Dogham et al.

BMC Nursing (2024) 23:249 BMC Nursing

https://doi.org/10.1186/s12912-024-01885-1

RESEARCH Open Access

Deciphering the influence: academic stress

and its role in shaping learning approaches
among nursing students: a cross-sectional
study
Rawhia Salah Dogham1, Heba Fakieh Mansy Ali1, Asmaa Saber Ghaly3, Nermine M. Elcokany2,
Mohamed Mahmoud Seweid4 and Ayman Mohamed El-Ashry5*

Abstract
Background Nursing education presents unique challenges, including high levels of academic stress and varied
learning approaches among students. Understanding the relationship between academic stress and learning
approaches is crucial for enhancing nursing education effectiveness and student well-being.
Aim This study aimed to investigate the prevalence of academic stress and its correlation with learning approaches
among nursing students.
Design and Method A cross-sectional descriptive correlation research design was employed. A convenient sample
of 1010 nursing students participated, completing socio-demographic data, the Perceived Stress Scale (PSS), and the
Revised Study Process Questionnaire (R-SPQ-2 F).
Results Most nursing students experienced moderate academic stress (56.3%) and exhibited moderate levels of
deep learning approaches (55.0%). Stress from a lack of professional knowledge and skills negatively correlates with
deep learning approaches (r = -0.392) and positively correlates with surface learning approaches (r = 0.365). Female
students showed higher deep learning approach scores, while male students exhibited higher surface learning
approach scores. Age, gender, educational level, and academic stress significantly influenced learning approaches.
Conclusion Academic stress significantly impacts learning approaches among nursing students. Strategies
addressing stressors and promoting healthy learning approaches are essential for enhancing nursing education and
student well-being.
Nursing implication Understanding academic stress’s impact on nursing students’ learning approaches enables
tailored interventions. Recognizing stressors informs strategies for promoting adaptive coping, fostering deep
learning, and creating supportive environments. Integrating stress management, mentorship, and counseling
enhances student well-being and nursing education quality.
Keywords Academic stress, Education, Learning approaches, Nursing students

*Correspondence:
Ayman Mohamed El-Ashry
ayman.el-ashry@alexu.edu.eg
Full list of author information is available at the end of the article

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Dogham et al. BMC Nursing (2024) 23:249 Page 2 of 11

Introduction interest in nursing can lead to deep learning approaches,

Nursing education is a demanding field that requires which promote a comprehensive understanding of the
students to acquire extensive knowledge and skills to subject matter, allowing students to feel more confident
provide competent and compassionate care. Nursing and less overwhelmed by coursework and exams. Con-
education curriculum involves high-stress environ- versely, students employing surface learning approaches
ments that can significantly impact students’ learning may experience higher stress levels due to the reliance on
approaches and academic performance [1, 2]. Numerous memorization [3].
studies have investigated learning approaches in nurs- Understanding the interplay between academic stress
ing education, highlighting the importance of identify- and learning approaches among nursing students is
ing individual students’ preferred approaches. The most essential for designing effective educational inter-
studied learning approaches include deep, surface, and ventions. Nursing educators can foster deep learning
strategic approaches. Deep learning approaches involve approaches by incorporating active learning strategies,
students actively seeking meaning, making connections, critical thinking exercises, and reflection activities into
and critically analyzing information. Surface learning the curriculum [15]. Creating supportive learning envi-
approaches focus on memorization and reproducing ronments encouraging collaboration, self-care, and stress
information without a more profound understanding. management techniques can help alleviate academic
Strategic learning approaches aim to achieve high grades stress. Additionally, providing mentorship and counsel-
by adopting specific strategies, such as memorization ling services tailored to nursing students’ unique chal-
techniques or time management skills [3–5]. lenges can contribute to their overall well-being and
Nursing education stands out due to its focus on prac- academic success [16–18].
tical training, where the blend of academic and clinical Despite the scarcity of research focusing on the link
coursework becomes a significant stressor for students, between academic stress and learning methods in nurs-
despite academic stress being shared among all university ing students, it’s crucial to identify the unique stressors
students [6–8]. Consequently, nursing students are rec- they encounter. The intensity of these stressors can be
ognized as prone to high-stress levels. Stress is the physi- connected to the learning strategies employed by these
ological and psychological response that occurs when a students. Academic stress and learning approach are
biological control system identifies a deviation between intertwined aspects of the student experience. While
the desired (target) state and the actual state of a fitness- academic stress can influence learning approaches, the
critical variable, whether that discrepancy arises inter- choice of learning approach can also impact the level of
nally or externally to the human [9]. Stress levels can vary academic stress experienced. By understanding this rela-
from objective threats to subjective appraisals, making it tionship and implementing strategies to promote healthy
a highly personalized response to circumstances. Failure learning approaches and manage academic stress, educa-
to manage these demands leads to stress imbalance [10]. tors and institutions can foster an environment condu-
Nursing students face three primary stressors during cive to deep learning and student well-being.
their education: academic, clinical, and personal/social Hence, this study aims to investigate the correlation
stress. Academic stress is caused by the fear of failure in between academic stress and learning approaches experi-
exams, assessments, and training, as well as workload enced by nursing students.
concerns [11]. Clinical stress, on the other hand, arises
from work-related difficulties such as coping with death, Study objectives
fear of failure, and interpersonal dynamics within the
organization. Personal and social stressors are caused by •  Assess the levels of academic stress among nursing
an imbalance between home and school, financial hard- students.
ships, and other factors. Throughout their education, •  Assess the learning approaches among nursing
nursing students have to deal with heavy workloads, students.
time constraints, clinical placements, and high academic •  Identify the relationship between academic stress
expectations. Multiple studies have shown that nursing and learning approach among nursing students.
students experience higher stress levels compared to stu- •  Identify the effect of academic stress and related
dents in other fields [12–14]. factors on learning approach and among nursing
Research has examined the relationship between aca- students.
demic stress and coping strategies among nursing stu-
dents, but no studies focus specifically on the learning
approach and academic stress. However, existing litera-
ture suggests that students interested in nursing tend to
experience lower levels of academic stress [7]. Therefore,
Dogham et al. BMC Nursing (2024) 23:249 Page 3 of 11

Materials and methods (0 = never, 1 = rarely, 2 = sometimes, 3 = reasonably often,

Research design and 4 = very often), with a total score ranging from 0 to
A cross-sectional descriptive correlation research design 116. The cut-off points of levels of perceived stress scale
adhering to the STROBE guidelines was used for this according to score percentage were low < 33.33%, mod-
study. erate 33.33–66.66%, and high more than 66.66%. Higher
scores indicate higher stress levels. The items are cat-
Setting egorized into six subscales reflecting different sources of
A research project was conducted at Alexandria Nurs- stress. The first subscale assesses “stress stemming from
ing College, situated in Egypt. The college adheres to the lack of professional knowledge and skills” and includes 3
national standards for nursing education and functions items. The second subscale evaluates “stress from caring
under the jurisdiction of the Egyptian Ministry of Higher for patients” with 8 items. The third subscale measures
Education. Alexandria Nursing College comprises nine “stress from assignments and workload” with 5 items.
specialized nursing departments that offer various nurs- The fourth subscale focuses on “stress from interactions
ing specializations. These departments include Nursing with teachers and nursing staff ” with 6 items. The fifth
Administration, Community Health Nursing, Geronto- subscale gauges “stress from the clinical environment”
logical Nursing, Medical-Surgical Nursing, Critical Care with 3 items. The sixth subscale addresses “stress from
Nursing, Pediatric Nursing, Obstetric and Gynecological peers and daily life” with 4 items. El-Ashry et al. (2022)
Nursing, Nursing Education, and Psychiatric Nursing and reported an excellent internal consistency reliability of
Mental Health. The credit hour system is the fundamen- 0.83 [21]. Two bilingual translators translated the English
tal basis of both undergraduate and graduate programs. version of the scale into Arabic and then back-translated
This framework guarantees a thorough evaluation of aca- it into English by two other independent translators to
demic outcomes by providing an organized structure for verify its accuracy. The suitability of the translated ver-
tracking academic progress and conducting analyses. sion was confirmed through a confirmatory factor analy-
sis (CFA), which yielded goodness-of-fit indices such as
Participants and sample size calculation a comparative fit index (CFI) of 0.712, a Tucker-Lewis
The researchers used the Epi Info 7 program to calculate index (TLI) of 0.812, and a root mean square error of
the sample size. The calculations were based on specific approximation (RMSEA) of 0.100.
parameters such as a population size of 9886 students for
the academic year 2022–2023, an expected frequency of Tool three: revised study process questionnaire (R-SPQ-2 F)
50%, a maximum margin of error of 5%, and a confidence It was developed by Biggs et al. (2001). It examines deep
coefficient of 99.9%. Based on these parameters, the pro- and surface learning approaches using only 20 questions;
gram indicated that a minimum sample size of 976 stu- each subscale contains 10 questions [22]. On a 5-point
dents was required. As a result, the researchers recruited Likert scale ranging from 0 (never or only rarely true of
a convenient sample of 1010 nursing students from dif- me) to 4 (always or almost always accurate of me). The
ferent academic levels during the 2022–2023 academic total score ranged from 0 to 80, with a higher score
year [19]. This sample size was larger than the minimum reflecting more deep or surface learning approaches.
required, which could help to increase the accuracy and The cut-off points of levels of revised study process ques-
reliability of the study results. Participation in the study tionnaire according to score percentage were low < 33%,
required enrollment in a nursing program and voluntary moderate 33–66%, and high more than 66%. Biggs et
agreement to take part. The exclusion criteria included al. (2001) found that Cronbach alpha value was 0.73 for
individuals with mental illnesses based on their response deep learning approach and 0.64 for the surface learning
and those who failed to complete the questionnaires. approach, which was considered acceptable. Two trans-
lators fluent in English and Arabic initially translated a
Tools scale from English to Arabic. To ensure the accuracy of
Tool one the translation, they translated it back into English. The
socio-demographic data that include students’ age, sex, translated version’s appropriateness was evaluated using
educational level, hours of sleep at night, hours spent a confirmatory factor analysis (CFA). The CFA produced
studying, and GPA from the previous semester. several goodness-of-fit indices, including a Comparative
Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of
Tool two: the perceived stress scale (PSS) 0.912, and a Root Mean Square Error of Approximation
It was initially created by Sheu et al. (1997) to gauge (RMSEA) of 0.100. Comparative Fit Index (CFI) of 0.790,
the level and nature of stress perceived by nursing stu- a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean
dents attending Taiwanese universities [20]. It com- Square Error of Approximation (RMSEA) of 0.100.
prises 29 items rated on a 5-point Likert scale, where
Dogham et al. BMC Nursing (2024) 23:249 Page 4 of 11

Procedures five-person jury of professionals from the education and

Ethical considerations psychiatric nursing departments. The scales were found
The Alexandria University College of Nursing’s Research to have sufficiently evaluated the intended structures by
Ethics Committee provided ethical permission before the jury.
the study’s implementation. Furthermore, pertinent
authorities acquired ethical approval at participating Pilot study
nursing institutions. The vice deans of the participating A preliminary investigation involved 100 nursing student
institutions provided written informed consent attesting applicants, distinct from the final sample, to gauge the
to institutional support and authority. By giving writ- efficacy, clarity, and potential obstacles in utilizing the
ten informed consent, participants confirmed they were research instruments. The pilot findings indicated that
taking part voluntarily. Strict protocols were followed to the instruments were accurate, comprehensible, and suit-
protect participants’ privacy during the whole investiga- able for the target demographic. Additionally, Cronbach’s
tion. The obtained personal data was kept private and Alpha was utilized to further assess the instruments’ reli-
available only to the study team. Ensuring participants’ ability, demonstrating internal solid consistency for both
privacy and anonymity was of utmost importance. the learning approaches and academic stress tools, with
values of 0.91 and 0.85, respectively.
Tools validity
The researchers created tool one after reviewing perti- Data collection
nent literature. Two bilingual translators independently The researchers convened with each qualified student in
translated the English version into Arabic to evaluate the a relaxed, unoccupied classroom in their respective col-
applicability of the academic stress and learning approach lege settings. Following a briefing on the study’s objec-
tools for Arabic-speaking populations. To assure accu- tives, the students filled out the datasheet. The interviews
racy, two additional impartial translators back-translated typically lasted 15 to 20 min.
the translation into English. They were also assessed by a
Data analysis
Table 1 Distribution of nursing students according to their The data collected were analyzed using IBM SPSS soft-
socio- demographic data (N = 1010) ware version 26.0. Following data entry, a thorough
Socio-demographic data Number Percentage (%)
examination and verification were undertaken to ensure
Age
accuracy. The normality of quantitative data distributions
18 ≤ 21 392 38.8
was assessed using Kolmogorov-Smirnov tests. Cron-
21 ≤ 24 332 32.9
bach’s Alpha was employed to evaluate the reliability and
24 ≤ 28 286 28.3
internal consistency of the study instruments. Descrip-
Mean ± SD. 22.79 ± 4.69
tive statistics, including means (M), standard deviations
Gender
(SD), and frequencies/percentages, were computed to
Male 232 23.0
summarize academic stress and learning approaches
Female 778 77.0
Educational
for categorical data. Student’s t-tests compared scores
1st 149 14.8
between two groups for normally distributed variables,
2nd 347 34.4
while One-way ANOVA compared scores across more
3rd 217 21.5 than two categories of a categorical variable. Pearson’s
4th 297 29.4 correlation coefficient determined the strength and
Hours spent for studying direction of associations between customarily distributed
Less than 2 h 109 10.8 quantitative variables. Hierarchical regression analysis
3–4 h 355 35.1 identified the primary independent factors influencing
5–6 h 323 32.0 learning approaches. Statistical significance was deter-
More than 7 h 223 22.1 mined at the 5% (p < 0.05).
Hours of sleep / night
Less than 2 h 24 2.4 Results
3–4 h 174 17.2 Table 1 presents socio-demographic data for a group of
5–6 h 556 55.0 1010 nursing students. The age distribution shows that
More than 7 h 256 25.3 38.8% of the students were between 18 and 21 years
GPA of previous semester old, 32.9% were between 21 and 24 years old, and 28.3%
2–2.5 212 21.0 were between 24 and 28 years old, with an average age
2.5–3 413 40.9 of approximately 22.79. Regarding gender, most of the
3–3.5 385 38.1 students were female (77%), while 23% were male. The
Dogham et al. BMC Nursing (2024) 23:249 Page 5 of 11

Fig. 1 Nursing students? levels of learning approach (N=1010)

Fig. 2 Nursing students? levels of academic stress subtypes (N=1010)

students were distributed across different educational and 19.1% with a low level. The surface learning approach
years, a majority of 34.4% in the second year, followed by was more prevalent, with 47.8% of students showing
29.4% in the fourth year. The students’ hours spent study- a moderate level, 41.7% showing a low level, and only
ing were found to be approximately two-thirds (67%) of 10.5% exhibiting a high level.
the students who studied between 3 and 6 h. Similarly, Figure 2 provides the types of academic stress levels
sleep patterns differ among the students; more than among nursing students. Among nursing students, vari-
three-quarters (77.3%) of students sleep between 5- to ous stressors significantly impact their academic experi-
more than 7 h, and only 2.4% sleep less than 2 h per night. ences. Foremost among these stressors are the pressure
Finally, the student’s Grade Point Average (GPA) from the and demands associated with academic assignments
previous semester was also provided. 21% of the students and workload, with 30.8% of students attributing their
had a GPA between 2 and 2.5, 40.9% had a GPA between high stress levels to these factors. Challenges within the
2.5 and 3, and 38.1% had a GPA between 3 and 3.5. clinical environment are closely behind, contributing
Figure 1 provides the learning approach level among significantly to high stress levels among 25.7% of nurs-
nursing students. In terms of learning approach, most ing students. Interactions with peers and daily life stress-
students (55.0%) exhibited a moderate level of deep ors also weigh heavily on students, ranking third among
learning approach, followed by 25.9% with a high level sources of high stress, with 21.5% of students citing this
Dogham et al. BMC Nursing (2024) 23:249 Page 6 of 11

Fig. 3 Nursing students? levels of total academic stress (N=1010)

Table 2 Correlation between academic stress subscales and those experiencing low academic stress (29.9%), and a
deep and superficial learning approach among nursing students minority experienced high academic stress (13.8%).
(N = 1010) Table 2 displays the correlation between aca-
Academic stress subscales Learning approach demic stress subscales and deep and surface learning
Deep approach Superficial approaches among 1010 nursing students. All stress sub-
approach scales exhibited a negative correlation regarding the deep
Stress from lack of professional r -0.392* 0.365* learning approach, indicating that the inclination toward
knowledge and skills p < 0.001* < 0.001*
deep learning decreases with increasing stress levels. The
Stress from assignments and r -0.103* 0.262*
most significant negative correlation was observed with
workload p 0.001* < 0.001*
stress stemming from the lack of professional knowl-
Stress from taking care of patients r -0.093* 0.334*
edge and skills (r=-0.392, p < 0.001), followed by stress
p 0.003* < 0.001*
from the clinical environment (r=-0.109, p = 0.001), stress
Stress from clinical environment r -0.109* 0.254*
from assignments and workload (r=-0.103, p = 0.001),
p 0.001* < 0.001*
stress from peers and daily life (r=-0.095, p = 0.002),
Stress from teachers and nursing r -0.083* 0.262*
staff and stress from patient care responsibilities (r=-0.093,
p 0.009* < 0.001*
p = 0.003). The weakest negative correlation was found
Stress from peers and daily life r -0.095* 0.186*
p 0.002* < 0.001*
with stress from interactions with teachers and nursing
Overall r -0.159* 0.355*
staff (r=-0.083, p = 0.009). Conversely, concerning the
p < 0.001* < 0.001* surface learning approach, all stress subscales displayed
r: Pearson correlation coefficient a positive correlation, indicating that heightened stress
*: Statistically significant at p ≤ 0.05 levels corresponded with an increased tendency toward
superficial learning. The most substantial positive cor-
relation was observed with stress related to the lack of
as a significant factor. Similarly, interaction with teach- professional knowledge and skills (r = 0.365, p < 0.001),
ers and nursing staff closely follow, contributing to followed by stress from patient care responsibilities
high-stress levels for 20.3% of nursing students. While (r = 0.334, p < 0.001), overall stress (r = 0.355, p < 0.001),
still significant, stress from taking care of patients ranks stress from interactions with teachers and nursing staff
slightly lower, with 16.7% of students reporting it as a sig- (r = 0.262, p < 0.001), stress from assignments and work-
nificant factor contributing to their academic stress. At load (r = 0.262, p < 0.001), and stress from the clinical
the lowest end of the ranking, but still notable, is stress environment (r = 0.254, p < 0.001). The weakest positive
from a perceived lack of professional knowledge and correlation was noted with stress stemming from peers
skills, with 15.9% of students experiencing high stress in and daily life (r = 0.186, p < 0.001).
this area. Table 3 outlines the association between the socio-
Figure 3 provides the total levels of academic stress demographic characteristics of nursing students and
among nursing students. The majority of students expe- their deep and surface learning approaches. Concerning
rienced moderate academic stress (56.3%), followed by age, statistically significant differences were observed in
Dogham et al. BMC Nursing (2024) 23:249 Page 7 of 11

Table 3 Relation between nursing students’ socio- demographic surface learning approach (F = 3.550, p = 0.014), with
data and the study variables (N = 1010) scores increasing as study hours increased. However, no
Socio-demographic data Deep Learning Surface Learn- significant difference was observed in the deep learning
approach ing approach
approach (F = 0.861, p = 0.461). Hours of sleep per night
Age
and GPA from the previous semester did not exhibit sta-
18 ≤ 21 29.65 ± 7.11 24.43 ± 6.88
tistically significant differences in deep or surface learn-
21 ≤ 24 31.00 ± 8.16 27.17 ± 8.17
ing approaches.
24 ≤ 28 34.76 ± 10.46 26.02 ± 9.54
F (p) 3.661* (0.003*) 7.983* (< 0.001*)
Table 4 presents a multivariate linear regression
Gender
analysis examining the factors influencing the learning
Male 29.59 ± 7.73 29.97 ± 7.36
approach among 1110 nursing students. The deep learn-
Female 31.59 ± 8.28 24.90 ± 7.97 ing approach was positively influenced by age, gender
t(p) 3.290* (0.001*) 8.638* (< 0.001*) (being female), educational year level, and stress from
Educational level teachers and nursing staff, as indicated by their positive
1–2 31.21 ± 7.35 22.23 ± 5.83 coefficients and significant p-values (p < 0.05). However,
3–4 29.85 ± 8.15 25.67 ± 7.43 it was negatively influenced by stress from a lack of pro-
5–6 31.29 ± 7.68 27.13 ± 8.01 fessional knowledge and skills. The other factors do not
7–8 32.47 ± 8.80 27.68 ± 9.23 significantly influence the deep learning approach. On
F (p) 5.599* (0.001*) 17.284* the other hand, the surface learning approach was posi-
(< 0.001*) tively influenced by gender (being female), educational
Hours spent for studying year level, stress from lack of professional knowledge and
Less than 2 h 30.64 ± 8.10 28.42 ± 7.06 skills, stress from assignments and workload, and stress
3–4 h 30.72 ± 8.55 25.82 ± 8.16 from taking care of patients, as indicated by their positive
5–6 h 31.36 ± 7.86 25.61 ± 7.72 coefficients and significant p-values (p < 0.05). However,
More than 7 h 31.70 ± 8.14 25.97 ± 8.91 it was negatively influenced by gender (being male). The
F (p) 0.861 (0.461) 3.550* (0.014*) other factors do not significantly influence the surface
Hours of sleep / night learning approach. The adjusted R-squared values indi-
Less than 2 h 28.38 ± 10.97 26.50 ± 8.79 cated that the variables in the model explain 17.8% of the
3–4 h 30.85 ± 8.62 25.92 ± 7.82 variance in the deep learning approach and 25.5% in the
5–6 h 31.40 ± 8.02 25.78 ± 8.14 surface learning approach. Both models were statistically
More than 7 h 30.99 ± 7.96 26.75 ± 8.20
significant (p < 0.001).
F (p) 1.202 (0.308) 0.892 (0.445)
GPA of previous semester
Discussion
2–2.5 30.95 ± 7.97 26.26 ± 7.80
Nursing students’ academic stress and learning
2.5–3 31.33 ± 8.11 25.91 ± 8.34
approaches are essential to planning for effective and effi-
3–3.5 31.02 ± 8.42 26.12 ± 8.06
cient learning. Nursing education also aims to develop
F (p) 0.213 (0.808) 0.145 (0.865)
F: One way ANOVA test
knowledgeable and competent students with problem-
*: Statistically significant at p ≤ 0.05
solving and critical-thinking skills.
The study’s findings highlight the significant presence
of stress among nursing students, with a majority experi-
deep and surface learning approaches (F = 3.661, p = 0.003 encing moderate to severe levels of academic stress. This
and F = 7.983, p < 0.001, respectively). Gender also dem- aligns with previous research indicating that academic
onstrated significant differences in deep and surface stress is prevalent among nursing students. For instance,
learning approaches (t = 3.290, p = 0.001 and t = 8.638, Zheng et al. (2022) observed moderated stress levels in
p < 0.001, respectively). Female students exhibited higher nursing students during clinical placements [23], while
scores in the deep learning approach (31.59 ± 8.28) com- El-Ashry et al. (2022) found that nearly all first-year nurs-
pared to male students (29.59 ± 7.73), while male stu- ing students in Egypt experienced severe academic stress
dents had higher scores in the surface learning approach [21]. Conversely, Ali and El-Sherbini (2018) reported
(29.97 ± 7.36) compared to female students (24.90 ± 7.97). that over three-quarters of nursing students faced high
Educational level exhibited statistically significant differ- academic stress. The complexity of the nursing program
ences in deep and surface learning approaches (F = 5.599, likely contributes to these stress levels [24].
p = 0.001 and F = 17.284, p < 0.001, respectively). Both The current study revealed that nursing students iden-
deep and surface learning approach scores increased tified the highest sources of academic stress as workload
with higher educational levels. The duration of study from assignments and the stress of caring for patients.
hours demonstrated significant differences only in the This aligns with Banu et al.‘s (2015) findings, where
Dogham et al. BMC Nursing (2024) 23:249 Page 8 of 11

Table 4 Multivariate linear regression analysis for the parameters affecting learning approach (N = 1010)
#
Socio-demographic data Multivariate
Deep Learning approach Surface Learning approach
p B (LL– UL 95%C.I) p B (LL– UL 95%C.I)
Age 0.040 0.116(0.005–0.227) 0.342 0.051(-0.054-0.156)
Gender (Female /Male) 0.028 1.260(0.134–2.385) < 0.001* -4.039(-5.125- -2.953)
Educational year level 0.008 0.665(0.177–1.153) < 0.001* 1.401(0.940–1.863)
Hours spent for studying - - 0.901 -0.030 (-0.507–0.446)
Stress from lack of professional knowledge and skills < 0.001* -1.178(-1.348 - -1.008) < 0.001* 0.640 (0.479-0.800)
Stress from assignments and workload 0.979 -0.002(-0.131–0.128) 0.001* 0.217 (0.094–0.339)
Stress from taking care of patients 0.270 0.047(-0.037-0.131) < 0.001* 0.160(0.081–0.240)
Stress from clinical environment 0.868 -0.018(-0.229-0.193) 0.720 0.036(-0.163–0.236)
Stress from teachers and nursing staff 0.020* 0.143(0.023–0.263) 0.778 0.016(-0.097- 0.130)
Stress from peers and daily life 0.748 -0.028(-0.197-0.141) 0.058 -0.154 (-0.314- 0.005)
R2 = 0.185, Adj. R2 = 0.178, F = 25.271*,p < 0.001* R2 = 0.262, Adj. R2 = 0.255,
F = 35,457*,p < 0.001*
B: Unstandardized Coefficients C.I: Confidence Interval LL: Lower Limit UL: Upper Limit
#: All variables with p < 0.05 was included in the multivariate *: Statistically significant at p ≤ 0.05

academic demands, assignments, examinations, high surface learning approaches and overall stress levels.
workload, and combining clinical work with patient Elevated academic stress levels may diminish motiva-
interaction were cited as everyday stressors [25]. Addi- tion and engagement in the learning process, potentially
tionally, Anaman-Torgbor et al. (2021) identified lectures, leading students to feel overwhelmed, disinterested, or
assignments, and examinations as predictors of academic burned out, prompting a shift toward a surface learning
stress through logistic regression analysis. These stress- approach. This finding resonates with previous research
ors may stem from nursing programs emphasizing the indicating that nursing students who actively seek posi-
development of highly qualified graduates who acquire tive academic support strategies during academic stress
knowledge, values, and skills through classroom and clin- have better prospects for success than those who do not
ical experiences [26]. [29]. Nebhinani et al. (2020) identified interface concerns
The results regarding learning approaches indicate and academic workload as significant stress-related fac-
that most nursing students predominantly employed the tors. Notably, only an interest in nursing demonstrated
deep learning approach. Despite acknowledging a surface a significant association with stress levels, with partici-
learning approach among the participants in the present pants interested in nursing primarily employing adaptive
study, the prevalence of deep learning was higher. This coping strategies compared to non-interested students.
inclination toward the deep learning approach is antici- The current research reveals a statistically significant
pated in nursing students due to their engagement with inverse relationship between different dimensions of aca-
advanced courses, requiring retention, integration, and demic stress and adopting the deep learning approach.
transfer of information at elevated levels. The deep learn- The most substantial negative correlation was observed
ing approach correlates with a gratifying learning expe- with stress arising from a lack of professional knowledge
rience and contributes to higher academic achievements and skills, succeeded by stress associated with the clini-
[3]. Moreover, the nursing program’s emphasis on active cal environment, assignments, and workload. Nursing
learning strategies fosters critical thinking, problem-solv- students encounter diverse stressors, including deliver-
ing, and decision-making skills. These findings align with ing patient care, handling assignments and workloads,
Mahmoud et al.‘s (2019) study, reporting a significant navigating challenging interactions with staff and faculty,
presence (83.31%) of the deep learning approach among perceived inadequacies in clinical proficiency, and facing
undergraduate nursing students at King Khalid Univer- examinations [30].
sity’s Faculty of Nursing [27]. Additionally, Mohamed In the current study, the multivariate linear regres-
&Morsi (2019) found that most nursing students at sion analysis reveals that various factors positively influ-
Benha University’s Faculty of Nursing embraced the deep ence the deep learning approach, including age, female
learning approach (65.4%) compared to the surface learn- gender, educational year level, and stress from teachers
ing approach [28]. and nursing staff. In contrast, stress from a lack of pro-
The study observed a negative correlation between fessional knowledge and skills exert a negative influence.
the deep learning approach and the overall mean stress Conversely, the surface learning approach is positively
score, contrasting with a positive correlation between influenced by female gender, educational year level, stress
Dogham et al. BMC Nursing (2024) 23:249 Page 9 of 11

from lack of professional knowledge and skills, stress Conclusion

from assignments and workload, and stress from taking According to the present study’s findings, nursing stu-
care of patients, but negatively affected by male gender. dents encounter considerable academic stress, primarily
The models explain 17.8% and 25.5% of the variance in stemming from heavy assignments and workload, as well
the deep and surface learning approaches, respectively, as interactions with teachers and nursing staff. Addition-
and both are statistically significant. These findings ally, it was observed that students who experience lower
underscore the intricate interplay of demographic and levels of academic stress typically adopt a deep learning
stress-related factors in shaping nursing students’ learn- approach, whereas those facing higher stress levels tend
ing approaches. High workloads and patient care respon- to resort to a surface learning approach. Demographic
sibilities may compel students to prioritize completing factors such as age, gender, and educational level influ-
tasks over deep comprehension. This pressure could lead ence nursing students’ choice of learning approach. Spe-
to a surface learning approach as students focus on meet- cifically, female students are more inclined towards deep
ing immediate demands rather than engaging deeply with learning, whereas male students prefer surface learning.
course material. This observation aligns with the findings Moreover, deep and surface learning approach scores
of Alsayed et al. (2021), who identified age, gender, and show an upward trend with increasing educational levels
study year as significant factors influencing students’ and study hours. Academic stress emerges as a significant
learning approaches. determinant shaping the adoption of learning approaches
Deep learners often demonstrate better self-regulation among nursing students.
skills, such as effective time management, goal setting,
and seeking support when needed. These skills can help Implications in nursing practice
manage academic stress and maintain a balanced learn- Nursing programs should consider integrating stress
ing approach. These are supported by studies that stud- management techniques into their curriculum. Provid-
ied the effect of coping strategies on stress levels [6, 31, ing students with resources and skills to cope with aca-
32]. On the contrary, Pacheco-Castillo et al. study (2021) demic stress can improve their well-being and academic
found a strong significant relationship between academic performance. Educators can incorporate teaching strat-
stressors and students’ level of performance. That study egies that promote deep learning approaches, such as
also proved that the more academic stress a student problem-based learning, critical thinking exercises, and
faces, the lower their academic achievement. active learning methods. These approaches help students
engage more deeply with course material and reduce
Strengths and limitations of the study reliance on surface learning techniques. Recognizing
This study has lots of advantages. It provides insight- the gender differences in learning approaches, nursing
ful information about the educational experiences of programs can offer gender-specific support services and
Egyptian nursing students, a demographic that has yet resources. For example, providing targeted workshops or
to receive much research. The study’s limited generaliz- counseling services that address male and female nurs-
ability to other people or nations stems from its concen- ing students’ unique stressors and learning needs. Imple-
tration on this particular group. This might be addressed menting mentorship programs and peer support groups
in future studies by using a more varied sample. Another can create a supportive environment where students can
drawback is the dependence on self-reported metrics, share experiences, seek advice, and receive encourage-
which may contain biases and mistakes. Although the ment from their peers and faculty members. Encourag-
cross-sectional design offers a moment-in-time view of ing students to reflect on their learning processes and
the problem, it cannot determine causation or evaluate identify effective study strategies can help them develop
changes over time. To address this, longitudinal research metacognitive skills and become more self-directed
may be carried out. learners. Faculty members can facilitate this process by
Notwithstanding these drawbacks, the study sub- incorporating reflective exercises into the curriculum.
stantially contributes to the expanding knowledge of Nursing faculty and staff should receive training on rec-
academic stress and nursing students’ learning styles. ognizing signs of academic stress among students and
Additional research is needed to determine teaching providing appropriate support and resources. Addition-
strategies that improve deep-learning approaches among ally, professional development opportunities can help
nursing students. A qualitative study is required to ana- educators stay updated on evidence-based teaching strat-
lyze learning approaches and factors that may influence egies and practical interventions for addressing student
nursing students’ selection of learning approaches. stress.
Dogham et al. BMC Nursing (2024) 23:249 Page 10 of 11

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