google scholar research topics in nursing

Best Nursing Research Topics for Students

What is a nursing research paper.

• What They Include
• Choosing a Topic
• Best Nursing Research Topics
• Research Paper Writing Tips

Writing a research paper is a massive task that involves careful organization, critical analysis, and a lot of time. Some nursing students are natural writers, while others struggle to select a nursing research topic, let alone write about it.

If you're a nursing student who dreads writing research papers, this article may help ease your anxiety. We'll cover everything you need to know about writing nursing school research papers and the top topics for nursing research.  

Continue reading to make your paper-writing jitters a thing of the past.

A nursing research paper is a work of academic writing composed by a nurse or nursing student. The paper may present information on a specific topic or answer a question.

During LPN/LVN and RN programs, most papers you write focus on learning to use research databases, evaluate appropriate resources, and format your writing with APA style. You'll then synthesize your research information to answer a question or analyze a topic.

BSN , MSN , Ph.D., and DNP programs also write nursing research papers. Students in these programs may also participate in conducting original research studies.

Writing papers during your academic program improves and develops many skills, including the ability to:

• Select nursing topics for research
• Conduct effective research
• Analyze published academic literature
• Format and cite sources
• Synthesize data
• Organize and articulate findings

About Nursing Research Papers

When do nursing students write research papers.

You may need to write a research paper for any of the nursing courses you take. Research papers help develop critical thinking and communication skills. They allow you to learn how to conduct research and critically review publications.

That said, not every class will require in-depth, 10-20-page papers. The more advanced your degree path, the more you can expect to write and conduct research. If you're in an associate or bachelor's program, you'll probably write a few papers each semester or term.

Do Nursing Students Conduct Original Research?

Most of the time, you won't be designing, conducting, and evaluating new research. Instead, your projects will focus on learning the research process and the scientific method. You'll achieve these objectives by evaluating existing nursing literature and sources and defending a thesis.

However, many nursing faculty members do conduct original research. So, you may get opportunities to participate in, and publish, research articles.

Example Research Project Scenario:

In your maternal child nursing class, the professor assigns the class a research paper regarding developmentally appropriate nursing interventions for the pediatric population. While that may sound specific, you have almost endless opportunities to narrow down the focus of your writing. 

You could choose pain intervention measures in toddlers. Conversely, you can research the effects of prolonged hospitalization on adolescents' social-emotional development.

What Does a Nursing Research Paper Include?

Your professor should provide a thorough guideline of the scope of the paper. In general, an undergraduate nursing research paper will consist of:

Introduction : A brief overview of the research question/thesis statement your paper will discuss. You can include why the topic is relevant.

Body : This section presents your research findings and allows you to synthesize the information and data you collected. You'll have a chance to articulate your evaluation and answer your research question. The length of this section depends on your assignment.

Conclusion : A brief review of the information and analysis you presented throughout the body of the paper. This section is a recap of your paper and another chance to reassert your thesis.

The best advice is to follow your instructor's rubric and guidelines. Remember to ask for help whenever needed, and avoid overcomplicating the assignment!

How to Choose a Nursing Research Topic

The sheer volume of prospective nursing research topics can become overwhelming for students. Additionally, you may get the misconception that all the 'good' research ideas are exhausted. However, a personal approach may help you narrow down a research topic and find a unique angle.

Writing your research paper about a topic you value or connect with makes the task easier. Additionally, you should consider the material's breadth. Topics with plenty of existing literature will make developing a research question and thesis smoother.

Finally, feel free to shift gears if necessary, especially if you're still early in the research process. If you start down one path and have trouble finding published information, ask your professor if you can choose another topic.

The Best Research Topics for Nursing Students

You have endless subject choices for nursing research papers. This non-exhaustive list just scratches the surface of some of the best nursing research topics.

1. Clinical Nursing Research Topics

• Analyze the use of telehealth/virtual nursing to reduce inpatient nurse duties.
• Discuss the impact of evidence-based respiratory interventions on patient outcomes in critical care settings.
• Explore the effectiveness of pain management protocols in pediatric patients.

2. Community Health Nursing Research Topics

• Assess the impact of nurse-led diabetes education in Type II Diabetics.
• Analyze the relationship between socioeconomic status and access to healthcare services.

3. Nurse Education Research Topics

• Review the effectiveness of simulation-based learning to improve nursing students' clinical skills.
• Identify methods that best prepare pre-licensure students for clinical practice.
• Investigate factors that influence nurses to pursue advanced degrees.
• Evaluate education methods that enhance cultural competence among nurses.
• Describe the role of mindfulness interventions in reducing stress and burnout among nurses.

4. Mental Health Nursing Research Topics

• Explore patient outcomes related to nurse staffing levels in acute behavioral health settings.
• Assess the effectiveness of mental health education among emergency room nurses .
• Explore de-escalation techniques that result in improved patient outcomes.
• Review the effectiveness of therapeutic communication in improving patient outcomes.

5. Pediatric Nursing Research Topics

• Assess the impact of parental involvement in pediatric asthma treatment adherence.
• Explore challenges related to chronic illness management in pediatric patients.
• Review the role of play therapy and other therapeutic interventions that alleviate anxiety among hospitalized children.

6. The Nursing Profession Research Topics

• Analyze the effects of short staffing on nurse burnout .
• Evaluate factors that facilitate resiliency among nursing professionals.
• Examine predictors of nurse dissatisfaction and burnout.
• Posit how nursing theories influence modern nursing practice.

Tips for Writing a Nursing Research Paper

The best nursing research advice we can provide is to follow your professor's rubric and instructions. However, here are a few study tips for nursing students to make paper writing less painful:

Avoid procrastination: Everyone says it, but few follow this advice. You can significantly lower your stress levels if you avoid procrastinating and start working on your project immediately.

Plan Ahead: Break down the writing process into smaller sections, especially if it seems overwhelming. Give yourself time for each step in the process.

Research: Use your resources and ask for help from the librarian or instructor. The rest should come together quickly once you find high-quality studies to analyze.

Outline: Create an outline to help you organize your thoughts. Then, you can plug in information throughout the research process. 

Clear Language: Use plain language as much as possible to get your point across. Jargon is inevitable when writing academic nursing papers, but keep it to a minimum.

Cite Properly: Accurately cite all sources using the appropriate citation style. Nursing research papers will almost always implement APA style. Check out the resources below for some excellent reference management options.

Revise and Edit: Once you finish your first draft, put it away for one to two hours or, preferably, a whole day. Once you've placed some space between you and your paper, read through and edit for clarity, coherence, and grammatical errors. Reading your essay out loud is an excellent way to check for the 'flow' of the paper.

Helpful Nursing Research Writing Resources:

Purdue OWL (Online writing lab) has a robust APA guide covering everything you need about APA style and rules.

Grammarly helps you edit grammar, spelling, and punctuation. Upgrading to a paid plan will get you plagiarism detection, formatting, and engagement suggestions. This tool is excellent to help you simplify complicated sentences.

Mendeley is a free reference management software. It stores, organizes, and cites references. It has a Microsoft plug-in that inserts and correctly formats APA citations.

Don't let nursing research papers scare you away from starting nursing school or furthering your education. Their purpose is to develop skills you'll need to be an effective nurse: critical thinking, communication, and the ability to review published information critically.

Choose a great topic and follow your teacher's instructions; you'll finish that paper in no time.

Joleen Sams is a certified Family Nurse Practitioner based in the Kansas City metro area. During her 10-year RN career, Joleen worked in NICU, inpatient pediatrics, and regulatory compliance. Since graduating with her MSN-FNP in 2019, she has worked in urgent care and nursing administration. Connect with Joleen on LinkedIn or see more of her writing on her website.

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Basic Search

Try out a search in Google Scholar ( https://scholar.google.com ) using keywords related to your topic.

Then, focus your search using filters on the left side of the search results page by publication date or relevancy. If you find an article you want to read, click on the linked PDFs or add the Full Text @ CSUDH Lib link on the right to find the article through our library subscriptions.

Advanced Research Tools in Google Scholar

Cited by Search

Have you ever wanted to find more current research on your topic, find studies that apply a theory, or trace how a topic has been written about over time? In Google Scholar, you can use the Cited by  link to find a list of journal articles and books that have cited a source in your search! 

1. Start a search in Google Scholar , or search for the title of a specific article or book. Not finding a perfect match? Try using quotation marks around an exact book or article title.

2. Click on the Cited by link under the brief description. The number of times a source has been cited so far can provide some basic insight into how influential it has been on the research topic!

3. From this list, you can also use filters and narrow your search with keywords by checking the box Search within citing articles . 

Watch this short video on citation tracking in Google Scholar  to learn more!

Types of Scholarly Articles

• Types of Research Studies
• Critical Appraisal of Research Articles/Studies
• Reading a Scholarly Article
• Peer Review
• Evaluation Criteria
• Nursing Call Numbers
• Tutorials - Google/Google Scholar
• Open Access Books
• Nursing Database Tutorials
• Instructional Tutorials
• Journal Citation
• Website Citation
• Book Citation
• Government Sources
• DOIs and URLs
• Tutorials by APAStyle.org
• Presentations
• Zotero Reference Manager
• Nursing Boards & Licensing Information
• Nursing Career Interviews
• Professional Associations & Websites
• Publishing & Research Resources
• Research Methods & Statistics
• Research, Statistics, Writing, Dissertation & Publishing
• Theoretical Framework
• McClure Health Science High School

What type of article is right for your PICOT question? How do you read scholarly articles?

• Original Research / Empirical Study An empirical study is one that aims to gain new knowledge on a topic through direct or indirect observation and research. These include quantitative or qualitative data and analysis. Article reports on the results of one or more studies or experiments, written by the person(s) who conducted the research. This is considered a primary source. An empirical article will often include the following sections: Introduction, Methods, Results, and Discussion. Look in the title or abstract for words like study, research, measure, subjects, data, effects, survey, or statistical which might indicate empirical research.
• Literature Review This is a type of article that provides a synthesis of existing research on a particular topic. These are useful when you want to get an idea of a body of research that you are not yet familiar with. It differs from a systematic review in that it does not aim to capture ALL of the research on a particular topic. Summarizes the findings of others studies or experiments; attempts to identify trends or draw broader conclusions. Scholarly in nature but not a primary source or research article, however its references to other articles will include primary sources or research articles
• Meta-Analysis This is a type of research study that combines or contrasts data from different independent studies in a new analysis in order to strengthen the understanding of a particular topic. There are many methods, some complex, applied to performing this type of analysis. Often, this includes a mathematical synthesis of the results of two or more primary studies that addressed the same hypothesis in the same way.
• Case Study A description of a single case or situation with unique features. A process or record of research in which detailed consideration is given to the development of a particular person, group, or situation over a period of time. A particular instance of something used or analyzed in order to illustrate a thesis or principle.
• Systematic Review This is a methodical and thorough literature review focused on a particular research question. It's aim is to identify and synthesize all of the scholarly research on a particular topic in an unbiased, reproducible way to provide evidence for practice and policy-making. It may involve a meta-analysis.
• Literary Analysis Analysis is the practice of looking closely at small parts to see how they affect the whole. Literary analysis focuses on how plot/structure, character, setting, and many other techniques are used by the author to create meaning.
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• Last Updated: Apr 22, 2024 2:33 PM
• URL: https://libguides.ggc.edu/NURS

• Open access
• Published: 11 May 2024

Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

389 Accesses

Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

Almarwani AM. The effect of integrating a nursing licensure examination preparation course into a nursing program curriculum: a quasi-experimental study. Saudi J Health Sci. 2022;11:184–9.

Article   Google Scholar  

Horntvedt MT, Nordsteien A, Fermann T, Severinsson E. Strategies for teaching evidence-based practice in nursing education: a thematic literature review. BMC Med Educ. 2018;18:172.

Article   PubMed   PubMed Central   Google Scholar  

Larsson M, Sundler AJ, Blomberg K, Bisholt B. The clinical learning environment during clinical practice in postgraduate district nursing students’ education: a cross-sectional study. Nurs Open. 2023;10:879–88.

Article   PubMed   Google Scholar  

Sellberg M, Palmgren PJ, Möller R. A cross-sectional study of clinical learning environments across four undergraduate programs using the undergraduate clinical education environment measure. BMC Med Educ. 2021;21:258.

Saifan A, Devadas B, Mekkawi M, Amoor H, Matizha P, James J, et al. Managing the theory-practice gap in nursing education and practice: hearing the voices of nursing students in the United Arab Emirates. J Nurs Manag. 2021;29:1869–79.

Flott EA, Linden L. The clinical learning environment in nursing education: a concept analysis. J Adv Nurs. 2016;72:501–13.

Kalyani MN, Jamshidi N, Molazem Z, Torabizadeh C, Sharif F. How do nursing students experience the clinical learning environment and respond to their experiences? A qualitative study. BMJ Open. 2019;9:e028052.

Mahasneh D, Shoqirat N, Alsaraireh A, Singh C, Thorpe L. From learning on mannequins to practicing on patients: nursing students’ first-time experience of clinical placement in Jordan. SAGE Open Nurs. 2021;7:23779608211004298.

PubMed   PubMed Central   Google Scholar  

Stubin C. Clinical stress among undergraduate nursing students: perceptions of clinical nursing faculty. Int J Nurs Educ Scholarsh. 2020;17:20190111.

Ahmed WAM. Anxiety and related symptoms among critical care nurses in Albaha, Kingdom of Saudi Arabia. AIMS Med Sci. 2015;2:303–9.

Alhassan. Duke Phillips. 2024.

Ekstedt M, Lindblad M, Löfmark A. Nursing students’ perception of the clinical learning environment and supervision in relation to two different supervision models - a comparative cross-sectional study. BMC Nurs. 2019;18:49.

Bradshaw C, Murphy Tighe S, Doody O. Midwifery students’ experiences of their clinical internship: a qualitative descriptive study. Nurse Educ Today. 2018;68:213–7.

McCarthy B, Trace A, O’Donovan M, O’Regan P, Brady-Nevin C, O’Shea M, et al. Coping with stressful events: a pre-post-test of a psycho-educational intervention for undergraduate nursing and midwifery students. Nurse Educ Today. 2018;61:273–80.

Chaabane S, Chaabna K, Bhagat S, Abraham A, Doraiswamy S, Mamtani R, et al. Perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa: an overview of systematic reviews. Syst Rev. 2021;10:136.

Pines EW, Rauschhuber ML, Norgan GH, Cook JD, Canchola L, Richardson C, et al. Stress resiliency, psychological empowerment and conflict management styles among baccalaureate nursing students. J Adv Nurs. 2012;68:1482–93.

Lazarus RS. Coping theory and research: past, present, and future. Psychosom Med. 1993;55:234–47.

Article   CAS   PubMed   Google Scholar  

Boyd MA. Essentials of psychiatric nursing. Philadelphia, PA: Wolters Kluwer; 2017.

Google Scholar  

Labrague LJ, McEnroe-Petitte DM, Gloe D, Thomas L, Papathanasiou IV, Tsaras K. A literature review on stress and coping strategies in nursing students. J Ment Health. 2017;26:471–80.

Ni C, Lo D, Liu X, Ma J, Xu S, Li L. Chinese female nursing students’ coping strategies, self-esteem and related factors in different years of school. J Nurs Educ Pract. 2012;2:33–41.

Jan LK, Popescu L. Israel’s nursing students’ stress sources and coping strategies during their first clinical experience in hospital wards-a qualitative research. Soc Work Rev / Rev Asistenta Soc. 2014;13:163–88.

Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: a systematic review and meta-analysis. Nurse Educ Today. 2018;63:119–29.

Speziale HS, Streubert HJ, Carpenter DR. Qualitative research in nursing: advancing the humanistic imperative. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–12.

Bryman A. Integrating quantitative and qualitative research: how is it done? Qual Res. 2006;6:97–113.

Holloway I, Wheeler S. Qualitative research in nursing and healthcare. New York, NY: Wiley; 2013.

Richards L, Morse J. A user’s guide to qualitative methods. London, UK: Sage; 2007.

Lincoln Y, Guba EG. The SAGE handbook of qualitative research. Newbury Park, CA: SAGE Publications Inc; 2017.

Park S, Park KS. Family stigma: a concept analysis. Asian Nurs Res. 2014;8:165–71.

Onieva-Zafra MD, Fernández-Muñoz JJ, Fernández-Martínez E, García-Sánchez FJ, Abreu-Sánchez A, Parra-Fernández ML. Anxiety, perceived stress and coping strategies in nursing students: a cross-sectional, correlational, descriptive study. BMC Med Educ. 2020;20:370.

Albloushi M, Ferguson L, Stamler L, Bassendowski S, Hellsten L, Kent-Wilkinson A. Saudi female nursing students experiences of sense of belonging in the clinical settings: a qualitative study. Nurse Educ Pract. 2019;35:69–74.

Arkan B, Ordin Y, Yılmaz D. Undergraduate nursing students’ experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract. 2018;29:127–32.

Bhurtun HD, Azimirad M, Saaranen T, Turunen H. Stress and coping among nursing students during clinical training: an integrative review. J Nurs Educ. 2019;58:266–72.

Jamshidi N, Molazem Z, Sharif F, Torabizadeh C, Kalyani MN. The challenges of nursing students in the clinical learning environment: a qualitative study. ScientificWorldJournal. 2016;2016:1846178.

Porter SL. First year nursing students’ perceptions of stress and resilience during their initial clinical placement and the introduction of a stress management app: a mixed methods approach. A thesis submitted in partial fulfilment of the requirements of Edinburgh Napier University, for the award of Doctor of Philosophy. 2019. https://www.napier.ac.uk/~/media/worktribe/output-2086663/first-year-nursing-students-perceptions-of-stress-and-resilience-during-their-initial.pdf

Panda S, Dash M, John J, Rath K, Debata A, Swain D, et al. Challenges faced by student nurses and midwives in clinical learning environment - A systematic review and meta-synthesis. Nurse Educ Today. 2021;101:104875.

Ahmadi G, Shahriari M, Keyvanara M, Kohan S. Midwifery students’ experiences of learning clinical skills in Iran: a qualitative study. Int J Med Educ. 2018;9:64–71.

Harrison-White K, Owens J. Nurse link lecturers’ perceptions of the challenges facing student nurses in clinical learning environments: a qualitative study. Nurse Educ Pract. 2018;32:78–83.

Grobecker PA. A sense of belonging and perceived stress among baccalaureate nursing students in clinical placements. Nurse Educ Today. 2016;36:178–83.

Msiska G, Kamanga M, Chilemba E, Msosa A, Munkhondya TE. Sources of stress among undergraduate nursing students during clinical practice: a Malawian perspective. Open J Nurs. 2019;9:1.

Joolaee S, Amiri SRJ, Farahani MA, Varaei S. Iranian nursing students’ preparedness for clinical training: a qualitative study. Nurse Educ Today. 2015;35:e13–7.

Günay U, Kılınç G. The transfer of theoretical knowledge to clinical practice by nursing students and the difficulties they experience: a qualitative study. Nurse Educ Today. 2018;65:81–6.

Farzi S, Shahriari M, Farzi S. Exploring the challenges of clinical education in nursing and strategies to improve it: a qualitative study. J Educ Health Promot. 2018;7:115.

Hamaideh SH, Al-Omari H, Al-Modallal H. Nursing students’ perceived stress and coping behaviors in clinical training in Saudi Arabia. J Ment Health. 2017;26:197–203.

Yaghoobi A, Mohagheghi H, Zade MY, Ganji K, Olfatii N. The effect of time management training on test anxiety and academic achievement motivation among high school students. J Sch Psychol. 2014;3:131–44.

Kebriaei A, Bidgoli MS, Saeedi A. Relationship between use of time management skills and satisfaction with spending time among students of Zahedan University of Medical Sciences. J Med Educ Dev. 2014;6:79–88.

Chen YW, Hung CH. Predictors of Taiwanese baccalaureate nursing students’ physio-psycho-social responses during clinical practicum. Nurse Educ Today. 2014;34:73–7.

Ab Latif R, Mat Nor MZ. Stressors and coping strategies during clinical practice among diploma nursing students. Malays J Med Sci. 2019;26:88–98.

Al-Yateem N, Almarzouqi A, Dias JM, Saifan A, Timmins F. Nursing in the United Arab Emirates: current challenges and opportunities. J Nurs Manag. 2021;29:109–12.

Baraz-Pordanjani S, Memarian R, Vanaki Z. Damaged professional identity as a barrier to Iranian nursing students’ clinical learning: a qualitative study. J Clin Nurs Midwifery. 2014;3:1–15.

Labrague LJ, McEnroe-Petitte DM, Papathanasiou IV, Edet OB, Tsaras K, Leocadio MC, et al. Stress and coping strategies among nursing students: an international study. J Ment Health. 2018;27:402–8.

Madian AAEM, Abdelaziz MM, Ahmed HAE. Level of stress and coping strategies among nursing students at Damanhour University, Egypt. Am J Nurs Res. 2019;7:684–96.

Wu CS, Rong JR, Huang MZ. Factors associated with perceived stress of clinical practice among associate degree nursing students in Taiwan. BMC Nurs. 2021;20:89.

Zhao FF, Lei XL, He W, Gu YH, Li DW. The study of perceived stress, coping strategy and self-efficacy of Chinese undergraduate nursing students in clinical practice. Int J Nurs Pract. 2015;21:401–9.

Bektaş H, Terkes N, Özer Z. Stress and ways of coping among first year nursing students: a Turkish perspective. J Hum Sci. 2018;15:319–30.

John B, Al-Sawad M. Perceived stress in clinical areas and emotional intelligence among baccalaureate nursing students. J Indian Acad Appl Psychol. 2015;41:76–85.

Mapfumo JS, Chitsiko N, Chireshe R. Teaching practice generated stressors and coping mechanisms among student teachers in Zimbabwe. S Afr J Educ. 2012;32:155–66.

Timmins F, Corroon AM, Byrne G, Mooney B. The challenge of contemporary nurse education programmes. Perceived stressors of nursing students: mental health and related lifestyle issues. J Psychiatr Ment Health Nurs. 2011;18:758–66.

Hegberg NJ, Tone EB. Physical activity and stress resilience: considering those at-risk for developing mental health problems. Ment Health Phys Act. 2015;8:1–7.

Shudifat RM, Al-Husban RY. Perceived sources of stress among first-year nursing students in Jordan. J Psychosoc Nurs Ment Health Serv. 2015;53:37–43.

El Ansari W, Adetunji H, Oskrochi R. Food and mental health: relationship between food and perceived stress and depressive symptoms among university students in the United Kingdom. Cent Eur J Public Health. 2014;22:90–7.

Dias JM, Aderibigbe SA, Abraham MS. Undergraduate nursing students’ mentoring experiences in the clinical practicum: the United Arab Emirates (UAE) perspective. J Nurs Manag. 2022;30:4304–13.

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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2 Hospital for Sick Children, Toronto, ON, Canada

Whitney Berta

3 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Kristin Cleverley

4 Margaret and Wallace McCain Center for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, ON, Canada

Kimberley Widger

Associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Background: Pediatric nurses care for some of the most vulnerable patients in our healthcare system. Research on health care provider organizational behavior shows that the quality of care nurses provide is directly related to their well-being, influenced by Burnout and job stress, in the workplace. However, most of the research conducted on nursing populations neglects to separately study nurses who care for children. In a resource limited system where health care provider well-being is recognized as a priority, it is important for administrators to understand the environmental and attitudinal work factors most influential to pediatric nurse work outcomes in order to target optimization strategies. The aim of the study was to identify which modifiable work environment factors, e.g., [Incivility, Perceived Organizational Support, Quality of Work-life] make the greatest contribution to the work outcome of Burnout (i.e., Personal Accomplishment, Emotional Exhaustion, Depersonalization) in pediatric nurses.

Methods: A cross-sectional survey design was used at a large quaternary care pediatric hospital in Toronto, Canada. We administered a survey to a convenience sample of all registered nurses with >3 months experience in the Pediatric, Cardiac, and Neonatal Intensive Care Units from January 2021–March 2021. Path analysis was used to test our proposed model which was specified a priori based on a review of the literature.

Results: 143 nurses completed the survey. Path analysis of the tested model resulted in good fit. Quality of Work-life had the largest direct effect on Work Engagement (β = 0.582, S.E. = 0.111, p < 0.001). Work Engagement had the largest direct effect on Personal Accomplishment (β = 0.68, S.E. = 0.53, p < 0.001). Quality of Work-life had the largest indirect effect on Personal Accomplishment (β = 0.4, S.E. = 0.65, p < 0.001), Emotional Exhaustion (β = −0.33, S.E. = 0.87, p < 0.001), and Depersonalization (β =−0.17, S.E. = 0.41, p = 0.006), respectively. Work Engagement had the largest total effect on Personal Accomplishment (β = 0.68, S.E. = 0.64, p < 0.001) and the third largest total effect on Emotional Exhaustion (β = −0.57, S.E. = 0.83, p < 0.001). Quality of Work-life had the second largest total effect on Work Engagement (β = 0.58, S.E. = 0.11, p < 0.001) indicating that Quality of Work-life is mediated through Work Engagement for its effect on Burnout.

Conclusions: Our results indicate work environment and work attitude factors that can provide organizational leadership with a targeted focus to reduce pediatric critical care nurse Burnout, and thus improve provider well-being, in a resource limited system.

Pediatric nurses care for some of the most vulnerable patients in our healthcare system. These nurses skillfully manage the highly specialized care of children and the complex family dynamics that are inherent to the work ( 1 ). Pediatric nurse well-being in the workplace has been shown to be directly and positively related to nurses' attitudes about engaging with patients and families ( 2 ), and the quality of care provided ( 3 – 6 ). Pediatric nurses are a separate population from nurses who care for adults because of the specialized nature of providing care to children. Children are typically seen as a vulnerable population, and along with this, there is a high potential for empathetic engagement and inherent complexities in the relationships with families ( 7 , 8 ). More specifically, pediatric/neonatal critical care nurses care for the most severely ill and injured children at the highest risk of death ( 9 ). As the stakes for this patient population are arguably the highest in the hospital, stressors of the work environment are enhanced; the care needs are highly complex and the stress to the families adds additional challenges ( 10 , 11 ). Pediatric/neonatal critical care nurses are a subspecialty within a specialty. A supply-demand issue ensues as these nurses cannot be easily replaced or supplemented. Thus they are continually asked to do more (care for more patients, run more technology) with less (less time, resources, support) ( 1 ). Much of the organizational behavior research conducted to date on nursing populations has focused on general adult care nurses and excluded studying nurses who care for children ( 12 , 13 ), particularly in pediatric critical care settings.

Work outcomes refer to occupational performance factors that are influenced by work attitudes and the work environment ( 14 ). The current study focuses on the work outcome of Burnout as it is one of the most established organizational behavior concepts, with over 40 years of literature available on the topic across numerous industries ( 15 ). Maslach and Jackson (1981) define Burnout by three components; Emotional Exhaustion, Depersonalization, and lack of Personal Accomplishment ( 16 ). Emotional Exhaustion refers to nurses feeling emotionally drained from their work; Depersonalization is the development of cynicism, particularly toward patients; and lack of Personal Accomplishment refers to nurses' feelings of dissatisfaction with the care they are providing ( 16 ). Nurse Burnout impacts at the level of the provider, the patient, and the organization ( 17 ). Burnout is positively associated with nurses' intent to leave their jobs ( 18 ), decreased quality of life ( 19 ), and negatively associated with the safety of the work environment ( 3 , 4 ).

Nurses working in critical care commonly experience Burnout, with rates as high as 73% for Emotional Exhaustion, 60% for a lack of Personal Accomplishment, and 48% noting Depersonalization ( 20 ). Most of the currently available literature on pediatric nurse work outcomes, such as Burnout, focus on factors like race, marital status, or the experience of death in the workplace ( 21 – 23 ) or on high cost/low yield factors like nurses' personality traits ( 22 ). The former set of factors are non-modifiable and cannot be feasibly changed (e.g., race), while high cost/low yield factors are technically modifiable but it would not be fiscally or temporally responsible to try and impact (e.g., personality traits) ( 24 ). So while it is beneficial to be aware of the impact of these factors, they are not ideal targets for efficient modification by health care organizations. In a health care climate where resources are limited, it is important for administrators to know which environmental and attitudinal work factors make the greatest contribution to pediatric nurse work outcomes to target their optimization strategies in the most cost-effective way.

Our study began with a review of the literature on what is known about pediatric nurse Burnout ( 17 ). From there, an additional search of the literature was undertaken to investigate factors that impact Burnout in the broader health care population. Using this data and the framework of the Theory of Reasoned Action we proposed a conceptual model. Figure 1 illustrates the proposed conceptual model where the pediatric nursing work environment influences work outcomes through work attitudes, thus influencing work outcomes directly.

The relationship between factors of the work environment, work attitudes, and the work outcomes of Burnout.

Factors Related to Burnout

Work environment, incivility in the workplace.

Workplace Incivility is defined as; “low intensity behaviors that are rude, lack consideration of others, in violation of workplace norms for respect, where the intent to harm is ambiguous” ( 25 ). These behaviors serve as a pre-cursor for an exchange, or spiral, of coercive behavior.

Quality of Work Life

Sirgy et al. define quality of work life (QWL) as; “employee satisfaction with a variety of needs through resources, activities, and outcomes stemming from participation in the workplace. Thus, satisfaction from workplace experiences contributes to job satisfaction and satisfaction in other life domains. Satisfaction in the major life domains (e.g., work life, family life, home life, leisure life) contributes directly to satisfaction with overall life” ( 26 ).

Perceived Organizational Support

Perceived organizational support (POS) is defined by the extent to which the employee perceives “the organization values their contributions and cares about their well-being” ( 27 ). POS is inversely related to nurse Burnout ( 27 – 29 ); POS is positively related to Work Engagement in nurses ( 30 ); and POS is inversely related to nurses' intent to leave ( 31 – 33 ).

Work Attitudes

Work engagement.

Schaufeli, Bakker, & Salanova (2006) define Work Engagement as; “a positive, fulfilling work-related state of mind that is characterized by vigor, dedication, and absorption. To be able to increase nurses' engagement with their patients and families we must think about possible interventions in the same light. Highly engaged nurses are essential for ethical, safe, and comprehensive care ( 34 ). Work Engagement may be challenging to directly modify, but work outcomes can be influenced through more easily modifiable factors of the work environment ( 14 ). Similar to work environment factors, pediatric nurses have not been separately studied in the nursing Work Engagement literature.

Study Objectives

• 1) To test a model of modifiable work environment features and attitudes in relation to the work-related outcome of Burnout in a sample of pediatric critical care nurses.
• 2) To rank the modifiable work environment factors based on their relationship with Burnout among pediatric critical care nurses.

This study used a cross-sectional survey design to test a model of the relationships between organizational and attitudinal factors and Burnout in a convenience sample of nurses at a large quaternary care pediatric hospital in Toronto, Canada. The study was approved by the Research Ethics Board (#1000072502) at the Hospital for Sick Children.

Study Setting

The study took place in a 300-bed tertiary care hospital with a 41-bed critical care unit and a 38-bed neonatal intensive care unit in Toronto, Canada. A total of 443 Registered Nurses (RNs) work in the Cardiac Critical Care Unit (CCCU), Pediatric Critical Care Unit (PICU) and the Neonatal Intensive Care Unit (NICU) combined.

Sample and Recruitment

Inclusion criteria required that nurses had worked in the PICU, CCCU, or NICU for >3 months. Nurses undergoing orientation were excluded. All nurses in this organization are Registered Nurses (RNs). Nurses on leave (medical, parental, or otherwise) were excluded from participation as they were not actively working on the unit and not contactable via the hospital email server. All nurses working on these units were contacted via email for participation in the study. QR codes linking to the survey were also advertised on posters throughout the units. Surveys were completed and submitted automatically and anonymously online through REDCap Software ( 35 ). Data collection was conducted from January 6, 2021 to March 22, 2021. Of note, this data collection period was during the Coronavirus disease 2019 (COVID-19) pandemic. For context, participants were asked if they have cared for a COVID-19 positive patient or patient under investigation for COVID-19. Participant consent was implied by survey submission. Participants were offered a $5 coffee card as a thank you for their participation.

Data Collection Tools

The survey was made up of established instruments, previously used with nurses, that had good psychometric properties. Demographic information was also collected, along with a final open-ended question for nurses to include any other thoughts on the topic.

Maslach Burnout Inventory

Burnout was measured using the Maslach Burnout Inventory for Human Services Survey for Medical Personnel [MBI-HSS(MP)] with subscales for Depersonalization, Emotional Exhaustion, and Personal Accomplishment. Each subscale's items are scored on a Likert scale from 0 to 6, indicating the frequency that the item applies in the providers experience ranging from with 0 indicating “never” to 6 indicating a frequency of “everyday” ( 36 ).

Utrecht Work Engagement Scale

Work Engagement was measured by the Utrecht Work Engagement Scale shortened 9-item version (UWES-9). [All items are measured on a 7-point Likert scale (0 = never–6 = always) and Work Engagement scoring categories include “very high”, “high”, “average”, “low” and “very low” ( 37 )].

Work Environment Features

Workplace incivility scale.

The Workplace Incivility Scale (WIS), created by Cortina et al. was selected because it is a 7-item tool and measures a single construct of Workplace Incivility with an Cronbach's alpha = 0.89 and demonstrated validity ( 38 ). The tool is scored on a 7-point Likert scale where respondents self-report how often they experience instances of Workplace Incivility on a scale from 0 = never to 6 = daily ( 38 ).

The Survey of Perceived Organizational Support

The Survey of Perceived Organizational Support shortened 8-item tool uses a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree) ( 39 ).

Quality of Work Life Measure

The Quality of Work Life Measure, developed by Sirgy et al. in 2001, combines both needs satisfaction and spillover theories within the 7-factor, 16 item tool with response options on a 7-point Likert scale (1 = very untrue to 7 = very true) ( 26 ).

Where multiple options or versions of tools were available, we selected the shortest version if there were similar psychometric properties to reduce the overall survey length. (Cronbach's alpha was calculated for each data collection tool; all had acceptable reliability with a Cronbach's alpha >0.7 Data collection tools and their psychometric properties for this sample are in Table 1 ).

Data collection tools and psychometric properties.

Sample demographics and scale scores were summarized using descriptive statistics including means, standard deviations (SD), counts, and proportions as appropriate for the type of data and scoring guidelines for the scales. In addition, a correlation matrix was estimated to determine the relationship between each of the variables used in the path model.

Analysis Objective 1

Path analysis was used to test the model ( Figure 1 ) of the relationships amongst modifiable work environment features, work attitudes and Burnout among pediatric critical care nurses. Path analysis is a component of Structural Equation Modeling (SEM); a simple case that does not include latent variables. Path analysis is most appropriate for our study as our model does not contain latent variables, therefore no measurement model is needed. Three subscales of Burnout were included in the model: Emotional Exhaustion, Depersonalization, Personal Accomplishment. Quality of Work-life, Perceived Organizational Support and Civility were the exogeneous variables, and Work Engagement was modeled to mediate the relationship between the exogenous variables and the outcome. In addition, a path for the direct effect of Perceived Organizational Support on Burnout was tested ( Figure 1 ). STATA (Version 15) was used to conduct the path analysis and effect sizes were calculated ( 40 ). Indirect effects were calculated using bootstrapping. Acceptable model fit was indicated by a non-significant χ 2 value, a comparative fit index (CDI) >0.90, a Tucker-Lewis index (TLI) 0.0.90, a root mean square standard error of approximation (RMSEA) <0.05 ( 41 ). Missing values were addressed using full information maximum likelihood estimation (FIML).

Objective 2

Modifiable work environment factors were ranked (by their correlation coefficient) based on their contribution to explaining Burnout among pediatric critical care nurses ( 42 ).

Sample Size

Minimum sample size for our study was calculated using the N:q rule, there were q = 7 parameters that require estimates. The ratio of 10:1 was used, indicating a minimum sample size of n = 70 ( 41 ). In order to improve the trustworthiness of the results, we chose to use a ratio of 15:1, for a minimum sample size of n = 105 in order to adequately power the analysis.

Response Rate

The survey link was distributed to 443 nurses in the PICU/NICU/CCCU. The distribution of respondents was 44.8% from PICU, 37.1% from NICU, and 17.5% from CCCU. Of the 158 surveys opened, 15 had no data thus were excluded, and 143 were fully or partially completed for a response rate of 32.3%. Surveys that had any complete instruments were used in the calculation of mean scores. Only surveys that had all instruments completed were used for the path model ( n = 117). Surveys with missing data were analyzed for any commonalities. Distributions for years of experience, FTE, and highest degree achieved were all similar distribution to the fully completed survey sample. NICU incomplete surveys were slightly higher amongst the incomplete surveys, perhaps indicating a higher level of interruptions during completion. At baseline, NICU nurses carry a higher patient load (more 2:1 assignments) than the other two units.

Demographic Characteristics

The majority of respondents worked full time (>0.8 Full-time equivalent) and completed a bachelor's degree as their highest degree held. Our sample was fairly evenly distributed by nurses of different years of experience. The majority of our sample had also taken care of a COVID-19 positive patient ( Table 2 ).

Respondent characteristics ( n = 143).

Pediatric Intensive Care Unit (PICU), Cardiac Critical Care Unit (CCCU), Neonatal Intensive Care Unit (NICU) .

A summary of each of the mean scores for each of the tools used in the path analysis can be found in Table 3 . The mean Emotional Exhaustion score was 24.6 with 40% scoring high level of Emotional Exhaustion. The mean Depersonalization score was 9.1 with 44.6% scoring a high level of Depersonalization. The mean Personal Accomplishment score is 32.8 with 47.7% scoring a high level of Personal Accomplishment ( Table 4 ). The correlations between Work Engagement, Quality of Work-life, Workplace Incivility, Emotional Exhaustion, Depersonalization, and Personal Accomplishment were all significant ( Table 5 ).

Summary data of Work Environment and Work Engagement scores.

Burnout subscale scores by category.

Number of respondents, Pearson correlations, scale means and standard deviations (n = 117) .

Objective 1: Results of Path Analysis

Path analysis of the tested model resulted in good fit, as demonstrated by a non-significant (χ 2 (6) = 10.6, p = 0.1015), Root mean squared error of approximation (RMSEA) = 0.08, Comparative Fit Index (CFI) = 0.90, Tucker Lewis Index (TLI) 0.93, and CD = 0.33. Our model accounts for 27% of the variance in Work Engagement scores, 44% of the variance in Emotional Exhaustion scores, 16% of the variance in Depersonalization scores, and 46% of the variance in Personal Accomplishment scores. The coefficient of determination for the entire model is low (CD = 0.33) which is common for social science based research ( 43 ). Figure 2 presents the significant standardized coefficients from the path analysis.

Conceptualized framework with standard coefficients from path analysis. WISAVG, Workplace IncivilityScore Average; QWLAVG, Quality of Work-life Average; POSAVG, Perceived Organizational Support Average; UWESAVG, Utrecht Workplace Engagement Survey Average; EE, Emotional Exhaustion; DP, Depersonalization; PA, Personal Accomplishment.

Work Outcomes

Emotional Exhaustion is strongly inversely associated with Work Engagement (β = −0.570, p < 0.001) and moderately inversely associated with Perceived Organizational Support (β = −0.226, p = 0.003). Depersonalization is moderately inversely associated with Work Engagement (β = −0.290, p < 0.001) and Perceived Organizational Support (β = −0.200, p = 0.028) Personal Accomplishment is strongly associated with Work Engagement (0.680, p < 0.001) and not statistically significantly associated with Perceived Organizational Support (β = −0.034, p = 0.668). The subcomponents of Burnout are weakly associated with each other ( Figure 2 ).

Workplace Incivility is not associated with Work Engagement (β = 0.090, p = 0.333). Quality of Work-life is strongly positively associated with Work Engagement (β = 0.580, p < 0.001) Perceived Organizational Support is not associated with Work Engagement (β = −0.053, p = 0.593) ( Figure 2 ).

Direct Effects of Variables on Burnout

Quality of Work-life had a statistically significant direct positive association with Work Engagement. Both Work Engagement and Perceived Organizational support had significant direct effect on Emotional Exhaustion and Depersonalization. Work Engagement had a significant direct effect on Personal Accomplishment ( Table 6 ).

Direct effects with standardized coefficients.

Numbers that are bold also indicate top ranked numbers (just to make them stand out) .

Mediating Role of Work Engagement

Quality of Work-life impacted each of the relationships between the organizational factors and all three subcomponents of Burnout through the mediation of Work Engagement. Quality of Work-life has a statistically significant indirect effect on Emotional Exhaustion through Work Engagement of β = −0.332, z = −4.47, p < 0.001. Quality of Work-life has a statistically significant indirect effect on Depersonalization through Work Engagement of β = −0.170, z = −2.77, p = 0.006. Quality of Work-life has a statistically significant indirect effect on Personal Accomplishment through Work Engagement of β = 0.397, z = 4.73 p < 0.001. Workplace Incivility and Perceived Organizational Support did not have any statistically significant indirect effect on the subcomponents of Burnout mediated by Work Engagement ( Table 7 ).

Indirect effects with standardized coefficients.

Objective 2: Ranking of Variables

Based on the net value of the standardized coefficients representing the total effects, the strength of the relationships amongst the variables included in the path analysis rank in the following order from strongest to weakest: (1) Work Engagement and Personal Accomplishment, (2) Quality of Work-life and Work Engagement, (3) Work Engagement and Emotional Exhaustion, (4) Quality of Work-life and Personal Accomplishment, (5) Quality of Work-life and Emotional Exhaustion, and (6) Perceived Organizational Support and Emotional Exhaustion ( Table 8 ).

Total effects with standardized coefficients.

We tested a model of the relationships amongst modifiable environmental and attitudinal factors and Burnout, and ranked the strength of the relationship in order to guide managers and leaders on how to better support nursing staff. Our model had good fit, supporting the hypothesized relationships between the work environment, work attitudes and work outcomes assessed.

Direct Effects of Work Environment on Burnout

We observed a significant positive relationship between Quality of Work-life and Work Engagement, a relationship that has been supported in previous work on registered nurses ( 44 ). By addressing elements of work-life such as physical needs (e.g., compensation, time off, health benefits) and esteem and actualization needs (e.g., relationships, skill development, and the realization of one's potential) organizations can directly impact Work Engagement. Not only does this improve the well-being of clinicians, but their enhanced well-being has also been shown to improve patient care as well as increase hospital revenues ( 45 ). This is also in congruence with the Job-Demands Resources model (JD-R) that states greater job demands (stress) and lack of resources (defined as factors similar to those of Quality of Work-life) results in greater Burnout and the inverse results in greater Work Engagement ( 46 ).

Additionally, we found that Work Engagement has significant negative/inverse relationships with all of the sub-components of Burnout; a result that is also consistent with the results presented by Hetzel-Riggin et al. in 2020 when evaluating nurses and nursing students ( 47 ). By improving Work Engagement, organizations can significantly influence the experience of Emotional Exhaustion, Depersonalization, and Personal Accomplishment in their staff. However, directly modifying work attitudes, and more specifically Work Engagement, is challenging ( 14 ). The mediating role of Work Engagement between the work environment and Burnout that is identified in this study and explained below.

We identified Work Engagement as a significant mediator of the effect of Quality of Work-life on the subcomponents of Burnout. These results illuminate an important point: intervening on the work environment, without considering the mediating effects of Work Engagement, may have a limited effect on Burnout. Berta et al.'s study on Health Support Workers supports our model by where features of the work environment are related to Burnout through work attitudes, such as Work Engagement ( 14 ). Addressing Quality of Work-life occurs at the interface of the work environment and individuals' role identities. Some strategies to address Quality of Work-life include decentralized organizational structures, improved team work, key stakeholder involvement in decision-making, performance feedback and role clarity, incentive plans, and promotion opportunities from within ( 48 , 49 ). By improving work-life, there is also an opportunity to improve employees' overall life, through the concept of spillover ( 49 ). Sirgy et al. explain that spillover occurs when our reactions to work-life spill over into our non-work life, and note that the reverse can also occur ( 48 ). These could provide strategies for organizational leaders to influence pediatric nurse Burnout through Work Engagement with the modulation of the work environment.

Influencing Pediatric Critical Care Nurse Burnout

All three subcomponents of Burnout were influenced by Work Engagement. This means that hospital leadership can address Burnout through the influence of Quality of Work-life on Work Engagement.

Importantly, these results provide an evidence-based, directed strategy for administrators to target in a resource-limited system. The more engaged the nurse is with their work, the greater their sense of more Personal Accomplishment, and the less Emotional Exhaustion and feeling of Depersonalization (cynicism) they experience. This is supported by previous literature on the impact of Work Engagement on Burnout ( 14 , 50 ). Work Engagement can mediate the relationship between the demands of the job and nurse Burnout ( 47 , 51 , 52 ). Nurse Work Engagement also impacts the patients' experience of care ( 53 ). Increased nurse Work Engagement has been shown to have positive effects on both personal and organizational outcomes. To be able to increase nurses' engagement with their patients and families we must think about possible interventions in the same light. Highly engaged nurses are essential for ethical, safe, and comprehensive care ( 34 , 50 ). As Work Engagement is a work attitude that is difficult to directly influence, addressing areas of the work environment are instrumental in improving Work Engagement and, subsequently, Burnout. Quality of Work-life is not only directly correlated with Work Engagement, it is influenced by an employee's satisfaction with how their needs are being met through the resources, outcomes and activities that are derived from their participation in work, indicating that improving these factors of the work environment will also have a positive impact on nurse Burnout ( 26 ).

This study illustrates the importance of the impact of the work environment on Work Engagement and, subsequently, Burnout. We are hopeful that this data, and studies like it, will reinforce the thinking that workplace interventions can contribute in a meaningful way to reducing nurse Burnout. Many current workplace well-being recommendations focus only on self-care for pediatric nurse Burnout—our findings highlight that this recommendation is incomplete, and there are ways leadership can adapt the work environment to also optimize well-being ( 54 ). More needs to be done at an organizational level to intervene on the factors that significantly impact pediatric nurse Burnout in the workplace, as demonstrated in this study.

Limitations

This is a single center study in a Western setting, thus local context and experience limits generalizability ( 55 ). This is a cross-sectional study with a modest response rate which limits causal and temporal inference. Nurses historically have fairly poor survey response rates (<60%) ( 56 ). The results are sufficient to provide targeted recommendations for interventions at this study site ( 57 ), and, by providing a detailed description of the study context, the findings aim to be reproducible and adaptable to other health care settings and populations such as other pediatric critical care units and even pediatric nurses as a whole. The data reflects nurses who chose to participate in the study and may be influenced by selection bias. Effort was made to recruit a sample that is representative of the critical care nursing population at SickKids through distribution to all eligible participants, however despite our best efforts, the sample is not identical to the actual sample distribution. There is also vulnerability to possible bias in the responses due to perceived social desirability, despite anonymity. Participants self-selected to participate in the study; this could have introduced bias in that those with the most extreme feelings may be over-represented.

Path analysis is an explanatory technique and thus is guided by known or hypothesized relationships from the literature. It is important to note that the primary limitation of path analysis is that it does not infer causality or directionality ( 58 ).

We acknowledge the impact of the COVID-19 global pandemic and, specifically, its impact on front line essential workers such as pediatric critical care nurses. Nurses, now more than ever, are experiencing the impacts of their work on their well-being; these results will be timely and readily implementable. Further research to confirm and explore these results with pediatric critical care nurses is needed to fully illuminate the conclusions and to design practical interventions to address Burnout. Phase 2 of this study will aim to address this component.

Theoretical Contributions

At this time, and to our knowledge, there are no previous studies that have considered all of the concepts explored here simultaneously, nor could we find previous studies that have ranked the correlation of work attitudes and work environment factors' contributions to pediatric nurse Burnout. Therefore, the findings of this study advance the understanding of the impacts of the work environment and work attitudes on the work outcome of Burnout in pediatric critical care nurses.

We found that, in this single center study of pediatric critical care nurses, Burnout levels were high. Pediatric critical care nurse Burnout was most impacted by Work Engagement and quality of work life. Work Engagement is a significant mediator between the work environment and the subcomponents of Burnout. Future interventions for pediatric nurse Burnout by modifying work environment, particularly through the modulation of Work Engagement, have the potential to positively impact the well-being of nurses, and ultimately the care they provide to our most vulnerable patients.

Data Availability Statement

Ethics statement.

This study was approved by the Research Ethics Board at the Hospital for Sick Children in Toronto, Canada (REB #1000072502). It is also approved by the University of Toronto. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

LB was involved in the study design, data collection, data analysis, data interpretation, and drafting and finalizing the manuscript. WB and KC were involved in data interpretation, and substantively revised the manuscript for important intellectual content. KW was involved in the study design, data interpretation, and substantively revised the manuscript for important intellectual content. All authors read and approved the final manuscript and agree both to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved, and the resolution documented in the literature.

This study is funded by the Alma Rae Nursing Scholarship and through the Lawrence S. Bloomberg Faculty of Nursing Doctoral Program and the Grace Evelyn Simpson Reeves Award through the Hospital for Sick Children (Toronto, Canada).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We would like to thank Shelby Watson for her assistance with data collection, Sarah Brennenstuhl for her assistance with data analysis, and all of the critical care nurses at the Hospital For Sick Children for their dedication to providing excellence in pediatric critical care. Kristin Cleverley was supported by the CAMH Chair in Mental Health Nursing Research while writing this article.

Abbreviations