Article

Aspects of nurse education

programmes that frequently
cause stress to nursing
students fact-finding
sample survey
Fiona Timmins and M. Kaliszer

Fiona Timmins
RGN, BNS, FFNRSCI,
MSc, Lecturer/
Course Leader,
School of Nursing
and Midwifery,
Trinity College
Dublin, Trinity
Centre for Health
Sciences, St. James's
Street, Dublin 8.
Tel: 35 31
608 3699;
E-mail: timminsf@
tcd.ie
M. Kaliszer MSc,
Lecturer in Statistics,
Department of
Community Health,
Trinity College,
Dublin 2, Ireland
Manuscript
accepted:
19 September 2001

This study examined reported stress in 12 areas commonly reported to cause stress to
nursing students. A questionnaire was distributed to 110 third-year nursing students, and
the results indicate that stress exists for students in both the clinical and academic aspects
of the programme. Financial constraints and academic-related concerns emerged as the
most stressful areas for the students. A third of the students reported that relationships
with teachers and staff on the ward cause some degree of stress. Factor analysis revealed
that five factors emerged as sources of stress. Firstly, `academic' stress factors. The
second and third components concern relationships, the former involving teaching-related
staff, and the latter involving the clinical experience. The last two components suggest
that finance and death of patients are independent sources of stress. Major restructuring
is about to take place in nurse education in Ireland, with the introduction of degree
preparation for all nursing students in 2002. It is imperative that those involved with
nursing students, both in the clinical area and in education settings, take cognisance of
the stress that current students face. Recommendations for educators include adequate
support structures for clinical areas, preceptorship programmes and the availability of
student counselling services. & 2002 Published by Elsevier Science Ltd

Introduction
Nursing students up and down the
country are facing unprecedented stress
levels . . . nursing students have never had
it so bad. They are feeling the fall out
from the `revolution in nurse education'
and it is starting to take its toll.
(Snell 1995)
This anecdotal piece by a journalist published
in the Nursing Times indicates concern with
the effect that the changes in the structure in
nurse education are having on the student

& 2002 Published by Elsevier Science Ltd

doi:10.1054/nedt.2001.0698, available online at http: // www.idealibrary.com on

nurse population (Snell 1995). Although the

overall effects are not empirically tested,
several researchers indicate that the
programme is stressful and some suggest that
this stress is greater than that experienced by
certificate nursing students (Hamill 1995,
Lindop 1999). Nursing is recognized as a
stressful occupation. It was reported in 1993
that 170 000 nurses, doctors and other UK
health service staff suffered from mental health
problems each year, with a total loss of
80 million working days (News Report 1993).
Hence the issue of stress is an important

Nurse EducationToday (2002) 22, 203211 203

Aspects of education programmes that cause stress

consideration for educators of nursing

students, who, although supernumery to the
workforce and not officially employees of the
hospital, undoubtedly engage in a wide range
of patient care interventions. In addition, of
course, these students are faced with a wide
range of academic commitments, which may
further contribute to the development of stress.

Literature review
A review of the literature was performed to
examine the nature of stress experienced by
student nurses. The information for this
review was obtained from a search of the
databases Medline and the Cumulative Index
to Nursing Allied Health Literature (CINAHL).
A combination of key terms `student nurse',
`student' and `stress' were used. Manual
searching of relevant nursing journals and
sourcing of secondary references extended
the search. The literature review process
involved critically reviewing the studies. Nurse
education programmes were identified as a
source of stress to students in several studies
(Lindop 1991, Clarke & Ruffin 1992, Thyer &
Bazeley 1993, Hamill 1995, Rhead 1995,
Mahat 1996).
The dearth of literature examining this
topic in Ireland and the lack of consensus
regarding the definition of stress in this
group requires an exploration of the literature
that examines the phenomenon of stress in
the student nurse population. Lindop (1991)
explored the stress experiences of 413 student
nurses at various stages of training. Data
were collected using a 144-item questionnaire
devised by the author, based on a previous
study. Twenty-eight student nurses validated
the instrument. It was administered during
study periods in the school of nursing. The
results indicated that most learners saw
nursing as a good career and as a means of
personal fulfilment. The findings also revealed
a general agreement that stressful situations
exist in nurse education. Stressors included
examinations, and the intense amount of
work. Learners generally agreed that stress was
also present in the clinical area due to the
conflict between `ideal' and `real' and the
pressure of time when performing duties.
Specific experiences that caused stress included

204 Nurse EducationToday (2002) 22, 203211

`unfriendly atmosphere in the ward', `lack of

teaching and interest in learners', and being
reprimanded in front of staff and patients.
Dealing with death and dying also produced
stress and was experienced by third-year
students more than other levels of student.
Exhaustion was also a common manifestation
of stress. Lindop (1991) concluded that it was
the responsibility of managers of education,
including ward staff, to encourage student
morale. The need for an `open management
style' was emphasized and replacement of
the traditional `hierarchy of nursing' with
`supportive leadership'.
In a follow-up study, Lindop (1999)
compared the reported stress of 146 student
nurses undertaking a diploma programme to
the reported stress of the traditional students
who were studying at the college in 1988
(Lindop 1991). The same questionnaire was
used to collect data. The findings revealed
that the `intense amount of work' was more
stressful for the diploma students. However,
stress related to the clinical area was similar
in both groups.
Clarke and Ruffin (1992) examined
perceived sources of stress among 306 student
nurses from three institutions in the USA.
Data were collected using two self-reporting
questionnaires. The response rate was 72%.
The initial questionnaire assessed demographic
data and perceived stressors, which were
then used to form the basis of the second
questionnaire assessing 28 potential stressors.
The analysis of the mean results indicated
that the major stressors for nursing students
were the `total amount of work to be
completed', `coping with exams', `handling
emergencies in the clinical area', `fear of
making mistakes', `coping with the theoretical
course work' and `coping with terminally ill
patients'. The factors causing least concern
included `living away from home', `interaction
with fellow students', `interaction with
academic staff', `handling excreta' and
`interaction with patients'. The area with the
highest score for stress was study.
Thyer and Bazeley (1993) explored stressors
of 79 student nurses commencing a nurse
education programme in Australia. Data were
collected using a 38-item questionnaire
containing a series of items describing aspects

& 2002 Published by Elsevier Science Ltd

Aspects of education programmes that cause stress

of student life which may be stressful.

These items were constructed from a
previously used questionnaire designed from
a qualitative study of student nurses' stress
(Silus & Cooper 1985, cited in Thyer & Bazeley
1993). The questionnaire contained six broad
headings: general matters, assignments,
study, lecturers' time for consultation,
coursework and the course programme.
This was distributed during class time with
a 100% response rate. The subjects responded
to each item using a five-point likert scale.
Analysis of mean scores revealed that
students reported all areas as a source of
anxiety. Submission and assessment of
required work were areas where the greatest
anxiety was reported. Personal/interpersonal
items did not rate highly as a source of
stress, with the exception of finance, which
was rated as moderately stressful.
Hamill (1995) examined 35 third-year
student nurses' perceived stress in relation to
their diploma programme, utilizing a
qualitative approach. Data were collected
using an initial self-reporting questionnaire
followed by an in-depth recorded interview.
The questionnaire elicited information on
students' perceived stress, which was used
to guide the interviews. The interviews
were conducted using a grounded theory
approach. The questionnaire yielded a 52%
response rate. The major finding arising from
the study suggested that student nurses'
perceived stress related directly to two main
areas: college-based stressors and ward-based
stressors. These themes were labelled
`non-integration with tertiary education'
and `non-integration with the ward team'.
Non-integration with tertiary education
involved `not being treated as an adult
learner', `confusing assignment guidelines',
and, `the amount of self-directed learning'.
`Non-integration with the ward team' involved
the students' `lack of practical skills',
`negative attitudes' of the ward staff' and
`misunderstanding of supernumerary status'.
A core variable was identified which explained
this `non-integration' and was called the
`dependence/independence continuum'.
Hamill (1995) suggested that the students
experienced stress due to a total contrast
between their expectations of the programme

& 2002 Published by Elsevier Science Ltd

and the actual reality of the programme.

However, generalizing from the results of
this qualitative study is difficult given the
contextually subjective nature of the data,
and the author acknowledges this. There was
also poor response rate to the initial
questionnaire.
Rhead (1995) compared stress among
55 students undertaking a nursing certificate
programme and 51 students undertaking a
diploma programme at two different venues
in the UK. Data were collected using a
34-item questionnaire. The questionnaire was
an adaptation of the nurse stress scale
questionnaire (Graytoft & Anderson 1981
cited in Rhead 1995) with 16 extra items
derived from two in-depth interviews. Mean
results indicate that diploma students were
significantly more stressed than certificate
nursing students. This stress related to
practical and academic aspects of the course
equally. Factor analysis of the items on the
questionnaire revealed three overall factors
relating to stress. These were `the practical
elements of the programme', `the academic
elements', and, `issues of death and suffering
within nursing'.
Mahat (1996) examined events in the
clinical setting which 104 first-year nursing
students in Nepal identified as stressful.
Data were collected using critical incident
technique, where students were asked to
recall and write down the most stressful
event that they have experienced during
their clinical experience. From the findings
and a review of the literature, data were
classified into four categories: interpersonal
relationships, initial experiences, feeling
helpless and demeaning experiences.
Descriptive analysis was then applied. The
most frequently reported stressful event
was interpersonal relationships (50%). The
teacherstudent relationship was cited by
the author as one of the major sources of
stress in the clinical setting. However, only
35% of respondents report this. Interpersonal
relationships with staff nurses were reported
stressful by only 4% of the respondents and
29% reported clinical experiences as stressful.
Reliability and validity of the findings were
not assured and the role of the teacher in
the clinical area was not outlined.

Nurse EducationToday (2002) 22, 203211 205

Aspects of education programmes that cause stress

Using the same methodology, Mahat (1998)

examined all junior baccalaureate nursing
students' perceived stressors at one US
university. Descriptive analysis revealed five
categories: initial ward experiences,
interpersonal relationships, ability to perform,
heavy workload and feelings of helplessness.
Initial ward experiences were identified as
the stressor most frequently reported by the
students (34%). Twenty-seven percent of
students report interpersonal relationships as
a source of stress, 45% of these students
report problems interacting with their teachers
and 28% experience problems interacting
with staff nurses on the wards. However,
in the discussion the author states that 45%
of the sample report problems interacting
with their teachers and this is misleading, as
the true percentage is only 12.1%. This leads
Mahat (1998) to conclude that, `no matter
where the study was done, nursing students
perceived negative interpersonal relationships
with teachers', although this statement was
not supported by the data.
Cavanagh and Snape (1997) explored
sources of stress experienced by 72 student
midwives at various stages of training. Data
were collected using a self-reporting
questionnaire containing a grid enabling the
student to record stressful experiences under
three headings: a little, much and very much.
The response rate was 40%. The findings
revealed that tutors were a major source of
`very much' stress to the students. This
included tutors being insensitive to students'
needs, criticism in front of peers, and being
made to feel inadequate. Clinical placements
were another source of `very much' stress
due to the behaviour of staff, dealing with
procedures for the first time and working
with insensitive staff. Course work including
examinations and assignments, emerged as
a source of `a little' stress. Although
generalizing from qualitative studies is
difficult due to issues of reliability, this study
employed a large sample, thus adding
credibility to the results. Illuminating the
students' lived experience of stress from the
programme was also very informative.
Jones and Johnson (1997) measured levels
of stress and distress in first-year student
nurses using a quantitative approach. The

206 Nurse EducationToday (2002) 22, 203211

sample comprised 220 nurses at one hospital.

Instruments used to collect data include the
General Health Questionnaire (GHQ) and the
Beck and Sirvastava Stress Inventory (BSSI),
and were administered to students attending
a lecture, with a 100% response rate. The
findings revealed that common sources of
stress included academic items such as `fear
of failing', `lack of free time', `long hours of
study' and `college response to student need'.
Levels of distress identified in the study
were higher than that of fourth-year medical
students and the general female population
(Jones & Johnson 1997). Limitations of the
study include convenience sampling and lack
of a pilot study.
Kirkland (1998) examined stressors among
23 female African US baccalaureate nursing
students in the USA. Demographic data and
information about stressors were collected
using a questionnaire and structured interview.
The findings revealed that the reported priority
stressors are academic (37%), environmental
(21%), financial (17%) and interpersonal (12%).
The most frequently reported academic
stressors were `failure' and `uncertainty related
to performance', `expectations for written
work' and `clinical practice'.
Four main themes emerged, namely
stress-related factors that are present in the
clinical learning environment, academic
stress, stress among nursing diploma
students, and stress due to interpersonal
relationships. As a consensus emerged
regarding items, these themes were used to
develop the instrument used in the study
that is described in this paper. The clinical
learning experience was identified by several
studies as one of the main stressors to
nursing students (Lindop 1991, 1999,
Clarke & Ruffin 1992, Hamill 1995, Rhead 1995,
Mahat 1996, 1998, Jones & Johnson 1997).
There was also general agreement that
academic stressors exist (Lindop 1991,
Clarke & Ruffin 1992, Thyer & Bazeley 1993,
Hamill 1995, Rhead 1995) and some writers
suggested that there was an increase in
academic-related stress since the advent of
the diploma programme (Rhead 1995,
Lindop 1999). Interpersonal relationships
with both ward staff and teachers have
also been identified as potential stressors

& 2002 Published by Elsevier Science Ltd

Aspects of education programmes that cause stress

(Mahat 1996, 1998). The themes emerging

from the literature were as follows.

Stress-related factors that are present

in the clinical learning environment
Many factors have been identified that cause
stress to nursing students in the clinical area.
Witnessing death and dying emerges
frequently in the literature (Lindop 1991,
Clarke & Ruffin 1992, Rhead 1995).
Demeaning experiences have also been
reported as stressors (Lindop 1991, Mahat
1996). Other stressors that have been
identified include handling emergencies in
the clinical area, fear of making mistakes
(Clarke & Ruffin 1992), an unfriendly
atmosphere in the ward (Lindop 1991),
initial ward experiences (Mahat 1996, 1998)
and feelings of helpless (Mahat 1996, 1998).

Academic stress
Academic stressors that have been identified
among nursing students include examinations
and assignments (Lindop 1991, Thyer &
Bazeley 1993, Jones & Johnson 1997), the
intense amount of work (Lindop 1991),
theoretical course work (Clarke & Ruffin 1992),
study associated with the programme
(Clarke & Ruffin 1992, Thyer & Bazeley 1993,
Jones & Johnson 1997), general academic
elements (Rhead 1995) and lack of free time
(Jones & Johnson 1997). In some studies,
academic stressors scored more highly than
stress associated with the clinical learning
environment (Clarke & Ruffin 1992, Thyer &
Bazeley 1993). In addition, Lindop (1999)
demonstrated that academic stress and
theoretical workload associated with the new
diploma programme, Project 2000, were more
stressful for the current diploma students
compared with the certificate-nursing
predecessors.

Stress among nursing diploma

students versus traditionally
trained students
Rhead (1995) and Lindop (1999) demonstrated
that both academic- and ward-related
stressors exist for diploma nursing students.
This stress may be the intrinsic stress

& 2002 Published by Elsevier Science Ltd

associated with both of these domains, but

may in part be caused by `non-integration'
into the university sector as described by
Hamill (1995). He suggested that students
who spend their time alternating between
hospital and community placements and the
university setting often fail to identify
sufficiently with one institution or the other.
Another source of stress that emerged for
diploma students is that of financial
constraints. In the past, as hospital employees,
students received a salary. Now they survive
on a maintenance grant. This is normal for
undergraduates, but these students attend
the programme for up to 48 weeks of the
year, leaving little time for students to earn
extra money to support themselves. Although
Thyer & Bazeley (1993) state that finance as
a source of stress, `is not a matter for concern
to educators'. However, given on-going
structural changes in nurse education in
Ireland, financial hardship may be a reality
for some students. If this impacts on the
educational programme through absenteeism,
drop-out, poor examination performance or
poor clinical performances, it is likely to
become a nurse educator's concern.

Stress due to interpersonal

relationships
Mahat (1996) reported that interpersonal
relationships arise as the most frequently
reported stressful events in the clinical setting
for half the students in a study of 104 nursing
students in Nepal. Mahat (1998) stated, `no
matter where the study was done, nursing
students perceived negative interpersonal
relationships with teachers' [sic]. However,
relationships did not appear to be a major
source of stress in other studies.
Nurse education in Ireland has
undergone tremendous change in the last
6 years with the advent of the diploma
programme for nurse education. It has yet to
face its greatest challenge to date, with the
implementation of a 4-year degree programme
for nurse preparation commencing in 2002
(Government of Ireland 1988). In order to
develop a student-friendly curriculum, it is
necessary to have an insight into and some
understanding of current stressors faced by

Nurse EducationToday (2002) 22, 203211 207

Aspects of education programmes that cause stress

nursing students. It is important to ascertain

whether current diploma students in Ireland
find certain items stressful. From the literature
it is evident that nursing students at both
certificate and diploma-based programmes
experience stress as a result of their academic
commitments and their experiences in the
clinical environment (Lindop 1991, 1999,
Clarke & Ruffin 1992, Thyer & Bazeley 1993,
Hamill 1995, Rhead 1995, Mahat 1996, 1998,
Jones & Johnson 1997). There is also some
evidence to suggest that the stress due to the
academic component of the programme is
greater than previously demonstrated in
certificate student nurses (Rhead 1995,
Lindop 1999). Some studies also identify
interpersonal relationships with both staff
nurses and teachers as another source of
stress (Mahat 1996, 1998). It is important to
ascertain whether current diploma students
in Ireland find these items stressful: clinical
learning environment, academic stress, stress
among nursing diploma students, and stress
due to interpersonal relationships.

Materials and methods

One of the research objectives of this study,
which formed part of a larger study (Egan,
2000), was to investigate factors that cause
stress to nursing students. The population
addressed by the study are student nurses
undertaking the 3-year diploma in nursing
studies in Ireland. A sample survey of these
student nurses was carried out in November
1999. A 12-item questionnaire, based on
themes from the literature on stress in
student nurses, was used to collect data and
the respondents were asked to record their
response to each item on a four-point Likert
scale. The questionnaire was distributed to
all third-year students except 10, at two
separate hospital sites in Dublin, who were
present in class on the day of the study
(n 110), and assumed to be representative
of the target population. Six students were
absent on the day.
The ten excluded students were randomly
selected from the main sample of 120 to form
the pilot group for the purpose of testing the
main questionnaire. The pilot study was used
to identify problems in data collection and

208 Nurse EducationToday (2002) 22, 203211

analysis that could be rectified before

commencement of the main study. `Travelling
to secondments' was identified as an
additional stressor during the pilot, and the
questionnaire was modified accordingly. A
statistical package SPSS was used to analyse
the questionnaire responses. Data were
analysed by means of frequency distributions
of responses, mean scores, and principal
component analysis (PCA). The pilot
questionnaire was readministered after 1 week.
The test and retest pilot questionnaires were
highly correlated despite the small sample
sizes, indicating high reproducibility. The
values of the correlation coefficient (Pearson r)
for 14 of the 19 questions were large and
statistically significant (r > 0.5, P < 0.05). It
was assumed there was no systematic change
in the responses between the two
administrations. A panel of six nurse experts
ensured the content validity of the
questionnaire and one item was added:
relationships with clinical placement
coordinators (CPCs). CPCs are employed in
hospital-based nursing practice development
units in Ireland, and work alongside staff in
the clinical areas to facilitate student learning.
There was 100% take-up of the main
questionnaire and all the students responded
to all the stress-related questions.
Permission to conduct the study was
granted by Principal Tutors in each of the
schools of nursing and the Director of Nursing
where appropriate. Assurances of
confidentiality and anonymity of subjects and
hospitals involved was given and written
consent was obtained from all the students
involved. It was emphasized to the students
that the information obtained would be used
for the purposes of the study only and
questionnaires would be destroyed upon
completion of the study.

Results
Students were asked to consider statements
about factors that may cause stress, and to
select one of four stress levels in response to
each statement. The overall results for this
section are presented on Table 1. The levels
of stress were scored from 1 (not at all stressful)
to 4 (extremely stressful). Factors associated

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Aspects of education programmes that cause stress

Table 1

Distribution of percentage and mean responses to factors that may cause stress

No

1
2
3
4
5
6
7
8
9
10
11
12

Stress factor

Levels of stress percent breakdown

Mean
score

Description

Not at all
stressful

Moderately
stressful

Very
stressful

Extremely
stressful

Theory
Examinations
Assignments
Workload
Classroom hours
Financial constraints
Secondments: travel
Clinical placements
The death of a patient
Relationships with
ward staff
Relationships with nurse tutors
Relationships with clinical
placement coordinators

4
1
0
0
19
0
8
16
3
32

41
23
32
21
53
14
44
68
45
58

44
53
44
52
21
14
27
15
36
6

11
23
24
27
7
72
21
1
16
4

2.63
2.97
2.92
3.06
2.16
3.59
2.61
2.01
2.65
1.82

67
72

29
25

3
1

1
2

1.37
1.33

with academic performance, clinical

placements, financial constraints, death
of a patient and relationships with staff on
the wards cause considerable stress (mean > 2),
whereas relationships with nurse tutors
and clinical placement coordinators were
reported to be at most moderately stressful
(mean < 1.5). Financial stress received the
highest mean score and most students found
this factor extremely stressful.
All subjects agreed that the assignments
on the course, the workload of the course
and the financial constraints of the course
caused some degree of stress. The majority
of subjects agreed that scheduled examinations
(99%), being involved in the death of a
patient (97%), the theoretical content (96%),
travelling to secondments (92%), clinical
placements (84%), the classroom contact
hours (81%), and relationships with staff on
the ward (68%) caused some degree of stress.
A small proportion of subjects indicated
that relationships with nurse tutors (33%)
and relationships with clinical placement
coordinators (28%) caused stress.
Factor analysis (PCA) was carried out on
the 12 stress factors and five components
were extracted from the 12 original stress
factors (using varimex rotation, and retaining
all components with eigen values >1. All
and only the retained component loadings
were >0.05 and were statistically significant

& 2002 Published by Elsevier Science Ltd

at P < 0.01). The factors were as follows:

1. Theory, exams, assignments, workload,
contact hours
2. Relationships with tutors, relationships
with CPCs
3. Clinical placements, relationships with
staff on wards
4. Finance
5. Death of a patient.
The first component combines all the
`academic' stress factors. The second and
third components concern relationships, the
former involving teaching related staff, and
the latter involving the clinical experience.
The last two components suggest that
finance and death of patient are independent
sources of stress.

Discussion
This study supports the view that factors
concerning both the academic and clinical
component of nurse education programmes
are sources of stress to nursing students.
Academic commitments and financial
constraints emerge as the greatest source of
stress to students in this study. Academic
stress is well documented (Berman 1981,
Jones & Johnson 1997, Kirkland 1998,
Lindop 1991, 1999, Clarke & Ruffin 1992,

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Aspects of education programmes that cause stress

Thyer & Bailey 1993, Hamill 1995, Rhead 1995)

and some studies of diploma nursing
students demonstrate that students find this
component of the programme more stressful
than the clinical area (Clarke & Ruffin 1992,
Thyer & Bailey 1993). Consideration needs to
be given when programme planning to
ensure that academic `overload' does not occur.
Most students report that clinical
placements, being involved with the death of
a patient and relationships with staff on the
wards are sources of stress, and this concurs
with previous findings in this area (Berman
1981, Lindop 1991, Clarke & Ruffin 1992,
Hamill 1995, Mahat 1995, 1998, Rhead 1995).
There is a high correlation between reported
stress from relationships with staff on the
ward and reported stress from the clinical
area, suggesting that the experience of
difficulty with interpersonal relationships
with the ward staff is likely to affect the
students' overall perception of the placement.
Furthermore, since 68% of the students
report relationships with staff on the ward as
causing some degree of stress, this is an area
that requires closer attention. Clinical
placements by their very nature confront
students with many stressors. Witnessing
death and suffering among patients, have an
emotional impact on learners. Supportive
relationships with staff on the ward need to
be developed to lessen the impact of these
events, and equip students to deal with them.
The exact nature of current difficulties may
require further examination, to identify the
nature of the relationships on the ward that
students may find stressful. In the meantime,
however, it is essential that ward-based
teachers and clinical placements coordinators
develop strategies to strengthen studentstaff
relationships. This may include the
introduction or further development of
preceptorship programmes, facilitating
communication between the university and
the clinical area and continuous education of
staff in student-related matters.
These findings support those of Mahat
(1996, 1998) that teachers are a source of stress
to students. Approximately a third of the
students in this study reported that
relationships with teachers and clinical
placements coordinators cause some degree

210 Nurse EducationToday (2002) 22, 203211

of stress. Most students do not report stress

from interpersonal relationships. For those
who do, they are more likely to report stress
in all three relationship categories (tutors,
clinical placements coordinators and staff
on the ward). In addition, although most
students find the academic component of
the course stressful, there is no correlation
between reported stress from relationships
and academic stress. Students who report
academic stress are likely to report stress in
all categories (scheduled examinations, the
theoretical content, classroom contact hours,
the workload of the programme). This
individual nature of stress that is displayed
may necessitate the need for greater student
support structures, such as student counselling
to be available to students.
The most striking feature of the study is
that the financial constraints of the programme
are a source of stress to 99% of the students.
Finance as a source of stress is a relatively
new phenomenon, possibly because students
were paid employees in the past. Older
studies indicate that students have little
concern with pay (Clark 1975, Price 1984),
however more recent studies (Thyer & Bailey
1993) report finance as a moderate source
of stress. Thyer and Bailey (1993) suggest
that this factor is not a concern for nurse
educators, however the overall effect of
financial stress on the students may require
further examination. Consideration may
also need to be given to reducing the
total student contact hours to allow students
to fulfil financial obligations though
part-time work.
This study has limitations that must
be considered when interpreting the
results. Firstly, it was a small exploratory
study that only considered 12 common
student stressors. Each of these individual
stressors could be explored in more detail,
for example the clinical area may have a
multitude of stressors and this was
examined as one item. Secondly, quantitative
analysis of the stressors limited information.
More detail would be attainable by
qualitative techniques. However, despite
these limitations the results of the study
appear to concur with previous findings
on this topic.

& 2002 Published by Elsevier Science Ltd

Aspects of education programmes that cause stress

Conclusion
Many academic aspects of current nurse
education programmes appear to cause
stress to nursing students. Those educators
responsible for curriculum design need to
take cognizance of the possible emotional
consequence of a challenging curriculum.
Teacherstudent relationships are another
source of stress to many students and adequate
support structures for students while on
clinical placements is essential. Furthermore,
all personnel involved with teaching nursing
students need to be adequately prepared for
dealing with students, and become aware of
their own impact on students.
These potential stressors, together with
the fact that most students of today are
experiencing considerable financial pressure,
require that student counselling services are
readily available to equip students early on
to face the challenges entailed in a demanding
profession such as nursing.

Acknowledgements

We would like to acknowledge the assistance

of An Bord Altrainais, Dublin, who provided a
scholarship towards this project.

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