A Literature Review On Stress and Coping Strategies in Nursing Students
A Literature Review On Stress and Coping Strategies in Nursing Students
A Literature Review On Stress and Coping Strategies in Nursing Students
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To cite this article: Leodoro J. Labrague, Denise M. McEnroe-Petitte, Donna Gloe, Loretta
Thomas, Ioanna V. Papathanasiou & Konstantinos Tsaras (2016): A literature review on stress
and coping strategies in nursing students, Journal of Mental Health
REVIEW ARTICLE
Abstract Keywords
Background: While stress is gaining attention as an important subject of research in nursing stress, coping strategy, nursing students and
literature, coping strategies, as an important construct, has never been comprehensively clinical practice
reviewed.
Aim: The aims of this review were: (1) to identify the level of stress, its sources, and (2) to History
explore coping methods used by student nurses during nursing education.
Methods: This is a systematic review of studies conducted from 2000 to 2015 on stress and Received 24 July 2016
coping strategies in nursing students. CINAHL, MEDLINE, PsycINFO and PubMed were the Accepted 16 September 2016
primary databases for the search of literature. Keywords including ‘‘stress’’, ‘‘coping strategy’’, Published online 8 December 2016
‘‘nursing students’’ and ‘‘clinical practice’’ in 13 studies met the criteria.
Findings: Stress levels in nursing students range from moderate to high. Main stressors
identified included stress through the caring of patients, assignments and workloads, and
negative interactions with staff and faculty. Common coping strategies utilized by nursing
students included problem-solving strategies such as developing objectives to resolve
problems, adopting various strategies to solve problems, and finding the meaning of stressful
events.
Conclusion: Nurse educators may consider the use of formulation and implementation of
empirically tested interventions to reduce stress while enhancing coping skills.
history (Sheu et al., 2002), unfamiliar patients’ diagnoses and students and their coping mechanisms. A two-part analysis is
treatments (Sheu et al., 2002), fear of making mistakes (Kim, presented. Stress levels and its sources were the main focus of
2003; Pulido-Martos et al., 2012), giving medication to the first analysis. Identifying nursing students coping mech-
children (Oermann & Lukomski, 2001) and lack of control in anisms were the emphasis of the second analysis.
relationships with patients (Gorostidi et al., 2007).
Other reported stressors include: peers, daily life and the Search strategy
environment (Shaban et al., 2012), nursing staff and nurse CINAHL, MEDLINE, PsycINFO and PubMed were the
educators (Khater et al., 2014) finding of new friends, primary databases for the search of the literature as they
learning of new responsibilities (Seyedfatemi et al., 2007), contained vast numbers of journals including nursing research
being placed in unfamiliar situations, working with people journals. Keywords include ‘‘stress’’, ‘‘coping strategy’’,
they do not know, financial strain (Tully, 2004), relationships ‘‘nursing students’’ and ‘‘clinical practice’’ in various
with friends, tutors and companions (Gorostidi et al., 2007), combinations. To ensure rigorous and comprehensive search
negative interactions with instructor’s (Timmins & Kaliszer, of the literature, a manual search of nursing research journals
2002), being observed by instructors, being late (Kim, 2003) was conducted. In order to ensure the quality of the findings, a
and poor relationships with clinical staff (Nolan & Ryan, systematic method of appraising the article was utilized. The
2008). quality of the findings was evaluated using the Critical
Coping mechanisms are a necessity when dealing with Appraisal Checklist of the Center for Evidence-Based
stress and accompanying stressors. Lazarus & Folkman Management (2014) to select the articles that would be
(1987) classified coping ways as problem-based and emo- reviewed. The following flow diagram (see Figure 1) shows
tion-based. Several studies highlighted problem-solving the process used to identify articles for the systematic review.
approach as the most common coping behaviors in nursing
students while the avoidance approach as the least utilized Inclusion and exclusion criteria
coping behaviors in nursing students (Al-Zayyat & Al-Gamal,
2014a,b,c; Labrague, 2014; Shaban et al., 2012; Sheu et al., This review of the literature included articles based on the
2002). Problem-based coping ways are known to be beneficial following criteria: (1) studies published from 2000 to 2015,
to students’ learning, clinical performance and well-being, (2) studies including only nursing students, (3) studies in the
while emotion based coping ways were found to be harmful to English language and published in scientific journals, (4)
their health (Chang et al., 2007; Tully, 2004). studies that explored stress and its sources along with coping
Stress is considered beneficial in minimal amounts as it strategies and (5) studies with quantitative design. Finally, 32
increases excitement and motivation (Gibbons, 2010). studies were identified, of which, 13 met the set criteria.
However, unmanaged stress or failure to cope with chronic
stress may be harmful to the health and well-being of an Results
individual (Watson et al., 2008). Chronic stress may affect the
Setting
learning, decision-making, thinking and eventually the aca-
demic performance of the nursing student (Sheu et al., 2002). Thirteen studies were included in the review (Table 1).
Stress may even be a reason why they choose to leave the Five studies reviewed were from Asia: Hong Kong (Chan
nursing program (Watson et al., 2008). Unmanaged stress may et al., 2009), China (Zhao et al., 2014), Japan (Yamashita
also cause the nursing student to experience negative et al., 2012), Taiwan (Chen & Hung, 2013) and India (Shukla
emotional states such as sadness, apprehension, anxiety, et al., 2013). Three studies were from the Middle East
worry, anger, lack of self-esteem, guilt, grief, nervous (Al-Zayyat & Al-Gamal, 2014c; Seyedfatemi et al., 2007;
breakdown, depression, feeling of loneliness, listlessness or Shaban et al.,2012), two from the United States (Reeve et al.,
sleeplessness (Labrague, 2014). 2013; Wolf et al., 2015) and others were from various other
To date, only two papers exist which summarize sources of parts of the world (Bam et al., 2015; Evans & Kelly, 2004; Lo,
stress in nursing students (Al-Zayyat & Al-Gamal, 2014b; 2002).
Pulido-Martos et al., 2012). Both papers critically evaluated
existing studies on nursing students’ levels of stress. Coping Design and sample size
strategies, as an important construct, has never been reviewed, A majority of the studies reviewed were descriptive, cross-
thus this study is the pioneer and contribute significantly to sectional studies (Al-Zayyat & Al-Gamal, 2014c; Bam et al.,
the existing knowledge on stress and coping among nursing 2015; Chan et al., 2009; Chen & Hung, 2013; Evans & Kelly,
students. 2004; Seyedfatemi et al., 2007; Shaban et al., 2012; Shukla
et al., 2013; Yamashita et al., 2012; Zhao et al., 2014) with
Aim
sample sizes that ranged from 52 to 1370 nursing students.
The aims of this review were: (1) to identify the level of One study used a longitudinal design (Lo, 2002) and two
stress, its sources, and (2) to explore coping methods used by studies utilized a mixed method research design (Reeve et al.,
student nurses during nursing education. 2013; Wolf et al., 2015).
Methods Instrument
The narrative conceptual synthesis method was used to review Most of the studies utilized the Perceived Stress Scale (PSS)
quantitative studies reporting sources of stress in nursing developed by Sheu et al. (1997), to measure stress and
DOI: 10.1080/09638237.2016.1244721 Stress and coping in nursing students 3
Figure 1. Flow diagram of the process used to CINAHL, MEDLINE, PsycINFO and
identify references for the systematic review. PubMed 331 titles
Abstract Screening
154 papers
32 articles
identify specific stressors in nursing students. Other instru- and sources of stress and explored coping strategies of the
ments used to measure stress included the Student Stress nursing students. Utilizing the SNSI, item analysis revealed
Survey (SSS) (Seyedfatemi et al., 2007), General Health the majority of nursing students or 87% perceived fear of
Questionnaire (GHQ) (Lo, 2002; Yamashita et al., 2012), examinations as extremely stressful. Evans & Kelly (2004)
Student Nurse Stress Index (SNSI), Student Life Stress conducted a study to explore the stress experience and coping
Inventory (Reeve et al., 2013) and Perceived Stress skills in Diploma nursing students in Ireland. A self-reported
Questionnaire (PSQ) (Wolf et al., 2015). One study utilized instrument was used to measure stress and coping abilities.
a questionnaire developed by Lindop (1999) which consisted Analysis of the mean scores revealed that the highest ranked
of six sections: clinical stress, academic stress, emotional stressors were taking examinations and high workloads with
response to stress, coping and personal factors. mean scores of 4.60 and 4.40, respectively.
Coping strategies were measured primarily using the Three studies reported taking care of patients as the main
Coping Behavior Inventory (CBI) (Sheu et al., 2002) with source of stress in students (Al-Zayyat & Al-Gamal, 2014c;
the remaining studies utilizing the Adolescent Coping orien- Chen & Hung, 2013). Chen & Hung (2013) reported a cross-
tation for Problem Experiences (ACOPE) (Seyedfatemi et al., sectional study with 101 nursing students enrolled in a
2007), Brief Coping Orientations to Problems Experienced nursing program in Taiwan. The PSS, a standardized scale
(COPE) (Bam et al., 2015; Yamashita et al., 2012), Ways of developed by Sheu et al. (2002) was used to collect
Coping Instrument (Lazarus & Folkman, 1987), Modified information on stress and its sources. This study’s findings
Ways of Coping Scale (Carver, 1997) and the Deakin Coping showed that the most common stressors encountered by
Scale (Moore, 2003). students were caring for patients followed by assignments and
Some of the studies utilized stress and coping scales in workloads, instructors and staff. Recently, Al-Zayyat & Al-
combination with other scales to measure self-efficacy (Zhao Gamal (2014a,b,c) conducted a longitudinal study to measure
et al., 2014), responses to stress (Chen & Hung, 2013), self- the degrees of stress, sources of stress and coping methods in
esteem (Lo, 2002; Wolf et al., 2015) and perceived social Jordanian students. Analyzing the subscales of the PSS,
support (Reeve et al., 2013; Wolf et al., 2015). findings revealed the highest means obtained were from the
caring for patients’ subscale. The author explained this may
Stress be due to the fact that students in the study were training in
the Mental Health Nursing Course which focuses on funda-
Of the 13 studies, six reviewed reported levels of stress in mental mental health nursing and therapeutic communication
student nurses. High levels of stress were reported in one techniques. However, during their practicum, nursing students
study (Shukla et al., 2013) and moderate levels of stress in encountered other patients requiring complex nursing care,
five studies (Al-Zayyat & Al-Gamal, 2014c; Bam et al., 2015; which caused them to feel stressed.
Chan et al., 2009; Shaban et al., 2012; Zhao et al., 2014). Two studies reviewed reported stress from assignments
All of the studies reviewed identified sources of stress, of and workloads (Shaban et al., 2012; Zhao et al., 2014). In a
which, three studies reported taking examinations as the main study by Zhao et al. (2014) among 231 nursing students in
source. Yamashita et al. (2012), used the GHQ with the most China, workloads and assignments were reported as the main
frequently reported stressors were examinations, followed by sources of stress followed by stress from peers and daily life.
relations with friends, clinical practice and reports. In a cross- In a cross-sectional study conducted in Jordan, baccalaureate
sectional study in India, Shukla et al. (2013) assessed the level nursing students reported stressors mainly from assignments
4
(continued )
Type of clinical Type of coping
Author (s) Country Research question/aim Sample Research design Instrument/tool stressors Level of stress strategies
6. Shaban et al. Jordan To identify the level and 181 Descriptive Perceived Stress Scale Assignment, clinical Moderate Problem solving, stay-
(2012) types of stress per- cross-sec- (PSS) (Sheu et al., 1997) environment, ing optimistic and
ceived by baccalaur- tional design Cronbach’s alpha coeffi- staff nurses and transference
eate nursing students cient was 0.87 teachers
in Jordan in their Coping Behaviour
initial period of clin- Inventory (CBI) (Sheu
icalpractice and to et al., 2002).
identify the coping Cronbach’s alpha coeffi-
DOI: 10.1080/09638237.2016.1244721
(continued )
5
Table 1. Continued
Author (s) Country Research question/aim Sample Research design Instrument/tool stressors Level of stress strategies
10. Lo (2002) Australia To investigate the per- 333 Descriptive ana- General Health Academic studies, Level of stress Problem-focused coping
ception and sources First three years lyses Questionnaire financial, family, not measured (problem solving,
of stress,coping of study Longitudinal (GHQ) (Goldberg & Hillier, health in this study recreation and sport,
mechanisms used, Study 1979) social support) emo-
and self-esteem in Reliability and validity stu- tion-focused coping
nursing students dies with a range of (tension reduction
during 3 years of populations strategies)
their undergraduate are described by Goldberg
L. J. Labrague et al.
and the clinical environment (Shaban et al., 2012). Two nursing students was transference such as performing exer-
studies reported inadequate interactions with the staff and cises, watching movies, taking a shower and sleeping. Authors
faculty as well as a lack of clinical competence (Reeve et al., argued that nursing students in the study may not have learned
2013; Wolf et al., 2015). the different types of coping strategies aside from the fact that
One study reported academic studies, financial, family and this type of coping is easier and more convenient. Yamashita
health as the main sources of stress (Lo, 2002). In the study by et al. (2012) found nursing students, when faced by stress,
Bam et al. (2015), nursing students reported being stressed engaged in the coping strategies such as sleeping, eating and
when the clinical instruction varied from the class instruction. talking to someone. Other remaining studies reported a
Peer pressure, being disregarded and ignored by on-duty staff mixture of coping approaches such as praying, talking to
created an unhealthy work setting for the nursing students. A relatives and friends, ignoring their stress, crying and
lack of professional knowledge and skills was reported as the separating themselves from others (Bam et al., 2015; Evans
main source of stress in one study (Chan et al., 2009). & Kelly, 2004; Reeve et al., 2013; Seyedfatemi et al., 2007).
Determinants of stress were additionally reported in some Few determinants of coping were reported in the studies
of the studies. For instance, in a study by Shaban et al. (2012), reviewed. For example, nursing students in their senior level
female nursing students experienced higher levels of stress as (Chan et al., 2009) and those with a high level of self-efficacy
compared to their male counterparts. Shukla et al. (2013) and (Zhao et al., 2014) tended to use a problem-solving approach.
Shaban et al. (2012) revealed that some nursing students with Use of an avoidance method of coping was common in
no interest in nursing experienced high degrees of stress. In nursing students who experienced stress from their teachers
another study, older nursing students and those who had been and staff nurses (Chan et al., 2009). In one study, high levels
in the nursing program for a period of time, tended to have a of self-efficacy in nursing students influenced their frequency
lower level of stress (Bam et al., 2015). In a study by Wolf in using coping strategies (Zhao et al., 2014).
et al. (2015), a history of depression, year in the program,
self-esteem and social support predicted stress in students. Discussion
Four studies examined the association between stress and This review identified the levels of stress, its sources, and
other psychological constructs, aside from coping. For explored coping strategies used by student nurses when faced
example, Zhao et al. (2014) examined the moderating effects by stress during the nursing education process. It is very
of self-efficacy on stress levels and coping mechanisms in a evident in the review that majority of the studies were cross-
group of nursing students who were practicing in three sectional in nature (Al-Zayyat & Al-Gamal, 2014c; Bam
hospitals in China. Student self-efficacy moderated the effects et al., 2015; Chan et al., 2009; Chen & Hung, 2013; Evans &
of stress on coping strategies. Chen & Hung (2013) and Evans Kelly, 2004; Seyedfatemi et al., 2007; Shaban et al., 2012;
& Kelly (2004) examined nursing students’ responses to stress Shukla et al., 2013; Yamashita et al., 2012; Zhao et al., 2014)
such as emotional responses (e.g. feeling exhausted and under with only one study using the longitudinal design (Lo, 2002)
pressure) and physical symptoms (e.g. gastrointestinal upset). and two studies utilized a mixed method research design
In Reeve et al.’s study (2013), students reported feelings that (Reeve et al., 2013; Wolf et al., 2015). This may be because
they experienced during a stressful event such as fear, anxiety, this design is more convenient and easy to complete when
worry, anger, guilt, grief or depression. In one study, self- compared to other types of research designs. However, this
esteem was measured where it correlated significantly with might have some effects on the responses of the nursing
stress and coping behaviors (Lo, 2002). students considering the nature of stress. According to
Lazarus & Folkman (1987), stress levels change across time
Coping
and since they were asked to recall their previous clinical
This review identified coping strategies employed by nursing experiences, they may not be able to recall some of these
students during stressful events. Six studies reported problem- stressful experiences. The use of a longitudinal study may be
solving strategies as an approach in dealing with stress (Al- necessary to detect changes in the levels for stress and coping
Zayyat & Al-Gamal, 2014c; Lo, 2002; Shaban et al., 2012; abilities across school years.
Shukla et al., 2013; Wolf et al., 2015). For example, Jordanian It is also worth noting that all studies but one (Yamashita
nursing students who were attending clinical practice in a et al., 2012) evaluated utilized samples from one site only,
mental health setting utilized problem-solving as the main thus limiting generalizability of findings. Inclusion of other
approach in coping with stress (Al-Zayyat & Al-Gamal, students from other sites may provide a more generalizable
2014c). Previous clinical experiences of nursing students result. Therefore, future studies should be conducted utilizing
were seen by the authors as the main reason why nursing representative samples from other sites. In addition, all
students utilized this coping approach. A cross-sectional study studies reviewed, power analysis was not performed to
was conducted by Chen & Hung (2013) in 101 junior nursing determine sample size. Validity of the conclusions therefore
students in Taiwan. Students revealed they engaged in positive is in question. This suggests future research should include
coping strategies through the use of a problem-solving power calculation or sample size calculation to ensure the
approach. validity of the research findings.
Three studies reported the transference approach as the Comparing findings among studies reviewed was a chal-
main strategy in dealing with stress (Chan et al., 2009; lenge in the review considering the variety of tools used to
Yamashita et al., 2012; Zhao et al., 2014). Chan et al. (2009) measure stress and coping in nursing students. Most of the
reported that the most frequently utilized coping strategy in studies examined used tools which vary in the number of
8 L. J. Labrague et al. J Ment Health, Early Online: 1–10
items, content and even in the structure. This may hinder necessary in order to moderate the effects of stress (Zhao
researchers in comparing and contrasting research studies. et al., 2014).
Nevertheless, evidence from the studies reviewed suggested
that nursing students experience moderate levels of stress Implications for nursing
during nursing education. This finding is in keeping with the This review is the first to critically review and discuss stress
results obtained by previous authors (Hamaideh et al., 2016; and coping among nursing students during nursing education.
Jimenez et al., 2010; Labrague, 2014). Although stress in Stress during nursing education has deleterious effects on the
minimal amounts can be beneficial, stress beyond a tolerant nursing workforce as this may contribute to a shortage of
level may have profound effects on the individual. Further, nurses entering into the nursing profession. With that being
most studies suggested that nursing students encountered said, nursing faculty are in a prime position in which to assist
multiple stressors such as caring for patients, assignments and nursing students in dealing with their stress and stressors (Al-
workloads, negative interactions with staff and faculty, lack of Zayyat & Al-Gamal, 2014a,b,c; Labrague, 2014; Yamashita
clinical competence, and taking of examinations. et al., 2012; Zhao et al., 2014). Findings of this review may
Several interventions were mentioned to address stress in provide direction in nursing education as it will provide
nursing students. This included improving the clinical edu- relevant information to nurse educators in exploring and
cation program (Al-Zayyat & Al-Gamal, 2014c), inclusion of implementing empirically tested interventions to lessen,
stress management during orientation of activities (Bam et al., reduce and prevent stress in order to facilitate maximum
2015; Seyedfatemi et al., 2007), and enhancement of time learning both in the theory and clinical setting. In addition,
management skills of nursing students, and counseling (Chen these findings call for a greater challenge to nurse educators
& Hung, 2013). In one study, the authors suggested the in planning strategies to prevent recurrence of stress among
establishment of support systems to help equip nursing nursing students while keeping them driven to achieve
students with positive coping strategies along with the maximum knowledge.
formulation of hospital policies which will support nursing Since clinical training is essential for the acquisition of
student learning (Al-Zayyat & Al-Gamal, 2014c). Another skills, nurse educators should further strengthen the nursing
study suggested the use of social support system such as the students’ positive coping skills to deal with the different
family, friends, relatives and even co-workers is essential to stressors during educational experiences. Such interventions
counteract the harmful effects of stress (Lo, 2002). Evans & may include a counseling program (Seyedfatemi et al., 2007)
Kelly (2004) suggested implementing a teaching pedagogy, while other studies highlighted the role of self-efficacy in
which empowers nursing students to promote positive skills improving and enhancing nursing students’ coping (Zhao
such as interpersonal and intrapersonal skills. Both Chan et al., 2014). Both Chan et al. (2009) and Pulido-Martos et al.,
et al., (2009) and Pulido-Martos et al. (2012) suggested (2012) suggested providing nursing students with a supportive
providing nursing students with a supportive clinical learning clinical learning environment and teaching them effective
environment and teaching them effective coping strategies for coping strategies to deal with stressors positively while
them to deal with stressors positively while enhancing their enhancing their actual learning (Seyedfatemi et al., 2007;
learning. Yamashita, et al., 2012). Being able to assist the nursing
It is also evident that the most preferred strategy used by student with the appropriate interventions that may allow for
nursing students to cope with stress was the problem-solving positive outcomes of stressful situations in addition to
approach. This coping approach is considered the most promoting a process in which to utilize for future events not
effective way of dealing with stress which involves behaviors only in all aspects of their nursing education and as a graduate
to address the main cause of the problem such as: setting up nurse, but in their future. Furthermore, further studies should
objectives to resolve the problem, adopting various strategies be conducted identifying specific coping strategy appropriate
to solve problem, finding meaning of the stressful events, and to a certain stressor, thus covering in detail the complexities
employing past experience to solve the problem (Folkman & of an issue.
Lazarus, 1988). Conversely, few studies found student nurses
to use the emotion-focused approach. This approach, con-
Conclusion
sidered to be the least effective strategy in dealing with stress,
does not solve the cause of stress but rather manages feelings Mounting evidence suggests that stress has a detrimental
related to stress. In one study, the frequent use of an emotion- effect not only on the physio-psycho-social health of the
based coping strategy (transference) to deal with stressors nursing students but also with their well-being. This review is
lead to negative results such as the nursing students’ considered as the pioneer in the field of nursing. The review is
perceiving higher levels of stress (Al-Zayyat & Al-Gamal, valuable to nurse educators as this is the first to critically
2014a). Behaviors included sleeping, using self-distraction discuss stress and coping mechanisms among nursing students
activities, and watching TV or movies. Similarly, studies during the nursing education process. It demonstrates the need
suggested interventions aimed at enhancing nursing students for more research to link specific coping strategies to nursing
coping skills. One study proposed a counseling program for school stressors. Once that link is established, nursing
first year nursing students which introduce effective coping programs can provide better education and support for
strategies (Seyedfatemi et al., 2007). Other studies highlighted nursing students. In general, students experience moderate
the role of self-efficacy in improving and enhancing nursing to high levels of stress from various stressors (caring of
students’ coping abilities. One study suggested clinical patients, assignments and workloads, negative interactions
simulation to enhance nursing student self-efficacy which is with staff and faculty, lack of clinical competence, and taking
DOI: 10.1080/09638237.2016.1244721 Stress and coping in nursing students 9
of examinations) during nursing education. The most com- Gadzella BM, Baloglu M. (2001). Confirmatory factor analysis and
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