Pacific Adventist University

Title: Literature Review: The common causes and or contributing factors that increases

stress level and its impact on undergraduate nursing student’s mental and physical health and

academic performance.

An essay presented in

partial fulfilment of the

requirement for the subject

HN291- Research in Nursing 1

BY: Marjohry. Emmanuel

Date: 2nd of May 2019

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“The common causes and or contributing factors to increase stress level and its impact on

undergraduate nursing student’s mental and physical health and academic

performance”

Stress is associated with anxiety and depression among nursing students and is defined as

the state of mental or emotional strain or tension resulting from adverse or demanding

circumstances that has an impact on student’s health leading to poor academic performances

(Bosco, Silva & Costa, 2016). Undergraduate nursing training is complex (Bosco, et al, 2016)

and challenging as nursing is one of the most stressful profession globally (Najimi, Goudarzi &

Sharifirad, 2012) therefore, students undertaking this professional training encounter numerous

tremendous stressors at certain stages or even all throughout the entire course training period.

These stressors are due to the fact that nursing students undertake both theoretical and practical

or clinical aspect of the academic lessons which requires more dedication of time and

commitment all throughout the learning period (Rathnayake & Ekanayaka, 2016; Souza, Costa,

Rodrigues, Bevilaqua, Inoue, Oliveria, & Matsuda, 2017).

From the three articles, Article 2 by (Souza, et al, 2017) and the Article 3 by (Bosco, et al, 2016)

hold a common aim which is to determine the stress level among the undergraduate nursing

students, however, the Article 3 specifically focus more on comparing biosocial, academic

profile and the stress level between the first and final year nursing students while Article 1 by

(Rathnayake & Ekanayaka, 2016) aims to examine the incidence between depression, anxiety

and stress among nursing students. Although all Articles have relationship in their aims, which

Article 2 and Article 3 shared almost a common aim, the reasons to these aims and study

conducted are not exactly the same, but, all these studies were conducted because of the need

identified in the previous studies. In Article 1, the study was conducted because an undergraduate

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nursing programme was just introduced to the university system in Sri Lanka and the students

encountered several difficulties in addition to the common stressful indicators specific to the

nursing education. Moreover, there is little evidence relating to mental health problems among

university nursing students in Sri Lanka (Rathnayake & Ekanayaka, 2016). The reason for the

study conducted in Article 2 was because of identified serious signs of depression among nursing

students and highlights time management as the main stressor in previous studies (Souza, et al,

2017). Based on few studies that have evaluated and compared stress factors and levels between

first and final year nursing students, the study in Article 3 came about and its reason is to identify

the variation of stress levels and the factors that contribute the most to the phenomenon

throughout the course of nursing (Bosco, et al, 2016).

The intention of this review is to investigate the common causes and or factors that increased

stress level and in all the three Articles and to identify its impact on undergraduate nursing

student’s mental health and academic performances.

Study Method: Population, sample, tools and ethical clearance

The study population targeted in all the Articles was the undergraduate nursing students.

The Articles 1 and 2 study population covers all the undergraduate university nursing student

from year 1 to year 4 meanwhile, Article 3 involved only the first and the final year students. The

study method that was used to conduct the study on the targeted population as per Article record

was a quantitative cross-sectional study design.

In regard to sampling, Articles 1 and 2 study participants are representation from various course

years while Article 3 samples are only from first and final years. In Articles 2 and 3, the sample

selection apart from the course years, age was considered specifically the age group above 18

year.

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The Article 1 involved students in all year courses due to small number of undergraduate nursing

students enrolled at the university, the sample selection excluded students with previous

diagnosis of major psychiatric diseases and those who cannot read and understand Sinhala

language which resulted in reduced sample size. From the reduced sample size, only 86.4% fully

participated in the study. In Article 2, the selection for the sample includes students who are

regularly enrolled at the university and those over 18 years of age, out of the 134 nursing

students of various course years, 111 students became the sample for the study. In Article 3, the

study population was represent by all students enrolled in the first and fourth year totaling up to

83 students.

In all the three articles, a common tool used for data collection was questionnaires. In Article 1

the only tool used was a self-administered questionnaire consisting of 6 sections. For Articles 2

and 3, a proposed instrument by Costa and Polak for assessing Stress in Nursing Students was

used which consisted of 30 items grouped into six parts. In both studies, a Likert-type scale was

used to present these data which is purposely for collecting and grouping the points from the

respondents from ranges 0-4 depending on the criteria of the questions asked. More to that, the

Article 3 used both email and face-to-face distribution of questionnaire approach to collect data,

however, in both channels the same questions were asked, this approach was due to technical

faults and some students could not access their emails, so this are the group of students that were

given hard copy of the questionnaires.

The three Articles data statics were recorded and analyzed using the Statistical Package for

Social Sciences (SPSS), where Article 1 used version 22, Article 2 used version 20 and Article 3

used version 10.0. Apart from the use of SPSS, Article 3 also utilized Excel Software (office

2007) to record and organized the study findings and analyzed accordingly.

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Before the three studies were conducted, an ethical clearance was done and approved by the

Ethics committee in each respective university and permission was given for data collection, also

consent forms were issued and signed by the study participants which allowed commence of the

study.

Summary of Main themes

The common factors that contributes to increased stress level and poor academic

performances among undergraduate nursing students in the three universities where studies were

conducted includes: poor time management; increase workload and insufficient financial income.

Article 1 also revealed physical well-being health factors also increases stress level and poor

academic performance. Moreover, Article 1 and 3 explored that increasing age with increase

course years is another causative factor that increases stress level and poor academic

performance meanwhile Articles 2 and 3 defined fear and concern for future professional as

another leading cause of increasing stress level and poor academic performance among the

students.

The factors “poor time management” and “increase workload” are interrelated in these scenario.

Poor time management was identified across all course years, however, Article 3 found that the

first years are faced with more time-related issues than the other course years this is because they

are beginners in the nursing course and the university life to them is all new hence, adapting to

the new environment puts a lot of pressure on them. The Three studies also showed that with

increasing workload, there seemed to limited time available for students to perform all required

academic and or extracurricular activities and less or no time for personal life. When student do

not complete the tasks or accomplish the required task or even have time for own social life, it

adds another lot of pressure apart from other stressors and students turned to experience stress

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and other stress-related mental issue such as anxiety, which in turn to reduce the student’s ability

to perform with their best thus, end up achieving poor academic results. To avoid this matters,

students need to develop skills of good time management if need to prevent stress.

Articles 1 and 3 results showed that stress level increases with increasing age meaning that

nursing student in the junior years’ have lesser stress levels than the senior students. This is

because students in senior classes face problems in academic and personal life compared to the

younger students. For instance, the fourth years need to accomplish all heavy academic workload

and practical procedures also to pass the examination in order to graduate, this components

contributes to increase stress levels. With increased academic workload and pressure from

extracurricular activities within a short period, students tend to accomplish tasks without

spending more time to (re)check their task after accomplishing thus, they end up achieving

poorly in academic results.

Insufficient financial income is another mutual factor in all the studies conducted that contributes

to increased stress level and poor academic performance. Most students come from low income

earning families and they could not afford for more in terms of personal needs or pay tuition fees

within the given time frame and unable to pay for proper accommodation, these constituents turn

to increase stress among students. Studies shows that students experiencing stress turn to focus

less on academic work and as a consequence, they perform poorly in academic work. In addition,

the study in Article 2 found that because of insufficient income, majority of students perform

some kind of paid work which helps them financially however, it causes negative interference

with student’s schedules for academic obligations and social life, students involved in this have

difficulty in concerntration, low quality sleep and deficit in learning.

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Physical health is an important factor to student’s life and may affect their academic life and

professional life. Article 1 results showed that students presented many students have 1-9

physical well-being factors, with poor physical health and well-being, the student may be

affected mentally with stress related symptoms and end up performing poorly in test and exams,

when someone health is not balance, stress turned to be present.

Studies in Articles 2 and 3 found that as nursing students transit into next level of the course their

fear and concern for professional future also increases, the fear of making mistakes in

competencies, fear of not getting employed after completion of the course due to high

competition between other graduate nursing students, students also worry about not having

adequate knowledge and skills and thus they turn to avoid taking risks and feel more vulnerable

when exposed to the practical environment. These are the product of increasing requirements for

skills, increase productivity at work among trainee nurses that puts nursing students under high

pressure and (Nechita, Streba, Vere, Nechita & Rogoveanu, 2014) therefore, signs of emotional

imbalance such as anxiety and or worry early in the graduate course and all these issues becomes

the contributing factor to increase stress level which leads to decrease academic excellence.

Above all, the studies affirm the need for establishment of stress management and coping

mechanisms established for the undergraduate nursing students such as counselling centers in

place in order to prevent stressors that increases stress levels and affects academic performances.

Strengths

In all the presented Articles, each possesses its own area of strength. The Article 1 considered the

study as one of the initial studies that explore stress among undergraduate nursing students.

Therefore, it serves as baseline for future studies. In Article 2, the study results or findings served

as the source of knowledge for coordinators of the nursing undergraduate courses to (re)plan

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their teaching or educational projects, in order to establish preventive and or coping measures

that aimed at reducing the stress factors during the training process of nurses. The investigation

in Article 3 strength is that it allows identification of the variation of stress levels and the factors

that contribute the most to the issue throughout the course of nursing, also it makes it possible to

develop preventive actions to minimize stress and its negative outcomes on the students.

Furthermore, a common factor that strengthened the study was that the instruments or tools used

for data collection was pre-tested through a pilot study before the actual study was conducted to

ensure that there is accuracy in them and also to avoid repetition of the same study which would

be time consuming for the both parties.

Limitation and Recommendation

Across the three Articles, the use of cross-sectional study design appeared to be the define

limitation and a single study location. Cross- sectional study hinders the ability to track changes

of stress experiences, Rathnayake and Ekanayaka (2016) mentioned that cross-sectional study

design is less persuasive than a longitudinal study (Polit & Beck, 2014) as data is collected

within a short period of time in a point of time, it does not help establish a causal relationship

between variables and does not help determine cause and effect, thus, the findings can be

flawless and limited. For a single study location, where only one undergraduate nursing

programme was selected to collect data, the results of the study cannot be used to assume that the

other nursing schools would have the same responses to the study this is because the features or

condition of the setting that influences the respondents or participants perception of the study

may not be the same for the other nursing schools. For instance, all the three articles reports the

studies conducted in developing nations and the result cannot be generalized to a developed

nation as both are not from the same world. One limiting factor identified in Article 1 is that the

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language used was Sinhala language, which is the common language used in Sri Lanka however,

there are students who do not understand the language therefore they were excluded, if a

universal language was used, they could have responded differently and the result could have

been different. In addition, the study result in Article 1 does not specify the number of students

experiencing each possible factor instead they relied on the higher the number of possible

factors, the higher the stress level, yet, someone with less number of possible factors may still

experience a high stress level than one with higher number of possible factors depending on the

nature of the causative factor whether or not so stressful. Another additional significant factor

that limits the study result for Article 2 is the absence of inferential statistical. Andale (2014)

stated that Inferential Statistical Analysis describes data in a chart or graph form and allows the

reviewer to make predictions from that data it also helps in comparing the sample data to other

samples or to previous research. However, in this Article, the data was presented in a table form

and the reviewer may find it difficult to interpret the study result within a short period. In Article

3, the limitation second to the use of “cross-sectional study design” is the limited sample size so

the generalization is restricted (Polit & Beck, 2014).

For improvement in future research, Articles 2 and 3 recommended the use of different

methodological approaches. Article 2 suggested the use of qualitative study method where the

students can speak their perception of stress in relation to nursing course while article 3

emphasized on conducting study with larger samples using a longitudinal method to provide

more accurate information about the variation of stress and its outcomes on the same group of

students throughout the course. For Article 1, there was no direct recommendation given

however, this does not mean that there is no need for change, Article 1 also used a cross-sectional

study similar to the other two Articles and for improvement in the results, a different study

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approach should be undertaken for instance a qualitative or longitudinal design. In addition, in

future studies, an English language or a language that all student can understand should be used

in the questionnaires or in face to face interviews to collect data or the questionnaires can be

translated to different languages that are common to students so that no one is left out just

because he or she cannot read and or understand the language.

To conclude, the three Articles presented their studies on stress among undergraduate

nursing students, the common factors that each possessed that contributes to increase stress level

and poor academic performance includes poor time management, increase workload, insufficient

financial income, increases in age with high course level, physical well-being factors and fear

and concern for future professional. To avoid and prevent increase stress level, effective

interventions and initial stress management need to be established.

The study method used in all studies were quantitative cross-sectional approach and the targeted

population was the nursing students where the samples were collected. The tool used to conduct

the studies was self-administered questionnaire and the tools or resources used to record and

analyze the data were SPSS and Excel office. The limitation to the studies are the use of cross-

sectional study method, a single study population with lesser sample size. For Article 1, the use

of Sinhala language was another limiting factor while in Article 2, the absence of inferential

statistical analysis also limits the study result. The recommended approach for future

investigators to use is the use of qualitative and longitudinal research design and In Article 1, the

need for use of universal language is also significant.

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Reference

Andale. (2014). Inferential Statistics: Definition and uses. Retrieved on April 28, 2019 from
https://www.statisticswhowto.com/inferetial-statistics
Bosco, L. O., Silva, R. M. & Costa, A. L. S. (2017). Biosocial- academic profile and stress in
first-and fourth year nursing students. Investigation Education Enferm, 35(2):131-138.
doi: 10.17533/udea.iee.v35n2a02
Najimi, A., Goudarzi, A. M. & Sharifirad, G. (2016). Causes of job stress in nurses: A cross-
sectional study. Iranian Journal of Nursing and Midwifery Research, 17(4), 301-305.
Nechita, F., Streba, C. T., Vere, C. C., Nechita, D. & Rogoveanu, I. (2014). Stress in Romanian
first year nursing students. Current Health Sciences, 40(3): 210-213.
Polit. D. F. & Beck, C. T. (2014). Essentials of Nursing Research: appraising Evidence for
Nursing Practice. (8th ed.). Wolters Kluwer, Philadelphia.
Rathnayake, S. & Ekanayaka, J. (2016). Depression, Anxiety and Stress among Undergraduate
Nursing Students in a Public University in Sri Lanka. International Journal of Caring
Science, 9(3).1020-1031.

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