity across time. In terms of the existing
oriented coping. literature, this builds upon and confirms the study of Deary
This study was designed, prospectively, to investigate the et al. (2003), except that this is in a distinctly different
determinants of, and relationships among, personality, population, and extends the work of Zellars et al. (2000) by
stress, coping and burnout in nursing students in Hong adding repeated measures.
Kong. The results show that some important relationships
exist and that pre-existing dimensions of personality, coping 5.2. Coping strategies, stress and burnout
strategies and psychological morbidity indeed determine
subsequent psychological dimension when standard mea- Dimensions of stress become more strongly correlated
surements are made at entry to the programme and later in with emotional exhaustion across time whereby three dimen-

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 R. Watson et al. / International Journal of Nursing Studies 45 (2008) 15341542 1541

sions become correlated with depersonalisation and this is in timeframe of the present study and, in the absence of dropout
line with the study of Wu et al. (2007); however, the present from the programme, it could be hypothesised that they
study has the advantage of repeated measures. Higher could continue to increase and that they could become severe
emotion-oriented coping at wave 1 is correlated with higher and clinically relevant over a longer timeframe.
dimension of stress and negative aspects of burnout and the The main determinant of psychological morbidity was
negative effect of emotion-oriented coping is demonstrated neuroticism suggesting that administration of the NEOFFI
by predictive ability for all aspects of stress and the negative prior to students embarking on a nursing programme could
dimensions of burnout. An association between coping be of value. This is likely to be controversial; it is not
strategies, measured using the CISS, and burnout with suggested that this is used to screen potential students
emotion-oriented coping leading to greater burnout, has but, rather, to tailor support packages for individual students
previously been observed in nurses (Jaracz et al., 2005). or to aid student advisors and counselors to understand and
Emotion-oriented coping is strongly associated with psy- guide the students who seek their help. Understanding what
chological morbidity at wave 1 but does not appear to have makes a person tick could be the first step to helping them.
predictive value, possibly due to its strong association with
neuroticism. That depersonalisation is predicted by lower 5.5. Limitations
agreeableness and more emotion-oriented coping makes
sense as these people are more likely to treat patients as Limitations of the present study include the fact that only
objects than as individuals. one cohort of students from one university was included in
the study and this may not be representative of all nursing
5.3. Attrition students in Hong Kong. The time between waves of the study
was limited by the availability of the students in the class-
While some students were lost from the study, none were room for the distribution of questionnaires and a longer time
lost from the programme and this is a characteristic of between waves incorporating a period of intense clinical
nursing students in Hong Kong and, especially, at the practice between academic years, may have provided further
institution where the study was conducted, though it is insight into the relationships amongst the variables studied.
not specific to nursing or to this institutionthe average Clearly, further time waves would be desirable. An addi-
attrition rate is around 5%. This raises a question about the tional limitation is that baseline data on levels of psycho-
relationship between stress and attrition from nursing pro- logical morbidity, psychological support or psychotropic
grammes and, specifically, the relationship between stress medication were not measured. Future studies could include
and remaining on the programme in Hong Kong. It is very these variables and take account of these baseline measures.
hard to know why nursing students leave nursing pro-
grammes and a previous study (Deary et al., 2003) was 5.6. Conclusions and recommendations
only able to demonstrate a weak predictive ability of per-
sonality for likelihood of leaving. However, while students This study has met its aim of understanding some of the
who experience stress are often the most conscientious relationships between a range of psychological variables and
(Deary et al., 2003) and, as a result of this dimension of also in how these may be predictors of these variables in
personality, likely to remain on a programme, it is logical to nursing students in Hong Kong. The low attrition of nursing
assume that stress will contribute, to some extent, to attri- students in Hong Kong is something that the schools of
tion; but this remains to be demonstrated (Jones and John- nursing and those who fund their study should be proud of
son, 2000). However, where attrition is low as a result of but it could also be a statistic that hides a multitude of
anathematising leaving a programme, it could be argued that psychological sins requiring closer attention. There is little
the effects of stress could be severe and adverse in terms of point in educating a person within a healthcare system,
achievement over a longer period. This study demonstrated ultimately, to work in that system if they enter it as a
increased levels of stress within the timeframe of the study. casualty.
Nevertheless, it could be hypothesised that high mental The main predictors of stress, burnout and psychological
ability, where this should help individuals to obviate the morbidity appear to be the personality trait neuroticism and
stress of academic and clinical assessments, could be an the strategy of emotion-oriented coping with stress. These
effective protective factor against stress, regardless of cop- data are useful as they stand but the present work raises many
ing mechanisms. questions which could be answered by re-visiting the ori-
ginal research questions and incorporating them into a
5.4. Psychological morbidity longer study, along with the questions raised by this study,
following nursing students from entry to a programme to its
Psychological morbidity and its relationship to other conclusion and, possibly, into clinical practice.
psychological dimension measured in this study has already On the other hand, the story regarding these students is
been discussed. However, in relation to the discussion of not all negative. It is clear that conscientious students are
stress above, it should be noted that these increased in the more likely to use task-oriented coping with stress and these

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1542 R. Watson et al. / International Journal of Nursing Studies 45 (2008) 15341542

students are the one most likely to feel personal accomplish- Furnham, A., 2005. The Psychology of Behaviour at Work. Psy-
ment on the nursing programme. chology Press, Hove.
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need to conduct a more representative study of nursing Health Questionnaire. HFER-Nelson, Windsor.
Graham, A.C., 1991. Studies in Chinese Philosophy and Philoso-
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phical Literature. State University of New York Press, Albany,
ing students through to completion of their programme and New York.
into practice as staff nurses. The study has shown that Hogston, R., 1995. Nurses perceptions of the impact of continuing
personality and coping factors are related to adverse psy- professional education (CPE) on the quality of nursing care. J.
chological outcomes and this should alert university staff to Adv. Nurs. 22, 586593.
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This study was funded by the British Academy. student nurses: a review of the applied stress management
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