Context:
Nursing students experience psychosocial stress in their workplace. Available statistics are at variance, and hence, the need to know the overall prevalence of psychosocial stress among nursing students.
Aims:
This study aimed to determine the prevalence of psychosocial stress among nursing students through meta-analysis.
Materials and methods:
PubMed, Cochrane, Web of Science, CNKI, and China Biomedical Literature Service System were searched for articles. Search terms include “psychosocial stress,” “nursing students.” Articles were included if they used validated psychosocial stress assessment instruments. Of the 15 articles with data on stress prevalence, 8 met all inclusion criteria. Each article was independently reviewed by the authors and relevant data were abstracted. Statistical analysis was done using Revman 4.1.
Results:
Overall, the average score for stress among nursing students was 3.70 (95% confidence interval [CI]: [3.33, 4.06]) based on the analyzed 15 articles with a sample size of 9202.
Conclusion:
This study showed that the stress level of intern nursing students was mainly moderate.
Keywords: meta-analysis, nursing students, stress prevalence
1. Introduction
Nursing is a profession that requires nursing students to have comprehensive theoretical knowledge and proficiency in clinical operations.[1] The purpose of clinical education is to improve the professional knowledge and skill level of nursing students and to provide opportunities to translate their theory into practice.[2] Some studies have shown that positive clinical experiences improve nursing students’ critical thinking skills, and problem-solving abilities, and develop a sense of professional identity and belonging.[3] On the contrary, negative clinical experiences can reduce nursing students’ self-confidence, professional satisfaction, and sense of professional benefit.[4] Clinical placements are an important part of nursing education, but nursing students are often under greater stress during clinical placements due to their dynamic and challenging nature.[5–7]
In the latest study, according to Brianna Chu[8], any physical or psychological stimuli that disrupt homeostasis result in a stress response. The stimuli are called stressors and physiological and behavioral changes in response to exposure to stressors constitute the stress response. The stress response is adaptive, to begin with, that prepares the body to handle the challenges presented by an internal or external environmental challenge (stressor), for example, the body’s physiologic responses to trauma and invasive surgery serve to attenuate further tissue damage. But if the exposure to a stressor is actually or perceived as intense, repetitive (repeated acute stress), or prolonged (chronic stress), the stress response becomes maladaptive and detrimental to physiology, for example, exposure to chronic stressors can cause maladaptive reactions including depression, anxiety, cognitive impairment, and heart disease.[9] More white matter abnormalities have been reported in children and adolescents with bipolar disease than in those with unipolar disease. Importantly, more abnormalities have been documented in the brains of adolescents with bipolar depression than unipolar depression.[10] In addition, there is a close relationship between stress and suicide which is frequently underreported. Unfortunately, above 2% of traffic accidents (especially among young adolescents) are suicide behaviors. This phenomenon may be underreported considering that suicides by car accidents are reported as accidental in the national statistics. [11]
Related studies have found that medical professionals have higher levels of workplace stress and burnout compared to other jobs or occupations.[12] Nursing students can have higher levels of stress compared to students in other healthcare-related professions.[13] In many countries, nursing students also tend to report higher stress outcomes than other student groups,[14,15] and the clinical component of nursing education is more stressful than the theoretical component.[16] Studies have also shown that almost all nursing students experience moderate to high levels of stress while working in the clinical setting[17] but there is a lack of data on the stress levels of nursing students. Accurate and comprehensive assessment and analysis of intern nursing students’ stress levels is important to promote the physical and mental health of intern nursing students, improve the quality of their practice, and enhance clinical teaching. The purpose of this study was to provide a study to explore the issue of stress among nursing students.
2. Materials and Methods
This work has followed the systematic review, meta-analysis, and meta-regression methods. To identify relevant studies from literature PubMed, Cochrane, Web of Science, CNKI, and China Biomedical Literature Service System databases were searched. The keywords of prevalence, stress, nursing students, and all possible combinations of these words were used in the search strategy and for each of the above-mentioned databases. No lower time limit was considered in the search process. Once all related studies were identified, the identifying information about the selected sources was transferred into the EndNote bibliography management software. To maximize the comprehensiveness of the search, the reference lists within all selected articles were manually reviewed. Taking PubMed as an example, the specific search strategy is shown in Figure 1.
Figure 1.
Search strategy of PubMed.
2.1. Inclusion criteria
Cross-sectional study; the study population was intern nursing students; the results of the study were expressed as mean±standard deviation of stress levels.
2.2. Exclusion criteria
Criteria for excluding a study were: research works without sufficient data, duplicate papers, and studies with unclear methods (diagnostic methods other than those listed in the inclusion criteria).
2.3. Study selection
Initially, studies that were repeated in various databases were removed from the list. Subsequently, a list of the titles of all the remaining articles was prepared, so that the quality of articles could be evaluated. For the systematic review, the PRISMA guidelines were followed; in the first stage, screening, the title, and abstract of the remaining articles were carefully examined and several irrelevant articles were excluded, considering the inclusion and exclusion criteria. In the second stage, that is, eligibility evaluation, the full text of the possible related articles remaining from the screening stage were examined, and similarly, at this stage, several other irrelevant studies were removed. To prevent bias, all stages of resource review and data extraction were performed by 2 reviewers independently. If an article was not included, the reason for the exclusion was mentioned. In cases where there was a disagreement between the 2 reviewers, the third person reviewed the article.
2.4. Quality evaluation of articles
To evaluate the quality of articles (i.e., with respect to the methodological validity and results), a checklist appropriate to the type of study was used. Descriptive cross-sectional studies are usually used to describe the prevalence and incidence of disease. Hence, the Agency for Healthcare Quality and Research (AHRQ)[18] evaluates cross-sectional studies/prevalence studies. AHRQ consists of 11 items. If the answer is “no” or “unclear,” the item score is “0”; If the answer is “yes,” the item score is “1”. A score of 8–11 is considered high quality, 4–7 moderate quality, and below 4 poor quality. After the independent evaluation, 2 researchers will discuss and reach a consensus. If there is any disagreement, the third researcher will arbitrate, or the research group will discuss and decide.
2.5. Statistical analysis
Endnote X9 was used to summarize the literature. Excel software was used for data extraction management, statistics, and descriptive analysis of outcome indicators. Revman 4.1 software was used to merge the prevalence of stress levels in each study. The chi-square test and I2 index were used to determine whether there was heterogeneity among studies, and the heterogeneity of effect sizes was analyzed. The fixed-effect model was adopted if there was no heterogeneity among studies (P > .1, I2 < 50%). The random-effects model was used to combine effect sizes with heterogeneity among studies (P < .1, I2 ≥ 50%).
2.6. Ethical consideration
Based on the use of already published secondary data and the meta-analysis nature, ethical approval was not required.
3. Results
3.1. Literature screening process and results
As mentioned earlier, the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA guidelines) were used to conduct the systematic review, meta-analysis, and meta-regression. At the identification stage, 1235 possible related articles were identified and transferred into the EndNote bibliography management software. Of the total 1235 studies identified, 265 were duplicates and were therefore excluded. In the screening stage, of the 970 remaining studies, 745 articles were omitted by studying their title and abstract and based on the inclusion and exclusion criteria. In the evaluation eligibility stage, out of 225 remaining articles, 210 ineligible articles were removed following the examination of their full text, and similarly according to the inclusion and exclusion criteria. In the quality evaluation stage, by reading the full text of the article and based on the score obtained from AHRQ checklist, 15[19–33] articles were entered into the final analysis (Fig. 2).
Figure 2.
Literature screening process and result.
3.2. Basic characteristics of included studies
In total, 15 articles were included in this review. The included literature was published from 2011 to 2021. The sample size of the study subjects was 2999 at most and 121 at least, and the findings of these studies are based on a total of 9202 participants. The 15 articles all used cross-sectional studies, and all quantitative studies used validated scales for data collection. Among the 15 articles, there are 6 articles in English and 10 articles in Chinese. The most popular scales for measuring stress levels were the perceived stress scale (PSS), the stress in nursing students questionnaire (SINS), the student nurse stress index scale (SNSI-CHI), nursing student stressors scale (Zhang Guixia), etc. The basic characteristics of the included studies are shown in Table 1
Table 1.
Basic characteristics of included studies.
| Reference | Study design | Date of data collection | Country | Instruments | Sample | Score (M±SD) |
|---|---|---|---|---|---|---|
| María Dolore Onieva-Zafra (2020) |
cross-sectional | 2017 | Spain | Perceived Stress Scale (PSS) | 190 | 22.78 ± 8.54 |
| Ewa Kupcewicz (2020) | cross-sectional | May 2018 to April 2019 | Poland | Perceived Stress Scale (PSS) | 1002 | 18.60 ± 6.95, |
| 18.55 ± 6.07, | ||||||
| 18.66 ± 4.70, | ||||||
| Yanyan Zhao (2021) | cross-sectional | Not reported | China | Psychological Stress Questionnaire for College Students (PSQCS) |
2999 | 2.11 ± 0.73 |
| Wafaa Aljohani (2021) | cross-sectional | April to June 2017 | Saudi Arabia | Stress in Nursing Students (SINS) questionnaire. |
500 | 118.25 ± 24.29 |
| Yiru Zhu (2020) | cross-sectional | August 2017 to January 2018 | China | The Student Nurse Stress Index Scale (SNSI-CHI) |
1076 | 85.37 ± 18.73 |
| Perceived Stress Scale (PSS) | 25.83 ± 5.95 | |||||
| the Chinese Perceived Stress Scale (CPSS) | 58.37 ± 13.66 | |||||
| Zhiqing Zhou (2015) | cross-sectional | June to September 2019 | China | Nursing Student Stressors Scale (Zhang Guixia) | 590 | 84.42 ± 21.53 |
| Luping Ding (2016) | cross-sectional | February to April 2015 | China | Nursing Student Internship Pressure Scale (Xiao Meilian) | 460 | 1.34 ± 0.36 |
| Lifeng Yang (2020) | cross-sectional | March to April 2019 | China | Stress Sources and Stress Level Evaluation Scale for Nursing Students in Practice (Chu Yanxiang) |
306 | 78.15 ± 15.93 |
| Rujun Hu (2019) | cross-sectional | Not reported | China | Nursing student practice Stress scale(Lazarus) | 121 | 1.43 ± 0.43 |
| Yin Lin (2021) | cross-sectional | Not reported | China | Nursing Student Stressors Scale (Zhang Guixia) | 422 | 59.41 ± 12.00 |
| Zuqing Zhong (2011) | cross-sectional | 2009 | China | Nursing Student Stress Scale (self - made) | 235 | 1.21 ± 0.51 |
| Li Luo (2015) | cross-sectional | 2013–2014 | China | Nursing Student Stressors Scale (Zhang Guixia) | 145 | 3.55 ± 0.87 |
| Dengxin He (2021) | cross-sectional | February to May 2019 | China | Perceived Stress Scale(PSS) | 252 | 21.6 ± 4.9 |
| Feng Li (2021) | cross-sectional | December 2018 | China | College Student Stress Coping Personality Inventory | 836 | 183.1 ± 28.7 |
| Younkyung Lee (2014) | cross-sectional | 9th to 24th 2013 | Korea | The Korean version of Perceived Stress Scale (PSS) |
518 | 15.47 ± 5.49 |
3.3. Basic risk assessment results of included studies
The bias risk assessment results of the included studies are shown in Table 2. Among the 15 articles, the quality assessment grade of 1 literature was high, and 14 kinds of literature were medium.
Table 2.
Bias risk assessment results of included studies.
| ① | ② | ③ | ④ | ⑤ | ⑥ | ⑦ | ⑧ | ⑨ | ⑩ | ⑪ | Score | grade | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| María Dolore Onieva-Zafra (2020) |
Y | Y | Y | N | N | Y | Y | UN | Y | Y | N | 7 | Medium |
| Ewa Kupcewicz (2020) | Y | Y | Y | Y | N | N | Y | Y | Y | Y | UN | 8 | High |
| Yanyan Zhao (2021) | Y | Y | Y | Y | N | N | Y | N | Y | Y | N | 7 | Medium |
| Wafaa Aljohani (2021) | Y | Y | Y | Y | N | Y | N | UN | N | Y | UN | 6 | Medium |
| Yiru Zhu (2020) | Y | Y | Y | Y | N | N | Y | UN | Y | Y | N | 7 | Medium |
| Luping Ding (2016) | Y | Y | Y | N | N | N | N | Y | Y | Y | UN | 6 | Medium |
| Lifeng Yang (2020) | Y | Y | Y | Y | N | N | N | N | N | Y | N | 5 | Medium |
| Rujun Hu (2019) | Y | Y | Y | Y | N | N | N | UN | UN | Y | UN | 5 | Medium |
| Yin Lin (2021) | Y | Y | Y | N | N | Y | Y | UN | UN | Y | UN | 6 | Medium |
| Zuqing Zhong (2011) | Y | Y | Y | Y | N | N | N | Y | Y | N | N | 6 | Medium |
| Li Luo (2015) | Y | Y | Y | Y | N | N | N | Y | N | Y | UN | 6 | Medium |
| Dengxin He (2021) | Y | Y | Y | Y | UN | N | N | N | N | Y | N | 5 | Medium |
| Feng Li (2021) | Y | Y | Y | Y | UN | UN | N | N | N | Y | N | 5 | Medium |
| Younkyung Lee (2014) | Y | N | Y | Y | N | N | N | N | N | Y | N | 4 | Medium |
① Whether the source of the data is clear (investigation, literature review); ② Are the inclusion and exclusion criteria for exposure and no exposure groups (cases and controls) listed or referred to previous publications? ③ Is a time period given for identifying patients? ④ If not from the population, are the subjects continuous? ⑤ Does the subjective factor of the evaluator cover up other aspects of the research object? ⑥ Describe any assessment for quality assurance (e.g. testing/ retesting of primary outcome indicators); ⑦ The reasons for excluding any patients from the analysis were explained; ⑧ It describes how to evaluate and/ or control the confounding factors⑨ If possible, the explanation is that how to deal with the loss of data; ⑩ The response rate and data collection were summarized the integrity of the system; ⑪ If there is a follow-up, identify the percentage of expected incomplete data or follow-up results.
3.4. Meta-analysis results
Fifteen studies[19–33]were included, including 9202 patients. The results of the meta-analysis showed that the average score for stress among nursing students was 3.70 (95% confidence interval [CI]:[3.33, 4.06]). The results showed great heterogeneity (P < .00001, I2=71%), so the random effects model was used for analysis, as shown in Figure 3.
Figure 3.
Meta-analysis results.
4. Discussion
The purpose of this study was to conduct a systematic review, and meta-analysis to determine the prevalence of stress among nursing students in their internship. In this meta-analysis, the prevalence of stress among practicing nursing students was estimated to be 61.97% (CI 95%: 41.013–80.823) using a random effects model. Thus, the results suggest a high prevalence of psychological stress among practicing nursing students, which is very concerning. This is similar to the findings of Lin Bingchun, Cheng Qiuhong et al[34,35]. The reasons for this may be analyzed as follows: first, nursing students enter an unfamiliar clinical environment from the campus, a wide variety of nursing operations, and the gap between the theoretical knowledge learned in school and clinical practice, which can bring some psychological stress to the students.[36] Secondly, nursing students have less social experience and relatively less ability to communicate with people, and poor communication with their supervising teachers, patients and families as well as complex interpersonal relationships can bring corresponding stress.[37]
Mild stress can stimulate the organism to be in a state of tension and stimulate students to study, while high levels of stress or stress lasting too long can cause an imbalance in the organism and lead to physical and mental illness,[38] affecting nursing students’ ability to work in the clinic and even shaking their determination to pursue nursing. If nursing students lack appropriate strategies to cope with stress and the negative effects of their work life, it will not only affect their personal physical and psychological health, but also affect their clinical professional competence, affect the quality of care, and lead to burnout.[39] Therefore, the results obtained through this study suggest that attention should be focused on the stress level of intern nursing students and bring it down to an appropriate level.
Nursing students face multiple psychological stressors during their internship, and studies by Zhiqing Zhou,[25] Luping Ding,[26] and Yanyan Zhao[21] have all shown that among the stressors of internship nursing students, employment stress is the first stressor of nursing students during their internship. It is said that this may be related to the fact that the number of nursing students graduating has been increasing year by year in recent years, while the number of jobs offered by major hospitals is becoming less and less, the employment situation is becoming increasingly severe, and the gap between nursing students’ career expectations and employment reality causes them greater stress.[40,41]
Yin Lin,[29] Zuqing Zhong,[30] and Li Luo et al[31] reported that internship nursing students’ stressors to their knowledge and skills are the main stressors of nursing students’ internship. The reason for this is that nursing students end their familiar campus life and step into clinical practice, which brings them different degrees of stress due to the change of identity, learning environment, and employment pressure.
Dengxin He’s study[32] showed that intern nursing students’ professional identity and psychological resilience were influential factors of psychological stress. This is similar to Yanyan Zhao’s study[21]: stress was negatively correlated with nursing students’ professional identity, and the higher the professional identity and the stronger the psychological resilience of intern nursing students, the lower their psychological stress levels.
5. Limitations of this review
This review has important limitations. The most relevant shortcomings of this paper need to be extensively reported. We extracted data from cross-sectional studies to summarize associated factors; therefore, we must note that this type of study design is not suitable for making causal infer. Due to the characteristics of single rate meta-analysis, the included studies had high heterogeneity. Objective factors such as the source of literature and the amount of information provided have a certain impact on the research results. Therefore, it is necessary to carry out higher-quality case-control studies and cohort studies to provide evidence for clinical practice.
6. Conclusion
This study showed that the stress level of intern nursing students was mainly moderate, this result shows that the mental health of nursing students deserves our attention, and the intervention research of nursing students should be strengthened in future related research. In addition, in future studies, the stress level of intern nursing students should be accurately and comprehensively assessed and analyzed, and different specific interventions should be given for different stressors, which is important to promote the physical and mental health of intern nursing students, improve the quality of internship and improve clinical teaching.
Abbreviations:
- AHRQ =
- the Agency for Healthcare Quality and Research
- ASNS =
- Assessment of Stress in Nursing Students
- CNKI =
- China National Knowledge Infrastructure
- PSS =
- the perceived stress scale
Y-XZ and J-RJ contributed equally to this work.
The corresponding author has full access to all data in the study and is ultimately responsible for the decision to submit for publication.
The authors report no funding or conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Additional unpublished data is only available to authors.
How to cite this article: Zheng Y-X, Jiao JR, Hao W-N. Stress levels of nursing students: A systematic review and meta-analysis. Medicine 2022;101:36(e30547).
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