literature review stress among nursing students

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• Published: 05 May 2021

Perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa: an overview of systematic reviews

• Sonia Chaabane 1 ,
• Karima Chaabna 1 ,
• Sapna Bhagat 1 ,
• Amit Abraham 1 ,
• Sathyanarayanan Doraiswamy 1 ,
• Ravinder Mamtani 1 &
• Sohaila Cheema 1  

Systematic Reviews volume  10 , Article number:  136 ( 2021 ) Cite this article

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In nursing students, high stress levels can lead to burnout, anxiety, and depression. Our objective is to characterize the epidemiology of perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa region.

We conducted an overview of systematic reviews. We systematically searched PubMed, Embase, PsycInfo, and grey literature sources between January 2008 and June 2020 with no language restrictions. We included any systematic review reporting measurable stress-related outcomes including stress prevalence, stressors, and stress coping strategies in nursing students residing in any of the 20 Middle East and North Africa countries. We also included additional primary studies identified through a hand search of the reference lists of relevant primary studies and systematic reviews.

Seven systematic reviews and 42 primary studies with data from Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan were identified. Most studies included nursing students undergoing clinical training. The prevalence range of low, moderate, and high perceived stress among nursing students was 0.8–65%, 5.9–84.5%, and 6.7–99.2%, respectively. Differences related to gender, training period, or the type of tool used to measure stress remain unclear given the wide variability in the reported prevalence measures across all stress levels. Common clinical training stressors were assignments, workload, and patient care. Academic training-related stressors included lack of break/leisure time, low grades, exams, and course load. Nursing students utilized problem focused (dealing with the problem), emotion focused (regulating the emotion), and dysfunctional (venting the emotions) stress coping mechanisms to alleviate their stress.

Conclusions

Available data does not allow the exploration of links between stress levels, stressors, and coping strategies. Limited country-specific prevalence data prevents comparability between countries. Reducing the number or intensity of stressors through curriculum revision and improving students’ coping response could contribute to the reduction of stress levels among students. Mentorship, counseling, and an environment conducive to clinical training are essential to minimize perceived stress, enhance learning, and productivity, and prevent burnout among nursing students.

Peer Review reports

Mental health-related conditions are becoming increasingly prevalent among healthcare professionals worldwide [ 1 ]. Professions involving constant close human contact and emotional engagement such as nursing, are vulnerable to stress and burnout, which could manifest even before employment [ 2 , 3 , 4 ]. A standard baccalaureate nursing program is a very demanding 4-year college or university education [ 5 , 6 ]. Nursing students experience stress when curricular demands exceed their resources to deal with these demands [ 7 ]. Specifically, the clinical training component is dynamic and challenging and was identified as anxiety-producing situations by students during their initial clinical training period [ 8 ].

Psychological stress can impact nursing students’ academic and clinical performance [ 4 ] as well as their future work life as these may be associated with harmful substance use [ 9 , 10 ] and reduced empathy [ 11 ]. Stress is also associated with serious mental health disorders [ 12 , 13 , 14 ] including depression which is one of the leading causes of disability globally [ 15 ]. The prevalence of depression among nursing students in Arab states is reported to be 28% [ 4 ], approximately six times higher than the prevalence in the general population [ 16 , 17 ]. Moreover, nursing is a female-dominated profession [ 4 ] and evidence shows that female college students [ 18 , 19 , 20 ] are more susceptible to depression than their male counterparts [ 21 ].

The Middle East, as with many regions worldwide, has a shortage of professional nurses [ 22 , 23 ]. Published literature has previously reported that a significant percentage of nursing students leave school before program completion [ 24 , 25 ] as a consequence of stress [ 26 , 27 ]. Stress reduction programs have been identified to be one of the most effective interventions to decrease attrition in nursing programs [ 25 ]. Stress coping strategies are also important determinants that influence overall mental health and well-being [ 28 ]. Additionally, published studies report that emotional and behavioral problems, among high stress exposure groups, such as in nursing students may affect their lifetime risk of mental health disorders [ 29 , 30 , 31 , 32 ]. Understanding stressors that affect nursing students during their training and what coping strategies are utilized by them to address the various stressors is critical. This will enable nursing schools and educators to evaluate and utilize evidence-based interventions and support programs aimed at minimizing attrition in nursing training programs which in turn can help address the shortage of nurses in the region [ 33 ].

Several studies [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ] and systematic reviews [ 45 , 46 , 47 ] have assessed stress levels, stressors, and coping strategies among medical students; however, there is a paucity of research and reviews on the subject for nursing students in the region. Our systematic overview synthesizes evidence from published systematic reviews on perceived stress among nursing students in the Middle East and North Africa (MENA) countries. Specifically, we aim to (1) synthesize prevalence data on various stress levels, (2) identify stressors among nursing students, (3) describe stress coping strategies utilized by nursing students in the region, and (4) provide recommendations for stress management.

We conducted a systematic overview of published systematic reviews on stress, stressors, and coping strategies among nursing students in the MENA region. Our systematic overview is part of a series of research and publications aimed to improve the quality of evidence generated in the MENA region by synthesizing available literature on population health issues in the region [ 48 , 49 , 50 ]. This overview draws from an a priori protocol registered with the International Prospective Register of Systematic Reviews (PROSPERO registration number CRD42017076736) [ 51 ]. The methodology of the present systematic overview was informed by the Cochrane Collaboration handbook [ 52 ] and was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Table S1 ) [ 53 ], and the Preferred Reporting Items for Overviews of Systematic Reviews (PRIO-harms) tool (Table S2 ).

Search strategy and literature sources

Two independent reviewers (AA and SC1) systematically searched PubMed, Embase, and PsycInfo for any type of review on stress, stressors, and coping strategies on any country in the MENA region published between January 2008 and June 2020. Search terms related to stress, coping strategies/behaviors, and countries’ names were used. The full-search strategy is available in Supplementary , Panel 1 and was validated by a specialized librarian. Additionally, we searched, up to June 2020, literature sources (including grey literature) potentially relevant to the region with no language restrictions including Google Scholar, OpenGrey, E-Marefa, and ALMANHAL platform. We supplemented our literature search by checking the reference lists of relevant included studies and systematic reviews.

Inclusion and exclusion criteria

In this review, we include countries in the MENA region where Arabic, English, French, and/or Urdu are the primary official languages and/or the medium of instruction in the colleges/universities [ 51 ]. The 20 countries included are Algeria, Bahrain, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, the United Arab Emirates (UAE), and Yemen. We included any systematic review reporting measurable stress-related outcomes including stress prevalence, sources of stress, and stress coping strategies or behaviors in nursing students residing in any of the above countries. To ensure a comprehensive up-to-date synthesis of the available data, we also included additional primary studies that had not been identified by included systematic reviews as recommended by the PRIO-harms for preferred reporting items for overviews of systematic reviews [ 54 ].

A systematic review was defined as a literature review that had explicitly used a systematic literature search of at least one electronic database to identify all studies that met pre-defined eligibility criteria along with a study selection process [ 55 ]. Reviews not reporting a systematic methodology, such as narrative reviews, were excluded. We included published systematic reviews since 2008—the publication year of the first version of the Cochrane Handbook for Systematic Reviews of Interventions [ 55 ].

Data screening and data extraction

Using Rayyan software, duplicates were removed [ 56 ]. Two independent reviewers (AA and SB) conducted a multi-stage screening following a standard process. Three reviewers (AA, SB, SC1) independently extracted the data from the included systematic reviews. Discrepancies in the inclusion of systematic reviews and the extracted data were resolved through discussions with the involvement of a fourth reviewer (KC) and under the supervision of the senior authors (SC2 and RM). Extracted data included characteristics of the included systematic reviews as well as the primary studies. From each included systematic review, the following characteristics were extracted: the geographical coverage, literature search period, data literature sources, name of the MENA country for which data was retrieved, along with the number of included studies, targeted review population, and reported stress-related outcomes. From each included primary study, the following characteristics were collected: study design and sample size, years of data collection, population characteristics (type, age, gender), and stress-related outcomes (definition or level, measurement tool, and/or prevalence measure). Study characteristics and any additional data on a stress-related outcome found in an included primary study but not reported by the systematic review were also extracted. In case of discordance between reported data in the systematic review and the primary study, data from the primary study publication was retained.

Methodological quality assessment

The methodological quality of the included systematic reviews and primary studies was assessed by two independent reviewers (SB, SC1). The AMSTAR measurement tool [ 57 ] was used to perform the quality assessment of the included systematic reviews.

A customized tool was used to assess the quality of the included primary studies to accommodate the specific issues related to the methodology and the assessed outcomes. A quality assessment checklist was based on the Cochrane approach for risk of bias (ROB) assessment [ 58 ] using an adapted PICOTS framework [ 59 ] to assess the quality of included studies with a focus on bias and precision assessment. Classification of studies as low and high risk of bias was based on three quality domains: the description of the study subjects (age and gender), setting (academic year or clinical training), and the validity of the outcome measurement (the use of a validated tool). The precision assessment was based on two quality domains: the sampling methodology (probability-based versus non-probability-based sampling), and the sample size required to reach a study power of at least 80% (≥ 100 versus < 100). For instance, if probability-based sampling was used in a given study, the study was classified with a low (versus high) risk of bias for that domain. Studies were considered as having high (versus low) precision if the total sample size consisted of at least 100 participants. For a perceived stress prevalence of 50% and a sample size of 100, the 95% confidence interval (CI) is 48–52% [ 60 ]—a reasonable 95% CI estimate for perceived stress prevalence measure. Studies with missing information for any of the domains were classified as having an unclear risk of bias for that specific domain.

The characteristics of the included systematic reviews and primary studies were synthesized narratively. To quantify the stress levels among nursing students in the MENA region, available data on the prevalence of perceived stress was summarized using prevalence ranges according to three stress levels: low, moderate, and high, as defined by the different tools utilized in the studies. Prevalence measure variations according to gender, nature of ongoing training, and the type of measurement tools were explored. A measurement tool was considered validated if a validation record in the specific language was retrievable from published literature.

Reported stressors among nursing students are categorized according to the training period: clinical, academic, and stressors external to training periods. For our review, clinical training stressors are classified into six domains as per the perceived stress scale for stressors [ 61 ]. The total number of studies reporting each stressor as a source of stress in the study population is also summarized.

Reported stress coping strategies among nursing students in the MENA countries are categorized according to three mechanisms as per the theory of psychological stress and coping [ 62 ]: problem-focused (dealing with the problem), emotion-focused (regulating the emotion), and dysfunctional coping (venting the emotions). We summarize the total number of studies reporting each coping mechanism and each specific stress coping strategy.

Recommendations for stress management are synthesized based on the available evidence into three main categories: nursing students, the nursing institutions, and nursing faculty and educators.

Characteristics of the included systematic reviews and primary studies

In our overview, we include 7 systematic reviews and 42 primary studies on the epidemiology of perceived stress among nursing students containing data for at least 1 MENA country (Fig. 1 ). The included systematic reviews along with the primary studies are described in Tables S3 and S4 , respectively. We found stress-related outcomes for nine MENA countries: Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. The reported primary outcomes are measures of stress levels (six systematic reviews [ 63 , 64 , 65 , 66 , 67 , 68 ]) and stress coping strategies (one systematic review [ 69 ]). The included systematic reviews did not report stressors as a primary outcome. Five systematic reviews [ 63 , 64 , 65 , 66 , 69 ] searched any country (global coverage), one systematic review [ 67 ] searched for data on Saudi Arabia only, and one systematic review [ 68 ] searched Asian countries. Thirteen primary studies report prevalence measures on perceived stress, 36 on stressors, and 23 on stress coping strategies.

PRISMA 2009 flowchart of the systematic review’s inclusion

Methodological quality assessment of the included systematic reviews and primary studies

Quality assessment results of the systematic reviews included in our overview are described in Table S5 . None of the included systematic reviews reported a priori design, the list of excluded studies, or the conflict of interest for the included studies as per the AMSTAR recommendations [ 57 ]. Nor did any of the systematic reviews combine primary study findings through meta-analysis. All included systematic reviews conducted a comprehensive literature search and described the characteristics of the included studies. Only two systematic reviews [ 64 , 68 ] searched grey literature sources. Except for the systematic review of Younas, 2016 [ 68 ], all systematic reviews documented the scientific quality of their included studies.

Quality assessment of the included primary studies is summarized in Table S6 . All included primary studies provide a detailed description of the study subjects and the research setting. A total of 35 out of 42 primary studies (82.5%) used a validated tool to measure to assess the prevalence of perceived stress ((Perceived Stress Scale (PSS), Stress Assessment Scale (SAS), Physio-Psychosocial Stress Scale (PPSS)), stressors (PSS, Stressors in Nursing Students Scale (SINS), Student Stress Survey (SSS), Students Stress and Coping Inventory (SSCI), Student Clinical Stressor Scale (SCSS), Student Nurse Stress Index (SNSI)), or stress coping strategies ((The Coping Behaviors Inventory (CBI), abbreviated version of the full COPE Inventory (Brief COPE), Coping Orientation to Problems Experienced (COPE), Adolescent Coping Orientation for Problem Experiences (ACOPE), Revised Ways of Coping Strategies Questionnaire (RWCSQ), and Students Stress and Coping Inventory (SSCI)). Only 28 out of 42 primary studies (67.5%) had a sample size of 100 or above and 20 out of 42 primary studies (47.6%) used a probability-based sampling.

Overview of studies with stress prevalence data

Table 1 summarizes stress prevalence data retrieved from 13 included studies with data from Egypt, Jordan, Iraq, and Saudi Arabia. A total of 38 prevalence measures involving 2804 nursing students were found. Prevalence measures were categorized into three stress levels, low, moderate, or high, as per the tool utilized in the study. Retrieved prevalence data on perceived stress were collected between 2008 and 2019. Most of the included studies involved combined populations of male and female nursing students. Prevalence ranges reported in female only studies were comparable to reported prevalence ranges among combined populations of male and female nursing students. The prevalence range of low perceived stress among all nursing students was 0.8–65%, for moderate perceived stress was 5.9–84.5% and for high perceived stress was 6.7–99.2%. The stress prevalence range among students during the clinical training was comparable to that found in all academic years combined. Twelve out of 13 primary studies with prevalence data utilized a validated tool to measure the prevalence of perceived stress. The PSS was the most widely used psychological instrument for measuring stress perception. We found wide variability in the perceived stress prevalence measures for all stress levels.

Some studies reported significantly higher stress levels in nursing students living in rural areas [ 70 ], having a father with low school education or non-professional background (e.g., farmers or manual workers) [ 70 ], low grades in the previous year [ 70 ], low family income [ 71 , 72 ], enrolled in community courses [ 73 , 74 ], spending six or more hours studying per day [ 72 ], 6 h or less of sleep per night [ 72 ], and suffering from overweight and obesity [ 71 ] (Table S4 ). The impact of age [ 71 , 75 , 76 , 77 , 78 ], gender [ 71 , 76 , 79 , 80 ], marital status [ 77 , 78 ], stages/levels of student’s study [ 77 , 78 , 79 , 80 , 81 , 82 , 83 ], and student’s interest in nursing [ 74 , 75 ], on stress levels seems to be inconsistent (Table S4 ).

Overview of studies with data on stressors

Table 2 summarizes the various types of stressors reported among nursing students. A total of 36 primary studies reported data on stressors among nursing students in Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine, and Bahrain: 26 reported data on stressors during the clinical period, 15 during the academic period, and in 15, the exact academic or clinical period could not be determined. In addition to stressors during the clinical and academic periods, studies also identified stressors ‘external’ to the training periods. We grouped the external stressors to be related to the ‘physical environment’ or being ‘intrapersonal.’

Based on the total number of primary studies, stressors related to clinical training are most commonly reported among nursing students followed by academic stressors. The predominantly reported specific stressors during clinical training are associated with assignments and workload (e.g., pressure from the nature and quality of clinical practice, a feeling that requirements of clinical practice are exceeding their physical and emotional endurance) and patient care (e.g., lack of experience and ability in providing nursing care and in making judgments, ‘do not know how to help patients with physio-psycho-social problems’). Lack of break/leisure time, getting lower grades than anticipated, and examination and course load are the main specific sources of academic stressors. External stressors related to the physical environment include lack of recreation facilities; absence of a calm, safe, and secure environment; and congested classrooms. External stressors related to intrapersonal reasons reported by the nursing students include uncertainty about their future career, change in sleep pattern, and financial problems.

No significant differences are observed in the type and level of stressors between students in private nursing schools and those in public schools [ 79 ] or according to the place of residence [ 84 , 90 ], age [ 79 , 84 , 90 ], gender [ 84 , 90 ], religion [ 84 ], marital status [ 79 , 90 ], and grade point average (GPA) of the last term (Table S4 ).

Overview of studies with data on stress coping strategies

Table 3 summarizes the stress coping strategies that nursing students use to deal with stress. A total of 23 primary studies reported data on stress coping strategies used by nursing students in Saudi Arabia, Egypt, Jordan, Oman, Pakistan, and Sudan: 19 studies report the use of problem-focused coping, 20 studies the use of emotion-focused coping, and 17 studies the use of dysfunctional coping. The most widely used problem-focused stress coping strategies are active coping (e.g., problem understanding and solving) and seeking social support for instrumental reasons (e.g., asking others for help and developing social support). Whereas, positive reinforcement and growth (e.g., staying optimistic and wishful thinking) and turning to religion (e.g., use of religion, prayer, invocation, and finding comfort in religion or spiritual beliefs) are the most widely used emotion-focused stress coping strategies. The most commonly used forms of dysfunctional coping strategies are mental disengagement (e.g., transference, become involved in other activities) and behavioral disengagement (e.g., avoidance, social withdrawal).

The reported relationship between stress levels and the used coping strategies is inconsistent. Two included studies [ 81 , 91 ] suggest a significantly negative correlation between the total PSS score (stress level) and the use of specific coping strategies, namely problem-solving. Only one study reported higher stress levels among students who utilized coping strategies like avoidance or transference strategies [ 100 ].

Some included studies suggested differences in the type of specific coping strategies used according to gender [ 71 , 85 ], academic level [ 71 ], and living with family or alone [ 85 ]. The coping strategies used by the students also varied according to the stressor. During clinical training, students experiencing stress from assignments and patient care, peers, daily life, teachers, and nursing staff were found to frequently use avoidance [ 85 , 92 ], transference [ 92 ], problem solving [ 85 , 92 ], and staying optimistic [ 92 ]. Common external (physical environmental or intrapersonal) stressors were linked to the use of transference [ 92 ], problem solving [ 92 ], and staying optimistic [ 92 ].

Overview of stress management recommendations for nursing students, nursing faculty and educators, and nursing institutions

Recommendations reported in the included systematic reviews on how nursing students, nursing faculty and educators, and nursing institutions can aim to reduce stress levels, and manage stressors to maximize knowledge gain and productivity among nursing students are synthesized (Table 4 ).

Our overview synthesizes the evidence on nursing students in the MENA countries about perceived stress, stressors, and the stress coping strategies utilized by them to manage stress. We reviewed 7 systematic reviews and 42 primary studies that include data from nine the MENA countries namely, Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Prevalence data from the majority of studies suggest that moderate and high stress levels predominate among nursing students in the region. Differences related to gender, training period, or the type of tool used to measure stress remain unclear given the wide variability in the reported prevalence measures across all stress levels. Commonly reported stressors among nursing students are related to clinical training (assignments, workload, and patient care), and academic training (lack of break/leisure time, grades, and examination and course load). Studies report the utilization of three predominant stress coping mechanisms: problem-focused (dealing with the problem), emotion-focused (regulating the emotion), and dysfunctional coping (venting the emotions). The most commonly utilized strategies within the problem-focused mechanism include active coping which in turn includes, specific strategies namely “problem understanding and solving” and “seeking social support.” Similarly, within emotion-focused mechanism, positive reinforcement and growth strategy, which includes “staying optimistic” and “wishful thinking” were more common. In the case of dysfunctional coping mechanism, behavioral, and mental disengagement, “avoidance” and “transference” were the most commonly used strategies and specific strategies respectively.

Variation in perceived stress prevalence data and comparison with international data

While moderate stress levels are reported in studies conducted in China [ 133 ], Hong Kong [ 134 ], and Nepal [ 135 ], our findings suggest that the stress level among nursing students in the MENA region ranges from moderate to high. The prevalence range of stress levels similar to that observed in our study has also been found in medical students in the region [ 36 , 40 , 41 , 46 , 136 , 137 ], internationally [ 34 , 37 , 38 , 43 , 45 , 138 ], and among midwifery students [ 66 ]. The wide variability in the stress prevalence measures found in our review could be explained by certain characteristics of the tools used. Some questionnaires used to measure stress levels in the included studies evaluate stress during the previous month [ 139 ] and some others during an undetermined period [ 71 , 99 , 140 ]. Also, certain questionnaires used are designed to measure stress levels in any life situation [ 139 ] and some others have been adapted to be used among nursing students [ 71 , 72 , 93 , 99 , 140 ]. The wide range of prevalence measures across all levels of stress could be also explained by the limited sample size of the primary studies and representativeness of the selected students. Some evidence shows increased levels of stress as the nursing students progress in their educational program [ 102 , 141 ], whereas, some other studies conclude no change in the stress level [ 129 ] between the academic years [ 135 ].

Similar to our findings, studies conducted in non-MENA countries have reported clinical training stressors, particularly clinical assignments and workload, as the most common stressors among nursing students [ 133 , 134 , 135 ]. Specifically, we also found that patient care is a common stressor for nursing students during their clinical training. Procedures related to patient care, examination frequency, and the amount of overall workload during clinical training must be revisited.

A global systematic review excluding the MENA concluded that the most common stressors among nursing students are academic stressors (workload and problems associated with studying) followed by clinical stressors (such as fear of unknown situations, mistakes with patients or handling of technical equipment) [ 129 ]. This can be explained by the predominance of studies including nursing students in the preparatory and preclinical years (years 1–2) which are generally characterized by more academic workload than clinical years (years 3–4) in this systematic review [ 129 ].

Most of the published literature focuses on assessing academic and clinical stressors. The importance and potential impact of stressors external to training periods, such as the physical environment and intrapersonal stressors have been less studied. Likewise, the lack of a standardized approach to categorize stressors in these studies makes it difficult to compare results between studies. The grouping of stressors in this overview may be useful for future research on this topic. Researchers may choose to assess stressors based on academic, clinical, or factors external to training.

Data on the use of coping strategies

The wide variation found in coping strategies utilized by nursing students in the MENA countries and worldwide [ 133 , 134 , 135 , 142 ] can be explained by the differences in cultural, socio-economic, and geographic contexts [ 142 ]. Comparable to our findings, emotional (e.g., expressions of empathy) and instrumental social support (e.g., tangible aid and service), and religion are identified to be commonly used stress coping mechanisms by nursing students in Hong Kong [ 134 ] and Malaysia [ 142 ]. Other dysfunctional coping strategies, such as the use of alcohol or illicit drugs were not assessed in the included studies.

The relationship between socio-economic factors and stress levels or stressors could not be confirmed, as most of the included primary studies are cross-sectional and not designed to assess causal associations. A possible link between stress levels and factors, such as gender [ 90 ] and living with family or alone [ 85 ] can be established on the basis of studies included in our review.

Relationship between stress levels, stressors, and coping strategies

Published literature indicates a potential link between stressors and the coping strategies utilized by nursing students [ 71 , 85 ]. A recent study demonstrated a statistically significant correlation of the six domains of stressors during clinical practice comprising of patient care, clinical educators/instructors and ward staff, clinical assignments and workload, peers and nursing students from other colleges, lack of professional knowledge and skills, and the clinical environment) with coping strategies [ 142 ]. Available data on the relationship between stress levels and the used coping strategies is limited and inconsistent [ 81 , 91 , 100 ]. Data from another study, however, suggests that the use of optimism, self-efficacy, and resilient coping by nursing students can have an impact on their perceived stress [ 37 ]. Additional studies designed to assess these potential associations are needed to establish the evidence.

Recommendations for stress management

To manage stress among nursing students, it is highly recommended by several published studies that nursing institutions must recognize their role in improving stress management [ 63 , 64 , 65 , 67 , 69 , 86 , 100 , 115 , 116 , 117 , 118 , 119 , 120 , 121 ]. Nursing institutions are encouraged to provide a supportive clinical learning environment and to establish a strong support system to equip both nursing students and educators with effective coping strategies. Although evidence is absent about the type of intervention that would be effective to reduce excessive stress among nursing students, some statistically significant effect was found for interventions which focused on reducing the number or intensity of stressors through curriculum revision or improving students’ coping response by indulging in art therapy and biofeedback-assisted relaxation training [ 143 ].

Strengths and limitations

To our knowledge, this is the most comprehensive, up-to-date, systematic overview synthesizing several dimensions of stress and coping behavior in a key population of the health care system for the MENA region. We searched multiple grey and non-grey literature sources for systematic reviews and primary studies to provide comprehensive evidence on the epidemiology of perceived stress among nursing students in the region. This compilation of evidence will serve as a benchmark for nursing students, nursing faculty and educators, and nursing institutions to help direct future interventions to optimize learning and prepare nursing students to manage stress effectively. Moreover, most of the included primary studies (12 out of 13) with prevalence data utilized a validated tool to measure the prevalence of perceived stress which minimizes the bias from the measurement tool. Most of the validated tools utilized in the studies are designed to assess clinical stressors in nursing students [ 61 , 90 , 119 , 140 , 144 , 145 , 146 ].

Some included systematic reviews had specific inclusion criteria, such as, nursing students undergoing clinical training only or with a certain standard of methodological quality, which could explain the limited number of included primary studies in the systematic reviews. Moreover, none of the included systematic reviews have included studies published in a language other than English which could have led to an incomplete selection of primary studies relevant for the MENA countries. Out of the seven included systematic reviews, five had global geographical coverage and did not search grey literature or specific sources relevant for countries of the MENA region. Despite our best efforts to include all available data, data on the topic in other country-specific grey literature sources could exist. The included systematic reviews have searched data up to August 2018. In the absence of recent systematic reviews and to complete the collected data with recent studies published in the past 2 years, we conducted a hand search of primary studies in grey and non-grey literature sources. Despite this updated search, other recent primary studies could have been missed. Out of the seven included systematic reviews, five [ 63 , 65 , 66 , 68 , 69 ] were found through a hand search. This is explained by the fact that none of the hand searched systematic reviews have mentioned a term related to the MENA countries in the searchable fields of the used data platforms.

Our findings suggest that the stress level among nursing students in the MENA region ranges from moderate to high. The limited data on stress prevalence among nursing students in all the MENA countries prevents the estimation of its magnitude with certainty; hence, comparability of stress prevalence between countries and other regions is also not possible. Differences due to gender, clinical training period, or type of tool used remain unclear given the wide variability in the reported prevalence measures across all stress levels. Nursing students commonly report stressors related to both clinical and academic training components of the nursing curriculum. Studies report an equal utilization of three predominant stress coping strategies by the nursing students: problem focused (dealing with the problem), emotion focused (regulating the emotion), and dysfunctional (venting the emotions). The link between stressors, and coping strategies and stress levels remains unclear. Although the significance of using the problem-solving approach to manage stress is well-established, there is a need to identify effective strategies to reduce excessive stress and increase the utility of positive coping strategies. Nursing institutions should establish a strong support system for students and educators to equip them with effective coping strategies. Reducing the number or intensity of stressors through curriculum revision and improving students’ coping response could contribute to the reduction of stress levels among students. Nursing faculty and educators are encouraged to mentor students to develop and strengthen problem-based, rather than emotion-based behavior to cope with stress and to provide a supportive clinical learning environment. While stress may not be preventable, it appears coping with stressors especially during the clinical training of the nursing curriculum is essential to maximize knowledge gain and productivity and prevent burnout among nursing students.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

The Preferred Reporting Items for Overviews of Systematic Reviews

Middle East and North Africa

The United Arab Emirates

Risk of bias

Perceived Stress Scale

Stress Assessment Scale

Physio-Psychosocial Stress Scale

Stressors in Nursing Students Scale

Student Stress Survey

Students Stress and Coping Inventory

Student Clinical Stressor Scale

Student Nurse Stress Index

Coping Behaviors Inventory

Coping Orientation to Problems Experienced

Adolescent Coping Orientation for Problem Experiences

Revised Ways of Coping Strategies Questionnaire

Barry S, Ward L. Undergraduate nursing students’ understandings of mental health: a review of the literature. Issues Ment Health Nurs. 2017;38(2):160–75. https://doi.org/10.1080/01612840.2016.1251515 .

Article   PubMed   Google Scholar  

Moreira DP, Furegato ARF. Stress and depression among students of the last semester in two nursing courses. Rev Lat Am Enfermagem. 2013;21(spe):155–62. https://doi.org/10.1590/S0104-11692013000700020 .

Rudman A, Gustavsson JP. Burnout during nursing education predicts lower occupational preparedness and future clinical performance: a longitudinal study. Int J Nurs Stud. 2012;49(8):988–1001. https://doi.org/10.1016/j.ijnurstu.2012.03.010 .

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. https://doi.org/10.1016/j.nedt.2018.01.009 .

Phillips A. Nursing Education in Saudi Arabia. Ann Saudi Med. 1989;9(2):195–7. https://doi.org/10.5144/0256-4947.1989.195 .

Article   Google Scholar  

The American Association of Colleges of Nursing (AACN). Nursing Education Programs / Baccalaureate Education. 2020. Available from: https://www.aacnnursing.org/Nursing-Education-Programs/Baccalaureate-Education . Accessed 20 May 2020.

Moffat KJ, McConnachie A, Ross S, Morrison JM. First year medical student stress and coping in a problem-based learning medical curriculum. Med Educ. 2004;38(5):482–91. https://doi.org/10.1046/j.1365-2929.2004.01814.x .

Elliott M. The clinical environment: a source of stress for undergraduate nurses. Aust J Adv Nurs. 2002;20(1):34–8.

PubMed   Google Scholar  

Newbury-Birch D, Walshaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug Alcohol Depend. 2001;64(3):265–70. https://doi.org/10.1016/S0376-8716(01)00128-4 .

Article   CAS   PubMed   Google Scholar  

Ashton CH, Kamali F. Personality, lifestyles, alcohol and drug consumption in a sample of British medical students. Med Educ. 1995;29(3):187–92. https://doi.org/10.1111/j.1365-2923.1995.tb02828.x .

Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ. 2004;38(5):522–34. https://doi.org/10.1046/j.1365-2929.2004.01820.x .

Gibbons C. Stress, coping and burn-out in nursing students. Int J Nurs Stud. 2010;47(10):1299–309. https://doi.org/10.1016/j.ijnurstu.2010.02.015 .

Xie Z, Wang A, Chen B. Nurse burnout and its association with occupational stress in a cross-sectional study in Shanghai. J Adv Nurs. 2011;67(7):1537–46. https://doi.org/10.1111/j.1365-2648.2010.05576.x .

Mészáros V, Cserháti Z, Oláh A, Perczel Forintos D, Adám S. Coping with work-related stress in health care professionals -- strategies for the prevention of burnout and depression. Orv Hetil. 2013;154(12):449–54. https://doi.org/10.1556/OH.2013.29572 .

Institute for Health Metrics and Evaluation (IHME). Findings from the global burden of disease study 2017. Seattle: IHME; 2018.

Google Scholar  

World Health Organization. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization; 2017.

Ferrari AJ, Somerville AJ, Baxter AJ, Norman R, Patten SB, Vos T, et al. Global variation in the prevalence and incidence of major depressive disorder: a systematic review of the epidemiological literature. Psychol Med. 2013;43(3):471–81. https://doi.org/10.1017/S0033291712001511 .

Young CB, Fang DZ, Zisook S. Depression in Asian–American and Caucasian undergraduate students. J Affect Disord. 2010;125(1):379–82. https://doi.org/10.1016/j.jad.2010.02.124 .

Buchanan JL. Prevention of depression in the college student population: a review of the literature. Arch Psychiatr Nurs. 2012;26(1):21–42. https://doi.org/10.1016/j.apnu.2011.03.003 .

Steptoe A, Tsuda A, Tanaka Y, Wardle J. Depressive symptoms, socio-economic background, sense of control, and cultural factors in university students from 23 countries. Int J Behav Med. 2007;14(2):97–107. https://doi.org/10.1007/BF03004175 .

Olvera Alvarez H, Provencio-Vasquez E, Slavich G, Laurent J, Browning M, McKee-Lopez G, et al. Stress and health in nursing students. Nurs Res. 2019;68(6):453–63. https://doi.org/10.1097/NNR.0000000000000383 .

Article   PubMed   PubMed Central   Google Scholar  

Shukri R. Status of nursing in the Arab world. Ethn Dis. 2005;15(1 Suppl 1):S1-88–9.

Sheikh JI, Cheema S, Chaabna K, Lowenfels AB, Mamtani R. Capacity building in health care professions within the Gulf cooperation council countries: paving the way forward. BMC Med Educ. 2019;19(1):83. https://doi.org/10.1186/s12909-019-1513-2 .

Courage MM, Godbey KL. Student retention: policies and services to enhance persistence to graduation. Nurse Educ. 1992;17(2):29–32. https://doi.org/10.1097/00006223-199203000-00015 .

Smith-Wacholz HC, Wetmore JP, Conway C, McCarley M. Retention of nursing students: an integrative review. Nurs Educ Perspect. 2019;40(6):328–32. https://doi.org/10.1097/01.NEP.0000000000000477 .

Lindop E. Individual stress and its relationship to termination of nurse training. Nurse Educ Today. 1989;9(3):172–9. https://doi.org/10.1016/0260-6917(89)90041-5 .

Lindop E. Factors associated with student and pupil nurse wastage. J Adv Nurs. 1987;12(6):751–6. https://doi.org/10.1111/j.1365-2648.1987.tb01379.x .

Shikai N, Uji M, Chen Z, Hiramura H, Tanaka N, Shono M, et al. The role of coping styles and self-efficacy in the development of dysphoric mood among nursing students. J Psychopathol Behav Assess. 2007;29(4):241–8. https://doi.org/10.1007/s10862-007-9043-3 .

Harrington R, Fudge H, Rutter M, Pickles A, Hill J. Adult outcomes of childhood and adolescent depression: I. Psychiatric status. Arch Gen Psychiatry. 1990;47(5):465–73. https://doi.org/10.1001/archpsyc.1990.01810170065010 .

Hofstra MB, Van der Ende JAN, Verhulst FC. Continuity and change of psychopathology from childhood into adulthood: a 14-year follow-up study. J Am Acad Child Adolesc Psychiatry. 2000;39(7):850–8. https://doi.org/10.1097/00004583-200007000-00013 .

Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ, Poulton R. Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Arch Gen Psychiatry. 2003;60(7):709–17. https://doi.org/10.1001/archpsyc.60.7.709 .

Hofstra MB, Van Der Ende JAN, Verhulst FC. Child and adolescent problems predict dsm-iv disorders in adulthood: a 14-year follow-up of a dutch epidemiological sample. J Am Acad Child Adolesc Psychiatry. 2002;41(2):182–9. https://doi.org/10.1097/00004583-200202000-00012 .

Deary IJ, Watson R, Hogston R. A longitudinal cohort study of burnout and attrition in nursing students. J Adv Nurs. 2003;43(1):71–81. https://doi.org/10.1046/j.1365-2648.2003.02674.x .

Voltmer E, Kötter T, Spahn C. Perceived medical school stress and the development of behavior and experience patterns in German medical students. Med Teach. 2012;34(10):840–7. https://doi.org/10.3109/0142159X.2012.706339 .

Castaldelli-Maia JM, Lewis T, Marques dos Santos N, Picon F, Kadhum M, Farrell SM, et al. Stressors, psychological distress, and mental health problems amongst Brazilian medical students. Int Rev Psychiatry. 2019;31:7–8, 603–7.

Shawi AFA, Abdullateef AN, Khedher MA, Rejab MS, Khaleel RN. Assessing stress among medical students in Anbar governorate, Iraq: a cross-sectional study. Pan Afr Med J. 2018;31:96.

Heinen I, Bullinger M, Kocalevent R-D. Perceived stress in first year medical students - associations with personal resources and emotional distress. BMC Med Educ. 2017;17(1):4. https://doi.org/10.1186/s12909-016-0841-8 .

Melaku L, Mossie A, Negash A. Stress among medical students and its association with substance use and academic performance. J Biomed Educ. 2015;2015:9.

Ludwig AB, Burton W, Weingarten J, Milan F, Myers DC, Kligler B. Depression and stress amongst undergraduate medical students. BMC Med Educ. 2015;15(1):141. https://doi.org/10.1186/s12909-015-0425-z .

Abdulghani HM, AlKanhal AA, Mahmoud ES, Ponnamperuma GG, Alfaris EA. Stress and its effects on medical students: a cross-sectional study at a college of medicine in Saudi Arabia. J Health Popul Nutr. 2011;29(5):516–22.

Abdulghani HM. Stress and depression among medical students: a cross sectional study at a Medical College in Saudi Aarabia. Pak J Med Sci. 2008;24(1):12–7.

Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ. 2005;39(6):594–604. https://doi.org/10.1111/j.1365-2929.2005.02176.x .

Sherina MS, Rampal L, Kaneson N. Psychological stress among undergraduate medical students. Med J Malaysia. 2004;59(2):207–11.

CAS   PubMed   Google Scholar  

Kiessling C, Schubert B, Scheffner D, Burger W. First year medical students’ perceptions of stress and support: a comparison between reformed and traditional track curricula. Med Educ. 2004;38(5):504–9. https://doi.org/10.1046/j.1365-2929.2004.01816.x .

Esan O, Esan A, Folasire A, Oluwajulugbe P. Mental health and wellbeing of medical students in Nigeria: a systematic review. Int Rev Psychiatry. 2019:1–12.

Elzubeir MA, Elzubeir KE, Magzoub ME. Stress and coping strategies among Arab medical students: towards a research agenda. Educ Health (Abingdon). 2010;23(1):355.

CAS   Google Scholar  

Witt K, Boland A, Lamblin M, McGorry PD, Veness B, Cipriani A, et al. Effectiveness of universal programmes for the prevention of suicidal ideation, behaviour and mental ill health in medical students: a systematic review and meta-analysis. Evid Based Ment Health. 2019;22(2):84–90. https://doi.org/10.1136/ebmental-2019-300082 .

Doraiswamy S, Jithesh A, Chaabane S, Abraham A, Chaabna K, Cheema S. Perinatal mental illness in the Middle East and North Africa Region-a systematic overview. Int J Environ Res Public Health. 2020;17(15):5487.

Article   PubMed Central   Google Scholar  

Chaabna K, Cheema S, Abraham A, Alrouh H, Lowenfels AB, Maisonneuve P, et al. Systematic overview of hepatitis C infection in the Middle East and North Africa. World J Gastroenterol. 2018;24(27):3038–54. https://doi.org/10.3748/wjg.v24.i27.3038 .

Chaabane S, Chaabna K, Abraham A, Mamtani R, Cheema S. Physical activity and sedentary behaviour in the Middle East and North Africa: an overview of systematic reviews and meta-analysis. Sci Rep. 2020;10(1):9363. https://doi.org/10.1038/s41598-020-66163-x .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Chaabna K, Cheema S, Abraham A, Alrouh H, Mamtani R, Sheikh JI. Gray literature in systematic reviews on population health in the Middle East and North Africa: protocol of an overview of systematic reviews and evidence mapping. Syst Rev. 2018;7(1):94. https://doi.org/10.1186/s13643-018-0751-4 .

Becker L, Oxman A. Overviews of reviews. In: Cochrane handbook for systematic reviews of interventions version 510: The Cochrane Collaboration; 2011. p. 607–31. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/9780470712184.ch22 .

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006–12. https://doi.org/10.1016/j.jclinepi.2009.06.005 .

Bougioukas KI, Liakos A, Tsapas A, Ntzani E, Haidich A-B. Preferred reporting items for overviews of systematic reviews including harms checklist: a pilot tool to be used for balanced reporting of benefits and harms. J Clin Epidemiol. 2018;93:9–24. https://doi.org/10.1016/j.jclinepi.2017.10.002 .

Higgins J, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0: The Cochrane Collaboration; 2011. Available from: www.handbook.cochrane.org

Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. https://doi.org/10.1186/s13643-016-0384-4 .

Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7(1):10. https://doi.org/10.1186/1471-2288-7-10 .

Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Clinical research ed). 2011;343:d5928.

Institute of Medicine of the National Academies. Finding what works in health care: standards for systematic reviews. Washington, DC: The National Academies Press; 2011.

Daniel WW. Biostatistics: a foundation for analysis in the health sciences. 7th ed. New York: Wiley; 1999.

Sheu S, Lin HS, Hwang SL. Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice: the effect of coping behaviors. Int J Nurs Stud. 2002;39(2):165–75. https://doi.org/10.1016/S0020-7489(01)00016-5 .

Baqutayan S. Stress and coping mechanisms: a historical overview. Mediterr J Soc Sci. 2015;6(2 S1):479.

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(5):471–80. https://doi.org/10.1080/09638237.2016.1244721 .

Alzayyat A, Al-Gamal E. A review of the literature regarding stress among nursing students during their clinical education. Int Nurs Rev. 2014;61(3):406–15. https://doi.org/10.1111/inr.12114 .

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(5):266–72. https://doi.org/10.3928/01484834-20190422-04 .

McCarthy B, Trace A, O’Donovan M, Brady-Nevin C, Murphy M, O'Shea M, et al. Nursing and midwifery students’ stress and coping during their undergraduate education programmes: an integrative review. Nurse Educ Today. 2018;61:197–209. https://doi.org/10.1016/j.nedt.2017.11.029 .

Labrague LJ, McEnroe–Petitte DM, De Los Santos JAA, Edet OB. Examining stress perceptions and coping strategies among Saudi nursing students: a systematic review. Nurse Educ Today. 2018;65:192–200.

Younas A. Levels of stress and coping strategies used by nursing students in Asian countries: an integrated literature review. J Middle East North Afr Sci. 2016;2(4):50–7. https://doi.org/10.12816/0032673 .

Labrague LJ, McEnroe-Petitte DM, Al Amri M, Fronda DC, Obeidat AA. An integrative review on coping skills in nursing students: implications for policymaking. Int Nurs Rev. 2018;65(2):279–91. https://doi.org/10.1111/inr.12393 .

Amr A, El-Gilany A-H, El-Moafee H, Salama L, Jimenez C. Stress among Mansoura (Egypt) baccalaureate nursing students. Pan Afr Med J. 2011;8:26.

Madian A, Abdelaziz M, Ahmed H. Level of stress and coping strategies among nursing students at Damanhour University, Egypt. Am J Nurs Res. 2019;7(5):684–96. https://doi.org/10.12691/ajnr-7-5-3 .

Abd El All NH, Abou Shousha AAEF. Stress factors and coping strategies as perceived by nursing students = عوامل الضغوط و إستراتیجیات المواجهة من وجهة نظر طلبة كلیة التمریض . Zagazig Nurs J. 2015;11(1):16–32.

Elsayes H, Obied H. Association between senior nursing students’ perceived stress and learning environment in clinical practice. J Nurs Educ Pract. 2017;8(3):126. https://doi.org/10.5430/jnep.v8n3p126 .

Khater W, Akhu-Zaheya L, Shaban I. Sources of stress and coping behaviours in clinical practice among baccalaureate nursing students. Int J Humanit Soc Sci. 2014;4:194–202.

Alsaqri SH. Stressors and coping strategies of the Saudi nursing students in the clinical training: a cross-sectional study. Educ Res Int. 2017;2017:8.

Aziz F. Stressors and coping strategies among baccalaureate nursing students at Shifa College of Nursing Islamabad, Pakistan. Int J Nurs Educ. 2012;4:193.

Eswi AS, Radi S, Youssri H. Stress/ stressors as perceived by baccalaureate Saudi nursing students. Middle-East J Sci Res. 2013;14:193–202.

Al-Barrak MY, El-Nady MT, Fayad EA. Sources of stress as perceived by nursing students at King Saud University. Med J Cairo Univ. 2011;79:541–53.

Watson R, Rehman S, Ali PA. Stressors affecting nursing students in Pakistan. Int Nurs Rev. 2017;64(4):536–43. https://doi.org/10.1111/inr.12392 .

Kareem MS. Stress level among nursing students in hawler medical university at Erbil CIty-Iraq. Malays J Nurs. 2019;11(1):82–8. https://doi.org/10.31674/mjn.2019.v11i01.012 .

Basal A. Foundations of stressors and coping behaviors in different clinical practice areas among undergraduate nursing students in faculty of nursing Tanta University; 2018.

Mohamed BM, Ahmed ES. Perception of nursing students towards clinical stressors in the Faculty of Applied Medical Sciences – Al Jouf University – Saudi Arabia. J Am Sci. 2012;8:608–17.

Aedh AI, Elfaki NK, Mohamed IA. Factors associated with stress among nursing students (Najran University-Saudi Arabia). IOSR J Nurs Health Sci. 2015;4(6):33–8.

El Rafaey NM. Clinical setting related stressors perceived by medical surgical nursing students. J Nurs Health Sci. 2020;9(3):01–5.

Shdaifat E. Stress and coping strategies among nursing students. Global J Health Sci. 2018;10(5):33. https://doi.org/10.5539/gjhs.v10n5p33 .

Parveen A, Inayat S. Evaluation of factors of stress among nursing students. Adv Pract Nurs. 2017;02(2):136.

Afzal M, Hussain M, Waqas A, Sehar N. Sources of stress among the nursing students of private universities of Pakistan. S Am J Nurs. 2016.  https://doi.org/10.21522/TIJNR.2015.02.01.Art004 .

Bashir R. Sources of stress among nursing students of university of Lahore (LSN): Thesis. University of Lahore; 2014.

Al Zu’bi MAKM, Shawabka GAF. Assessment of stress factors for nursing student toward training in the critical areas of Princess Basma Hospital. J Middle East North Afr Sci. 2018;4(4):8–12.

Fashafsheh I, Ayed A, Alkaissi A. Stressors affecting baccalaureate nursing students in the clinical area in Palestinian Universities. J Health Med Nurs. 2015;14:42–52.

Al-Gamal E, Alhosain A, Alsunaye K. Stress and coping strategies among Saudi nursing students during clinical education. Perspect Psychiatr Care. 2018;54(2):198–205. https://doi.org/10.1111/ppc.12223 .

Ahmed WAM, Mohammed BMA. Nursing students’ stress and coping strategies during clinical training in KSA. J Taibah Univ Med Sci. 2019;14(2):116–22. https://doi.org/10.1016/j.jtumed.2019.02.002 .

Mohammed Q, Sajit K. Stress and its associated factors among students of the College of Nursing University of Baghdad. Iraqi Natl J Nurs Spec. 2016;29:30–7.

Ajweh AM, Shukri R, Kazem A, Saloom W. Stressors and coping strategies among nursing students at the College Nursing in Sultan Qaboos University. Int J Learn Man Sys. 2015;3:51–69.

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(3):197–203. https://doi.org/10.3109/09638237.2016.1139067 .

Ismaile S, et al. Open J Nurs. 2017;07(04):10.

Subhi Al-Zayyat A, Al-Gamal E. Perceived stress and coping strategies among Jordanian nursing students during clinical practice in psychiatric/mental health courses. Int J Ment Health Nurs. 2014;23(4):326–35. https://doi.org/10.1111/inm.12054 .

Shaban IA, Khater WA, Akhu-Zaheya LM. Undergraduate nursing students’ stress sources and coping behaviours during their initial period of clinical training: a Jordanian perspective. Nurse Educ Pract. 2012;12(4):204–9. https://doi.org/10.1016/j.nepr.2012.01.005 .

Maged R, El A, Hosny H, Ata A. Conflict management styles, assertiveness and stress among nursing students; 2019. p. 49–59.

Alzayyat A, Al-Gamal E. Correlates of stress and coping among jordanian nursing students during clinical practice in psychiatric/mental health course. Stress Health. 2016;32(4):304–12. https://doi.org/10.1002/smi.2606 .

John B, Al-Sawad M. Perceived stress in clinical areas and emotional intelligence among baccalaureate nursing students. J Indian Acad Appl Psychol. 2015;41(3):75–84.

Naqvi A, Alrasheed F, Ahmad R, Ahmad N. Academic stress and prevalence of stress-related self-medication among undergraduate female students of health and non-health cluster colleges of a public sector University in Dammam, Saudi Arabia. J Pharm Bioallied Sci. 2018;9:251–8.

Alghamdi S, Aljabri S, Jafari G, Alzebali R, Alkunaidiri N, Kalantan N. Sources of stress among undergraduate nursing students. Global J Health Sci. 2019;11(9):116. https://doi.org/10.5539/gjhs.v11n9p116 .

Shalaby S, AlDilh SMS. Exploring the relationship between perceived stress and academic achievement among critical care nursing students. Athens J Health. 2015;2(4):283–96. https://doi.org/10.30958/ajh.2-4-4 .

Shalaby S, Aljezani A. Exploring the relationship between perceived educational environment and academic achievement among critical care nursing students. Clin Nurs Stud. 2018;7(1):1. https://doi.org/10.5430/cns.v7n1p1 .

Yehia DBM, Jacoub SM, Eser SM. Predictors of coping strategies among nursing college students at AL-Zaytoonah University of Jordan. J Educ Pract. 2016;7(15):149–54.

Khalil Abdulqawi MS, Brair SL. Coping strategies regarding stress among bachelor nursing students in clinical practice, Khartoum State, 2018. Al Neelain Med J. 2018;(22). ISSN 1858-6155.

Hassanein S, Elshair I, Abdrbo A, Hassan E. Coping strategies as predictors of coursework stress among university nursing students. J Nurs Educ Pract. 2016;7(2):99–106.

Al Masaed AS. Relationships of positive and negative psychological stress coping strategies with locus of control and some variables among a sample of Al-al Bayt University students. 2013;7(3):19. مجلة الدراسات التربویة والنفسیة.

Mahfouz R, Alsahli H. Perceived stress and coping strategies among newly nurse students in clinical practice. J Educ Pract. 2016;7(23):118–28.

al Zamil L. Perceived level of stress, & coping strategies among Saudi nursing student. IOSR J Nurs Health Sci. 2017;06:06–13.

Ibrahim SR, Sayed FS. Stress level and coping behaviors of psychiatric nursing students pre and post clinical practice. J Nurs Health Sci. 2018;7(Issue 2 Ver. IV):54–64.

COPE Inventory. Measurement instrument database for the social science. Carver, C.S; 2013. Retrieved from www.midss.ie .

Carver CS. You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med. 1997;4(1):92–100. https://doi.org/10.1207/s15327558ijbm0401_6 .

Robotham D, Julian C. Stress and the higher education student: a critical review of the literature. J Furth High Educ. 2006;30(2):107–17. https://doi.org/10.1080/03098770600617513 .

Folkman S, Lazarus RS. The relationship between coping and emotion: implications for theory and research. Soc Sci Med. 1988;26(3):309–17. https://doi.org/10.1016/0277-9536(88)90395-4 .

Raymond J, Sheppard K. Effects of peer mentoring on nursing students’ perceived stress, sense of belonging, self-efficacy and loneliness. J Nurs Educ Pract. 2017;8(1):16. https://doi.org/10.5430/jnep.v8n1p16 .

Klainin-Yobas P, Keawkerd O, Pumpuang W, Thunyadee C, Thanoi W, He H-G. The mediating effects of coping on the stress and health relationships among nursing students: a structural equation modelling approach. J Adv Nurs. 2014;70(6):1287–98. https://doi.org/10.1111/jan.12283 .

Seyedfatemi N, Tafreshi M, Hagani H. Experienced stressors and coping strategies among Iranian nursing students. BMC Nurs. 2007;6(1):11. https://doi.org/10.1186/1472-6955-6-11 .

Zhao FF, Lei XL, He W, Gu YH, Li DW. The study of perceived stress, coping strategy and self-efficacy of C hinese undergraduate nursing students in clinical practice. Int J Nurs Pract. 2015;21(4):401–9. https://doi.org/10.1111/ijn.12273 .

Del Prato D, Bankert E, Grust P, Joseph J. Transforming nursing education: a review of stressors and strategies that support students’ professional socialization. Adv Med Educ Pract. 2011;2:109–16. https://doi.org/10.2147/AMEP.S18359 .

Ghodasara SL, Davidson MA, Reich MS, Savoie CV, Rodgers SM. Assessing student mental health at the Vanderbilt University School of Medicine. Acad Med. 2011;86(1):116–21. https://doi.org/10.1097/ACM.0b013e3181ffb056 .

Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. J Psychiatr Res. 2013;47(3):391–400. https://doi.org/10.1016/j.jpsychires.2012.11.015 .

Puthran R, Zhang MWB, Tam WW, Ho RC. Prevalence of depression amongst medical students: a meta-analysis. Med Educ. 2016;50(4):456–68. https://doi.org/10.1111/medu.12962 .

Nelwati N, McKenna L, Plummer V. Indonesian student nurses’ perceptions of stress in clinical learning: a phenomenological study. J Nurs Educ Pract. 2013;ISSN 1925-4040:56–65.

Zupiria Gorostidi X, Huitzi Egilegor X, Jose Alberdi Erice M, Jose Uranga Iturriotz M, Eizmendi Garate I, Barandiaran Lasa M, et al. Stress sources in nursing practice. Evolution during nursing training. Nurse Educ Today. 2007;27(7):777–87. https://doi.org/10.1016/j.nedt.2006.10.017 .

Lo R. A longitudinal study of perceived level of stress, coping and self-esteem of undergraduate nursing students: an Australian case study. J Adv Nurs. 2002;39(2):119–26. https://doi.org/10.1046/j.1365-2648.2000.02251.x .

Maalouf FT, Alamiri B, Atweh S, Becker AE, Cheour M, Darwish H, et al. Mental health research in the Arab region: challenges and call for action. Lancet Psychiatry. 2019;6(11):961–6. https://doi.org/10.1016/S2215-0366(19)30124-5 .

Pulido-Martos M, Augusto-Landa JM, Lopez-Zafra E. Sources of stress in nursing students: a systematic review of quantitative studies. Int Nurs Rev. 2012;59(1):15–25. https://doi.org/10.1111/j.1466-7657.2011.00939.x .

Chan CK, So WK, Fong DY. Hong Kong baccalaureate nursing students’ stress and their coping strategies in clinical practice. J Prof Nurs. 2009;25(5):307–13. https://doi.org/10.1016/j.profnurs.2009.01.018 .

Yamashita K, Saito M, Takao T. Stress and coping styles in Japanese nursing students. Int J Nurs Pract. 2012;18(5):489–96. https://doi.org/10.1111/j.1440-172X.2012.02056.x .

Penn TD. Enhancing student comfort in psychiatric clinical settings. Teach Learn Nurs. 2008;3(2):53–5. https://doi.org/10.1016/j.teln.2007.10.001 .

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(4):401–9. https://doi.org/10.1111/ijn.12273 .

Yan ATC. Prediction of perceived stress of Hong Kong nursing students with coping behaviors over clinical practicum: a cross-sectional study. J Biosci Med. 2019;7(5):50–60. https://doi.org/10.4236/jbm.2019.75008 .

Devkota R, Shrestha S. Stress among bachelor level nursing student. Nepal Med Coll J. 2018;20(1-3):33–40.

Carter A, Elzubeir M, Abdulrazzaq Y, Revel A, Townsend A. Health and lifestyle needs assessment of medical students in the United Arab Emirates. Med Teach. 2003;25(5):492–6. https://doi.org/10.1080/01421590310001605633 .

El-Gilany A-H, Amr M, Hammad S. Perceived stress among male medical students in Egypt and Saudi Arabia: effect of sociodemographic factors. Ann Saudi Med. 2008;28(6):442–8. https://doi.org/10.5144/0256-4947.2008.442 .

Saipanish R. Stress among medical students in a Thai medical school. Med Teach. 2003;25(5):502–6. https://doi.org/10.1080/0142159031000136716 .

Perceived Stress Scale (PSS). From: Cohen S, Kamarck T, Mermelstein R. A global measure of oerceived stress. J Health Soc Behav. 1983;24(4):385–96.

Jones MC, Johnston DW. The derivation of a brief Student Nurse Stress Index. Work Stress. 1999;13(2):162–81. https://doi.org/10.1080/026783799296129 .

Lindop E. Individual stress among nurses in training: why some leave while others stay. Nurse Educ Today. 1991;11(2):110–20. https://doi.org/10.1016/0260-6917(91)90146-2 .

Ab Latif R, Mat Nor MZ. Stressors and coping strategies during clinical practice among diploma nursing students. Malays J Med Sci. 2019;26(2):88–98. https://doi.org/10.21315/mjms2019.26.2.10 .

Turner K, McCarthy VL. Stress and anxiety among nursing students: a review of intervention strategies in literature between 2009 and 2015. Nurse Educ Pract. 2017;22:21–9. https://doi.org/10.1016/j.nepr.2016.11.002 .

Algaralleh A, Altwalbeh D, Alzayyat A. Preliminary psychometric properties of the Arabic version of Sheu and colleagues Perceived Stress Scale among nursing students at Jordanian universities. J Multidiscip Healthc. 2019;12:777–87. https://doi.org/10.2147/JMDH.S214456 .

Watson R, Deary IJ, Thompson DR, Li G. The stress in nursing students scale (SINS): principal components analysis of longitudinal data from Hong Kong. J Clin Nurs. 2010;19(7-8):1170–2. https://doi.org/10.1111/j.1365-2702.2009.03159.x .

Folkman S. Stress: appraisal and coping. In: Gellman MD, Turner JR (eds).  Encyclopedia of behavioral medicine. New York; Springer; 2013. https://doi.org/10.1007/978-1-4419-1005-9_215 .

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We would like to thank Danielle Jones, Lecturer, English as a Second Language, Weill Cornell Medicine-Qatar for editing the manuscript. We acknowledge Open Access funding provided by the Qatar National Library.

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Sonia Chaabane, Karima Chaabna, Sapna Bhagat, Amit Abraham, Sathyanarayanan Doraiswamy, Ravinder Mamtani & Sohaila Cheema

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Sonia Chaabane (SC1), Karima Chaabna (KC), Sapna Bhagat (SB), Amit Abraham (AA), Sathyanarayanan Doraiswamy (SD), Ravinder Mamtani (RM), and Sohaila Cheema (SC2) collectively contributed to the conception of the study. SC1, KC, SB, AA, and SC2 were involved in the literature search, screening, and extraction steps. Analysis and manuscript drafting were implemented by SC1 with support from KC, AA, SD, SC2, and RM. All authors read, edited, and approved the final manuscript.

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Additional file 1: table s1..

The 2009 PRISMA checklist for reporting a systematic review. Table S2. PRIO-harms checklist for reporting an overview of systematic reviews (OoSRs). Table S3. Characteristics of the included systematic reviews. Table S4. Prevalence of stress, stressors and coping strategies among nursing students in the MENA countries with available data. Table S5. Quality assessment of included systematic reviews. Table S6. Quality assessment of included studies.

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Chaabane, S., Chaabna, K., Bhagat, S. 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 10 , 136 (2021). https://doi.org/10.1186/s13643-021-01691-9

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A review of the literature regarding stress among nursing students during their clinical education

2014, International nursing review

There has been increased attention in the literature about stress among nursing students. It has been evident that clinical education is the most stressful experience for nursing students. The aim of this paper was to critically review studies related to degrees of stress and the type of stressors that can be found among undergraduate nursing students during their clinical education. The search strategy involved the utilization of the following databases: MEDLINE (Medical Literature on-Line), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO (Psychology Information) and PubMed. Keywords were stress, undergraduate nursing students, clinical practice. The review included those studies published between 2002 and 2013, conducted in any country as long as reported in English, and including a focus on the clinical practice experience of nursing students. Thirteen studies met the eligibility criteria. Four themes were identified: initial clinical experience, compa...

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• Published: 16 May 2024

Competency gap among graduating nursing students: what they have achieved and what is expected of them

• Majid Purabdollah 1 , 2 ,
• Vahid Zamanzadeh 2 , 3 ,
• Akram Ghahramanian 2 , 4 ,
• Leila Valizadeh 2 , 5 ,
• Saeid Mousavi 2 , 6 &
• Mostafa Ghasempour 2 , 4  

BMC Medical Education volume  24 , Article number:  546 ( 2024 ) Cite this article

Metrics details

Nurses’ professional competencies play a significant role in providing safe care to patients. Identifying the acquired and expected competencies in nursing education and the gaps between them can be a good guide for nursing education institutions to improve their educational practices.

In a descriptive-comparative study, students’ perception of acquired competencies and expected competencies from the perspective of the Iranian nursing faculties were collected with two equivalent questionnaires consisting of 85 items covering 17 competencies across 5 domains. A cluster sampling technique was employed on 721 final-year nursing students and 365 Iranian nursing faculties. The data were analyzed using descriptive statistics and independent t-tests.

The results of the study showed that the highest scores for students’ acquired competencies and nursing faculties’ expected competencies were work readiness and professional development, with mean of 3.54 (SD = 0.39) and 4.30 (SD = 0.45), respectively. Also, the lowest score for both groups was evidence-based nursing care with mean of 2.74 (SD = 0.55) and 3.74 (SD = 0.57), respectively. The comparison of competencies, as viewed by both groups of the students and the faculties, showed that the difference between the two groups’ mean scores was significant in all 5 core-competencies and 17 sub-core competencies ( P  < .001). Evidence-based nursing care was the highest mean difference (mean diff = 1) and the professional nursing process with the lowest mean difference (mean diff = 0.70).

The results of the study highlight concerns about the gap between expected and achieved competencies in Iran. Further research is recommended to identify the reasons for the gap between the two and to plan how to reduce it. This will require greater collaboration between healthcare institutions and nursing schools.

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Introduction| Background

Nursing competence refers to a set of knowledge, skills, and behaviors that are necessary to successfully perform roles or responsibilities [ 1 ]. It is crucial for ensuring the safe and high-quality care of patients [ 2 , 3 , 4 , 5 ]. However, evaluating nursing competence is challenging due to the complex, dynamic, and multi factorial nature of the clinical environment [ 3 ]. The introduction of nursing competencies and their assessment as a standard measure of clinical performance at the professional level has been highlighted by the Association of American Colleges of Nursing [ 6 , 7 ]. As a result, AACN (2020) introduces competence assessment as an emerging concept in nursing education [ 7 ].

On the other hand, the main responsibility of nursing education is to prepare graduates who have the necessary competencies to provide safe and quality care [ 3 ]. Although it is believed that it is impossible to teach everything to students, acquiring some competencies requires entering a real clinical setting and gaining work experience [ 8 ]. However, nursing students are expected to be competent to ensure patient safety and quality of care after graduation [ 9 ]. To the extent that the World Health Organization (WHO), while expressing concern about the low quality of nursing education worldwide, has recommended investing in nursing education and considers that the future to require nurses who are theoretically and clinically competent [ 5 ]. Despite efforts, the inadequate preparation of newly graduated nursing students and doubts about the competencies acquired in line with expectations to provide safe care for entering the nursing setting have become a global concern [ 10 , 11 , 12 , 13 ]. The results of studies in this field are different. The results of Amsalu et al. showed that the competence of newly graduated nursing students to provide quality and safe care was not satisfactory [ 14 ]. Some studies have also highlighted shortcomings in students’ “soft” skills, such as technical competency, critical thinking, communication, teamwork, helping roles, and professionalism [ 15 ]. Additionally, prior research has indicated that several nursing students have an unrealistic perception of their acquired competencies before entering the clinical setting and they report a high level of competence [ 2 ]. In other study, Hickerson et al. showed that the lack of preparation of nursing students is associated with an increase in patient errors and poor patient outcomes [ 16 ]. Some studies also discussed nursing competencies separately; Such as patient safety [ 17 ], clinical reasoning [ 18 ], interpersonal communication [ 19 ], and evidence-based care competence [ 20 ].

On the other hand, the growing need for safe nursing care and the advent of new educational technologies, the emergence of infectious diseases has increased the necessity of nursing competence. As a result, the nursing profession must be educated to excellence more than ever before [ 5 , 21 , 22 ]. Therefore, the self-assessment of students’ competence levels as well as the evaluation of nursing managers about the competencies expected from them is an essential criterion for all healthcare stakeholders, educators, and nursing policymakers to ensure the delivery of safe, and effective nursing care [ 9 , 23 , 24 ].

However, studies of nurse managers’ perceptions of the competence of newly graduated nursing students are limited and mostly conducted at the national level. Hence, further investigation is needed in this field [ 25 , 26 ]. Some other studies have been carried out according to the context and the needs of societies [ 3 , 26 , 27 , 28 ]. The results of some other studies in the field of students’ self-assessment of perceived competencies and managers’ and academic staff’s assessment of expected competency levels are different and sometimes contradictory, and there is the “academic-clinical gap” between expected and achieved competencies [ 25 , 29 , 30 ]. A review of the literature showed that this gap has existed for four decades, and the current literature shows that it has not changed much over time. The academe and practice settings have also been criticized for training nurses who are not sufficiently prepared to fully engage in patient care [ 1 ]. Hence, nursing managers must understand the expected competencies of newly graduated students, because they have a more complete insight into the healthcare system and the challenges facing the nursing profession. Exploration of these gaps can reveal necessities regarding the work readiness of nursing graduates and help them develop their competencies to enter the clinical setting [ 1 , 25 ].

Although research has been carried out on this topic in other countries, the educational system in those countries varies from that of Iran’s nursing education [ 31 , 32 ]. Iran’s nursing curriculum has tried to prepare nurses who have the necessary competencies to meet the care needs of society. Despite the importance of proficiency in nursing education, many nursing graduates often report feeling unprepared to fulfill expected competencies and they have deficiencies in applying their knowledge and experience in practice [ 33 ]. Firstly, the failure to define and identify the expected competencies in the nursing curriculum of Iran led to the absence of precise and efficient educational objectives. Therefore, it is acknowledged that the traditional nursing curriculum of Iran focuses more on lessons organization than competencies [ 34 ]. Secondly, insufficient attention has been given to the scheduling, location, and level of competencies in the nursing curriculum across different semesters [ 35 ]. Thirdly, the large volume of content instead of focusing on expected competencies caused nursing graduates challenged to manage complex situations [ 36 ]. Therefore, we should not expect competencies such as critical thinking, clinical judgment, problem-solving, decision-making, management, and leadership from nursing students and graduates in Iran [ 37 ]. Limited research has been conducted in this field in Iran. Studies have explored the cultural competence of nursing students [ 38 ] and psychiatric nurses [ 39 ]. Additionally, the competence priorities of nurses in acute care have been investigated [ 40 ], as well as the competency dimensions of nurses [ 41 ].

In Iran, after receiving the diploma, the students participate in a national exam called Konkur. Based on the results of this exam, they enter the field of nursing without conducting an aptitude test interview and evaluating individual and social characteristics. The 4-year nursing curriculum in Iran has 130 units including 22 general, 54 specific, 15 basic sciences, and 39 internship units. In each semester, several workshops are held according to the syllabus [ 42 ]. Instead of the expected competencies, a list of general competencies is specified as learning outcomes in the program. Accepted students based on their rank in the exam and their choice in public and Islamic Azad Universities (non-profit), are trained with a common curriculum. Islamic Azad Universities are not supported by government funding and are managed autonomously, this problem limits the access to specialized human resources and sufficient educational fields, and the lower salaries of faculty members in Azad Universities compared to the government system, students face serious challenges. Islamic Azad Universities must pay exorbitant fees to medical universities for training students in clinical departments and medical training centers, doubling these Universities’ financial problems. In some smaller cities, these financial constraints cause students to train in more limited fields of clinical training and not experience much of what they have learned in the classroom in practice and the real world of nursing. The evaluation of learners in the courses according to the curriculum is based on formative and summative evaluation with teacher-made tests, checklists, clinical assignments, conferences, and logbooks. The accreditation process of nursing schools includes two stages internal evaluation, which is done by surveying students, professors and managers of educational groups, and external accreditation is done by the nursing board. After completing all their courses, to graduate, students must participate in an exam called “Final”, which is held by each faculty without the supervision of an accreditation institution, the country’s assessment organization or the Ministry of Health, and obtain at least a score of 10 out of 20 to graduate.

Therefore, we conducted this comprehensive study as the first study in Iran to investigate the difference between the expected and perceived competence levels of final year nursing students. The study’s theoretical framework is based on Patricia Benner’s “From Novice to Expert” model [ 43 ].

Materials and methods

The present study had the following three objectives:

Determining self-perceived competency levels from the perspective of final year nursing students in Iran.

Determining expected levels of competency from the perspective of nursing faculties in Iran.

To determine the difference between the expected competencies from the perspective of nursing faculties and the achieved competencies from the perspective of final-year nursing students.

This study is a descriptive-comparative study.

First, we obtained a list of all nursing schools in the provinces of Iran from the Ministry of Health ( n  = 31). From 208 Universities, 72 nursing schools were randomly selected using two-stage cluster sampling. Among the selected faculties, we chose 721 final-year nursing students and 365 nursing faculties who met the eligibility criteria for the study. Final-year nursing students who consented to participate in the study were selected. Full-time faculty members with at least 2 years of clinical experience and nurse managers with at least 5 years of clinical education experience were also included. In this study, nursing managers, in addition to their educational roles in colleges, also have managerial roles in the field of nursing. Some of these roles include nursing faculty management, nursing board member, curriculum development and review, planning and supervision of nursing education, evaluation, and continuous improvement of nursing education. The selection criteria were based on the significant role that managers play in nursing education and curriculum development [ 44 ]. Non-full-time faculty members and managers without clinical education experience were excluded from the study.

The instrument used in this study is a questionnaire developed and psychometrically tested in a doctoral nursing dissertation [ 45 ]. To design the tool, the competencies expected of undergraduate nursing students in Iran and worldwide were first identified through a scoping review using the methodology recommended by the Joanna Briggs Institute (JBI) and supported by the PAGER framework. Summative content analysis by Hsieh and Shannon (2005) was used for analysis, which included: counting and comparing keywords and content, followed by interpretation of textual meaning. In the second step, the results of the first step were used to create tool statements. Then the validity of the instrument was checked by face validity, content validity (determination of the ratio and index of content validity), and validity of known groups. Its reliability was also checked by internal consistency using Cronbach’s alpha method and stability using the test-retest method. The competency questionnaire comprises 85 items covering 17 competencies across 5 domains: “individualized care” (4 competencies with 21 items), “evidence-based nursing care” (2 competencies with 10 items), “professional nursing process” (3 competencies with 13 items), “nursing management” (2 competencies with 16 items), and “work readiness and professional development” (6 competencies with 25 items) [ 45 ]. “The Bondy Rating Scale was utilized to assess the competency items, with ratings ranging from 1 (Dependent) to 5 (Independent) on a 5-point Likert scale [ 46 ]. The first group (nursing students) was asked to indicate the extent to which they had acquired each competency. The second group (nursing faculties) was asked to specify the level to which they expected nursing students to achieve each competency.

Data collection

First, the researcher contacted the deans and managers of the selected nursing schools by email to obtain permission. After explaining the aims of the study and the sampling method, we obtained the telephone number of the representative of the group of final year nursing students and also the email of the faculty members. The representative of the student group was then asked to forward the link to the questionnaire to 10 students who were willing to participate in the research. Informed consent for students to participate in the online research was provided through the questionnaires, while nursing faculty members who met the eligibility criteria for the study received an informed consent form attached to the email questionnaire. The informed consent process clarified the study objectives and ensured anonymity of respondent participation in the research, voluntary agreement to participate and the right to revoke consent at any time. An electronic questionnaire was then sent to 900 final year nursing students and 664 nursing faculties (from 4 March 2023 to 11 July 2023). Reminder emails were sent to nursing faculty members three times at two-week intervals. The attrition rate in the student group was reported to be 0 (no incomplete questionnaires). However, four questionnaires from nursing faculty members were discarded because of incomplete responses. Of the 900 questionnaires sent to students and 664 sent to nursing faculties, 721 students and 365 nursing faculty members completed the questionnaire. The response rates were 79% and 66% respectively.

Data were analyzed using SPSS version 22. Frequencies and percentages were used to report categorical variables and mean and standard deviations were used for quantitative variables. The normality of the quantitative data was confirmed using the Shapiro-Wilk and Skewness tests. An independent t-test was used for differences between the two groups.

Data analysis revealed that out of 721 students, 441 (61.20%) was female. The mean and deviation of the students’ age was 22.50 (SD = 1.21). Most of the students 577 (80%) were in their final semester. Also, of the total 365 faculties, the majority were female 253 (69.31%) with a mean of age 44.06 (SD = 7.46) and an age range of 22–65. The academic rank of most nursing faculty members 156 (21.60%) was assistant professor (Table  1 ).

The results of the study showed that in both groups the highest scores achieved by the students and expected by the nursing faculty members were work readiness and professional development with a mean and standard deviation of 3.54 (0.39) and 4.30 (0.45) respectively. The lowest score for both groups was also evidence-based nursing care with a mean and standard deviation of 2.74 (0.55) for students and 3.74 (0.57) for nursing faculty members (Table  2 ).

Also, the result of the study showed that the highest expected competency score from the nursing faculty members’ point of view was the safety subscale. In other words, faculty members expected nursing students to acquire safety competencies at the highest level and to be able to provide safe care independently according to the rating scale (Mean = 4.51, SD = 0.45). The mean score of the competencies achieved by the students was not above 3.77 in any of the subscales and the highest level of competency achievement according to self-report of students was related to safety competencies (mean = 3.77, SD = 0.51), preventive health services (mean = 3.69, SD = 0.79), values and ethical codes (mean = 3.67, SD = 0.77), and procedural/clinical skills (mean = 3.67, SD = 0.71). The other competency subscales from the perspective of the two groups are presented in Table  3 , from highest to lowest score.

The analysis of core competencies achieved and expected from both students’ and nursing faculty members’ perspectives revealed that, firstly, there was a significant difference between the mean scores of the two groups in all five core competencies ( P  < .001) and that the highest mean difference was related to evidence-based care with mean diff = 1 and the lowest mean difference was related to professional care process with mean diff = 0.70 (Table  4 ).

Table  5 indicates that there was a significant difference between the mean scores achieved by students and nursing faculty members in all 5 core competencies and 17 sub-core Competencies ( p  < .001).

The study aimed to determine the difference between nursing students’ self-perceived level of competence and the level of competence expected of them by their nursing faculty members. The study results indicate that students scored highest in work readiness and professional development. However, they were not independent in this competency and required support. The National League for Nursing (NLN) recognizes nursing professional development as the goal of nursing education programs [ 47 ] However, Aguayo-Gonzalez [ 48 ] believes that the appropriate time for professional development is after entering a clinical setting. This theme includes personal characteristics, legality, clinical/ procedural skills, patient safety, preventive health services, and mentoring competence. Personality traits of nursing students are strong predictors of coping with nursing stress, as suggested by Imus [ 49 ]. These outcomes reflect changes in students’ individual characteristics during their nursing education. Personality changes, such as the need for patience and persistence in nursing care and understanding the nurse identity prepare students for the nursing profession, which is consistent with the studies of Neishabouri et al. [ 50 ]. Although the students demonstrated a higher level of competence in this theme, an examination of the items indicates that they can still not adapt to the challenges of bedside nursing and to use coping techniques. This presents a concerning issue that requires attention and resolution. Previous studies have shown that nursing education can be a very stressful experience [ 51 , 52 , 53 ].

Of course, there is no consensus on the definition of professionalism and the results of studies in this field are different. For example, Akhtar et al. (2013) identified common viewpoints about professionalism held by nursing faculty and students, and four viewpoints emerged humanists, portrayers, facilitators, and regulators [ 54 ]. The findings of another study showed that nursing students perceived vulnerability, symbolic representation, role modeling, discontent, and professional development are elements that show their professionalism [ 55 ]. The differences indicate that there may be numerous contextual variables that affect individuals’ perceptions of professionalism.

The legal aspects of nursing were the next item in this theme that students needed help with. The findings of studies regarding the legal competence of newly graduated nursing students are contradictory reported that only one-third of nurse managers were satisfied with the legal competence of newly graduated nursing students [ 56 , 57 ]. Whereas the other studies showed that legality was the highest acquired competence for newly graduated nursing students [ 58 , 59 ]. However, the results of this study indicated that legality may be a challenge for newly graduated nursing students. Benner [ 43 ] highlighted the significant change for new graduates in that they now have full legal and professional responsibility for the patient. Tong and Epeneter [ 60 ] also reported that facing an ethical dilemma is one of the most stressful factors for new graduates. Therefore, the inexperience of new graduates cannot reduce the standard of care that patients expect from them [ 60 ]. Legal disputes regarding the duties and responsibilities of nurses have increased with the expansion of their roles. This is also the case in Iran. Nurses are now held accountable by law for their actions and must be aware of their legal obligations. To provide safe healthcare services, it is essential to know of professional, ethical, and criminal laws related to nursing practice. The nursing profession is accountable for the quality of services delivered to patients from both professional and legal perspectives. Therefore, it is a valuable finding that nurse managers should support new graduates to better deal with ethical dilemmas. Strengthening ethical education in nursing schools necessitates integrating real cases and ethical dilemmas into the curriculum. Especially, Nursing laws are missing from Iran’s undergraduate nursing curriculum. By incorporating authentic case studies drawn from clinical practice, nursing schools provide students with opportunities to engage in critical reflection, ethical analysis, and moral deliberation. These real cases challenge students to apply ethical principles to complex and ambiguous situations, fostering the development of ethical competence and moral sensitivity. Furthermore, ethical reflection and debriefing sessions during clinical experiences enable students to discuss and process ethical challenges encountered in practice, promoting self-awareness, empathy, and professional growth. Overall, by combining theoretical instruction with practical application and the use of real cases, nursing schools can effectively prepare future nurses to navigate ethical dilemmas with integrity and compassion.

However, the theme of evidence-based nursing care was the lowest scoring, indicating that students need help with this theme. The findings from studies conducted in this field are varied. A limited number of studies reported that nursing students were competent to implement evidence-based care [ 61 ], while other researchers reported that nursing students’ attitudes toward evidence-based care to guide clinical decisions were largely negative [ 20 , 62 ]. The principal barriers to implementing evidence-based care are lack of authority to change patient care policy, slow dissemination of evidence and lack of time at the bedside to implement evidence [ 10 ], and lack of knowledge and awareness of the process of searching databases and evaluating research [ 63 ]. While the European Higher Education Area (EHEA) framework and the International Council of Nurses Code of Ethics introduce the ability to identify, critically appraise, and apply scientific information as expected learning outcomes for nursing students [ 64 , 65 ], the variation in findings highlights the complexity of the concept of competence and its assessment [ 23 ]. Evidence-Based Nursing (EBN) education for nursing students is most beneficial when it incorporates a multifaceted approach. Interactive workshops play a crucial role, providing students with opportunities to critically appraise research articles, identify evidence-based practices, and apply them to clinical scenarios. Simulation-based learning further enhances students’ skills by offering realistic clinical experiences in a safe environment. Additionally, clinical rotations offer invaluable opportunities for students to observe and participate in evidence-based practices under the guidance of experienced preceptors. Journal clubs foster a culture of critical thinking and ongoing learning, where students regularly review and discuss current research articles. Access to online resources such as databases and evidence-based practice guidelines allows students to stay updated on the latest evidence and best practices. To bridge the gap between clinical practice and academic theory, collaboration between nursing schools and healthcare institutions is essential. This collaboration can involve partnerships to create clinical learning environments that prioritize evidence-based practice, inter professional education activities to promote collaboration across disciplines, training and support for clinical preceptors, and continuing education opportunities for practicing nurses to strengthen their understanding and application of EBN [ 66 ]. By implementing these strategies, nursing education programs can effectively prepare students to become competent practitioners who integrate evidence-based principles into their clinical practice, ultimately improving patient outcomes.

The study’s findings regarding the second objective showed that nursing faculty members expected students to achieve the highest level of competence in work readiness and professional development, and the lowest in evidence-based nursing care competence. The results of the studies in this area revealed that there is a lack of clarity about the level of competence of newly graduated nursing students and that confusion about the competencies expected of them has become a major challenge [ 13 , 67 ]. Evidence of nurse managers’ perceptions of newly graduated nursing student’s competence is limited and rather fragmented. There is a clear need for rigorous empirical studies with comprehensive views of managers, highlighting the key role of managers in the evaluation of nurse competence [ 1 , 9 ]. Some findings also reported that nursing students lacked competence in primary and specialized care after entering a real clinical setting [ 68 ] and that nursing managers were dissatisfied with the competence of students [ 30 ].

The results of the present study on the third objective confirmed the gap between expected and achieved competence requirements. The highest average difference was related to evidence-based nursing care, and the lowest mean difference was related to the professional nursing process. The findings from studies in this field vary. For instance, Brown and Crookes [ 13 ] reported that newly graduated nursing students were not independent in at least 26 out of 30 competency domains. Similar studies have also indicated that nursing students need a structured program after graduation to be ready to enter clinical work [ 30 ]. It can be stated that the nursing profession does not have clear expectations of the competencies of newly graduated nursing students, and preparing them for entry into clinical practice is a major challenge for administrators [ 13 ]. These findings can be explained by the Duchscher transition shock [ 69 ]. It is necessary to support newly graduated nursing students to develop their competence and increase their self-confidence.

The interesting but worrying finding was the low expectations of faculty members and the low scores of students in the theme of evidence-based care. However, nursing students need to keep their competencies up to date to provide safe and high-quality care. The WHO also considers the core competencies of nurse educators to be the preparation of effective, efficient, and skilled nurses who can teach the evidence-based learning process and help students apply it clinically [ 44 ]. The teaching of evidence-based nursing care appears to vary across universities, and some clinical Faculties do not have sufficient knowledge to support students. In general, it can be stated that the results of the present study are in line with the context of Iran. Some of the problems identified include a lack of attention to students’ academic talent, a lack of a competency-based curriculum, a gap between theory and clinical practice, and challenges in teaching and evaluating the achieved competencies [ 42 ].

Strengths and limitations

The study was conducted on a national level with a sizable sample. It is one of the first studies in Iran to address the gap between students’ self-perceived competence levels and nursing faculty members’ expected competency levels. Nevertheless, one of the limitations of the study is the self-report nature of the questionnaire, which may lead to social desirability bias. In addition, the COVID-19 pandemic coinciding with the student’s first and second years could potentially impact their educational quality and competencies. The limitations established during the outbreak negatively affected the nursing education of students worldwide.

Acquiring nursing competencies is the final product of nursing education. The current study’s findings suggest the existence of an academic-practice gap, highlighting the need for educators, faculty members, and nursing managers to collaborate in bridging the potential gap between theory and practice. While nursing students were able to meet some expectations, such as value and ethical codes, there is still a distance between expectations and reality. Especially, evidence-based care was identified as one of the weaknesses of nursing students. It is recommended that future research investigates the best teaching strategies and more objective assessments of competencies. The findings of this study can be used as a guide for the revision of undergraduate nursing education curricula, as well as a guide for curriculum development based on the development of competencies expected of nursing students. Nursing managers can identify existing gaps and plan to fill them and use them for the professionalization of students. This requires the design of educational content and objective assessment tools to address these competencies at different levels throughout the academic semester. This significant issue necessitates enhanced cooperation between healthcare institutions and nursing schools. Enhancing nursing education requires the implementation of concrete pedagogical strategies to bridge the gap between theoretical knowledge and practical skills. Simulation-based learning emerges as a pivotal approach, offering students immersive experiences in realistic clinical scenarios using high-fidelity simulators [ 70 ]. Interprofessional education (IPE) is also instrumental, in fostering collaboration among healthcare professionals and promoting holistic patient care. Strengthening clinical preceptorship programs is essential, with a focus on providing preceptors with formal training and ongoing support to facilitate students’ clinical experiences and transition to professional practice [ 71 ]. Integrating evidence-based practice (EBP) principles throughout the curriculum cultivates critical thinking and inquiry skills among students, while technology-enhanced learning platforms offer innovative ways to engage students and support self-directed learning [ 72 ]. Diverse and comprehensive clinical experiences across various healthcare settings ensure students are prepared for the complexities of modern healthcare delivery. By implementing these practical suggestions, nursing education programs can effectively prepare students to become competent and compassionate healthcare professionals.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Huston C, et al. The academic-practice gap: strategies for an enduring problem . In nursing forum . Wiley Online Library; 2018.

Meretoja R, Isoaho H, Leino-Kilpi H. Nurse competence scale: development and psychometric testing. J Adv Nurs. 2004;47(2):124–33.

Article   Google Scholar  

Järvinen T, et al. Nurse educators’ perceptions of factors related to the competence of graduating nursing students. Nurse Educ Today. 2021;101:104884.

Satu KU, et al. Competence areas of nursing students in Europe. Nurse Educ Today. 2013;33(6):625–32.

World Health Organization. State of the world’s nursing 2020: investing in education, jobs and leadership. 2020 [cited 12 June 2023; https://www.who.int/publications-detail-redirect/9789240003279 .

Lee W-H, Kim S, An J. Development and evaluation of korean nurses’ core competency scale (KNCCS) 2017.

American Association of Colleges of Nursing. The essentials: core competencies for professional nursing education… 2020 [cited 2023; https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf .

Gardulf A, et al. The Nurse Professional competence (NPC) scale: self-reported competence among nursing students on the point of graduation. Nurse Educ Today. 2016;36:165–71.

Kajander-Unkuri S, et al. The level of competence of graduating nursing students in 10 European countries-comparison between countries. Nurs Open. 2021;8(3):1048–62.

Labrague LJ et al. A Multicountry Study on Nursing Students’ Self-Perceived Competence and Barriers to Evidence‐Based Practice 2019. 16(3): pp. 236–246.

Visiers-Jiménez L, et al. Clinical learning environment and graduating nursing students’ competence: a multi-country cross-sectional study. Nurs Health Sci. 2021;23(2):398–410.

Herron EK. New graduate nurses’ preparation for recognition and prevention of failure to rescue: a qualitative study. J Clin Nurs. 2018;27(1–2):e390–401.

Google Scholar  

Brown RA, Crookes PA. What are the ‘necessary’ skills for a newly graduating RN? Results of an Australian survey. BMC Nurs. 2016;15:23.

Amsalu B, et al. Clinical practice competence of Mettu University nursing students: a cross-sectional study. Adv Med Educ Pract. 2020;11:791–8.

Song Y, McCreary LL. New graduate nurses’ self-assessed competencies: an integrative review. Nurse Educ Pract. 2020;45:102801.

Hickerson KA, Taylor LA, Terhaar MF. The Preparation-Practice gap: an Integrative Literature Review. J Contin Educ Nurs. 2016;47(1):17–23.

Huang FF, et al. Self-reported confidence in patient safety competencies among Chinese nursing students: a multi-site cross-sectional survey. BMC Med Educ. 2020;20(1):32.

Hong S et al. A Cross-Sectional Study: What Contributes to Nursing Students’ Clinical Reasoning Competence? Int J Environ Res Public Health, 2021. 18(13).

Mcquitty DJPE, Counseling. Teaching interpersonal communication concepts to increase awareness and reduce health disparities: Presenter (s): DaKysha Moore, NCAT, United States 2023. 109: pp. 25–26.

Lam CK, Schubert CF, Herron EK. Evidence-based practice competence in nursing students preparing to transition to practice. Worldviews Evid Based Nurs. 2020;17(6):418–26.

Lake MA. What we know so far: COVID-19 current clinical knowledge and research. Clin Med (Lond). 2020;20(2):124–7.

Shustack L. Integrating Google Earth in Community Health nursing courses: preparing globally aware nurses. Nurse Educ. 2020;45(2):E11–2.

Zeleníková R, et al. Self-assessed competence of final-year nursing students. Nurs Open. 2023;10(7):4607–18.

Hyun A, Tower M, Turner C. Exploration of the expected and achieved competency levels of new graduate nurses. J Nurs Manag. 2020;28(6):1418–31.

Kukkonen P, et al. Nurse managers’ perceptions of the competence of newly graduated nurses: a scoping review. J Nurs Manag. 2020;28(1):4–16.

Nilsson J et al. Nurse professional competence (NPC) assessed among newly graduated nurses in higher educational institutions in Europe. 2019. 39(3): p. 159–67.

Kajander-Unkuri S et al. Students’ Self-assessed Competence Levels during Nursing Education Continuum - A Cross-sectional Survey. Int J Nurs Educ Scholarsh, 2020. 17(1).

Salminen L, et al. The competence of nurse educators and graduating nurse students. Nurse Educ Today. 2021;98:104769.

Numminen O, et al. Newly graduated nurses’ competence and individual and organizational factors: a multivariate analysis. J Nurs Scholarsh. 2015;47(5):446–57.

Södersved Källestedt ML, et al. Perceptions of managers regarding prerequisites for the development of professional competence of newly graduated nurses: a qualitative study. J Clin Nurs. 2020;29(23–24):4784–94.

Ezzati E, et al. Exploring the social accountability challenges of nursing education system in Iran. BMC Nurs. 2023;22(1):7.

Farsi Z, et al. Comparison of Iran’s nursing education with developed and developing countries: a review on descriptive-comparative studies. BMC Nurs. 2022;21(1):105.

Salem OA et al. Competency based nursing curriculum: establishing the standards for nursing competencies in higher education. 2018. 5(11): p. 1–8.

Noohi E, Ghorbani-Gharani L. and A.J.S.i.D.o.M.E. Abbaszadeh, A comparative study of the curriculum of undergraduate nursing education in Iran and selected renowned universities in the world 2015. 12(3): pp. 450–471.

Rassouli M, Zagheri Tafreshi M. J.J.o.c.e. Esmaeil. Challenges Clin Nurs Educ Iran Strategies. 2014;2(1):11–22.

Riazi S, et al. Understanding gaps and needs in the undergratue nursing curriculum in Iran: a prelude to design a competency-based curriculum model %J payesh (Health Monitor). Journal. 2020;19(2):145–58.

ADIB HM, Mazhariazad F. Nursing Bachelor’s Education program in Iran and UCLA: A comparative study 2019.

Farokhzadian J, et al. Using a model to design, implement, and evaluate a training program for improving cultural competence among undergraduate nursing students: a mixed methods study. BMC Nurs. 2022;21(1):85.

Sargazi O, et al. Improving the professional competency of psychiatric nurses: results of a stress inoculation training program. Psychiatry Res. 2018;270:682–7.

Faraji A, et al. Evaluation of clinical competence and its related factors among ICU nurses in Kermanshah-Iran: a cross-sectional study. Int J Nurs Sci. 2019;6(4):421–5.

Atashzadeh-Shoorideh F, et al. Essential dimensions of professional competency examination in Iran from academic and clinical nurses’ perspective: a mixed-method study. J Educ Health Promot. 2021;10:414.

Purabdollah M, et al. Comparison of the Iranian and scandinavian bachelor of nursing curriculum (Sweden): a scoping review. J Educ Health Promotion. 2023;12(1):389.

Benner P. J.B.o.s., technology and society, using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education . 2004. 24(3): p. 188–99.

World Health Organization. Nurse educator core competencies. Geneva, Switzerland: World Health Organization. 2016 [cited 23 June 2023; https://www.who.int/hrh/nursing_midwifery/nurse_educator050416.pdf .

Purabdollah M, et al. Competencies expected of undergraduate nursing students: a scoping review. Nurs Open. 2023;10(12):7487–508.

Bondy KN. Clinical evaluation of student performance: the effects of criteria on accuracy and reliability. Res Nurs Health. 1984;7(1):25–33.

NLf N. Outcomes for graduates of practical/vocational, diploma, associate degree, baccalaureate, master’s, practice doctorate, and research doctorate programs in nursing . New York 2010; 201]. https:api.semanticscholar.org/corpus ID: 68620057.

Aguayo-González M, Castelló-Badía M, Monereo-Font C. Critical incidents in nursing academics: discovering a new identity. Rev Bras Enferm. 2015;68(2):195–202. 219 – 27.

Scott Imus FJJNEP. Nurse anesthesia student’s personality characteristics and academic performance: A big five personality model perspective 2019. 9: pp. 47–55.

Neishabouri M, Ahmadi F, Kazemnejad A. Iranian nursing students’ perspectives on transition to professional identity: a qualitative study. Int Nurs Rev. 2017;64(3):428–36.

Zheng S, et al. New nurses’ experience during a two year transition period to clinical practice: a phenomenological study. Nurse Educ Today. 2023;121:105682.

Aryuwat P, et al. An integrative review of resilience among nursing students in the context of nursing education. Nurs Open. 2023;10(5):2793–818.

Ayaz-Alkaya S, Simones J. Nursing education stress and coping behaviors in Turkish and the United States nursing students: a descriptive study. Nurse Educ Pract. 2022;59:103292.

Akhtar-Danesh N, et al. Perceptions of professionalism among nursing faculty and nursing students. West J Nurs Res. 2013;35(2):248–71.

Keeling J, Templeman J. An exploratory study: student nurses’ perceptions of professionalism. Nurse Educ Pract. 2013;13(1):18–22.

Nilsson J, et al. Development and validation of a new tool measuring nurses self-reported professional competence–the nurse professional competence (NPC) scale. Nurse Educ Today. 2014;34(4):574–80.

Berkow S, et al. Assessing new graduate nurse performance. J Nurs Adm. 2008;38(11):468–74.

Lofmark A, Smide B, Wikblad K. Competence of newly-graduated nurses–a comparison of the perceptions of qualified nurses and students. J Adv Nurs. 2006;53(6):721–8.

Park E, Choi J. Attributes associated with person-centered care competence among undergraduate nursing students. Res Nurs Health. 2020;43(5):511–9.

Tong V, Epeneter BJ. A comparative study of newly licensed registered nurses’ stressors: 2003 and 2015. J Contin Educ Nurs. 2018;49(3):132–40.

Florin J, et al. Educational support for research utilization and capability beliefs regarding evidence-based practice skills: a national survey of senior nursing students. J Adv Nurs. 2012;68(4):888–97.

Reid J, et al. Enhancing utility and understanding of evidence based practice through undergraduate nurse education. BMC Nurs. 2017;16:58.

Phillips JM, Cullen D. Improving the adoption of evidence-based practice through RN-to-BSN education. J Contin Educ Nurs. 2014;45(10):467–72.

Stievano A, Tschudin V. The ICN code of ethics for nurses: a time for revision. Int Nurs Rev. 2019;66(2):154–6.

Ministry of Education and Research. Norwegian qualifications framework: levels and learning outcome descriptors… 2011 [cited 23 June 2023; https://www.regjeringen.no/contentassets/e579f913fa1d45c2bf2219afc726670b/nkr.pdf .

Chen Q, et al. Differences in evidence-based nursing practice competencies of clinical and academic nurses in China and opportunities for complementary collaborations: a cross‐sectional study. J Clin Nurs. 2023;32(13–14):3695–706.

Missen K, McKenna L, Beauchamp A. Registered nurses’ perceptions of new nursing graduates’ clinical competence: a systematic integrative review. Nurs Health Sci. 2016;18(2):143–53.

Leonardsen AL, et al. Nurses’ perspectives on technical skill requirements in primary and tertiary healthcare services. Nurs Open. 2020;7(5):1424–30.

Duchscher JE. B.J.J.o.a.n. Transition Shock: Initial Stage role Adaptation New Graduated Registered Nurses. 2009;65(5):1103–13.

Ajemba MN, Ikwe C, Iroanya JC. Effectiveness of simulation-based training in medical education: assessing the impact of simulation-based training on clinical skills acquisition and retention: a systematic review. World J Adv Res Reviews. 2024;21(1):1833–43.

Krystallidou D et al. Interprofessional education for healthcare professionals. A BEME realist review of what works, why, for whom and in what circumstances in undergraduate health sciences education: BEME Guide No. 83 Medical Teacher, 2024: pp. 1–18.

Sun Y, et al. Critical thinking abilities among newly graduated nurses: a cross-sectional survey study in China. Nurs Open. 2023;10(3):1383–92.

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Acknowledgements

The authors extend their gratitude to all the nursing students and faculties who took part in this study.

This article is part of research approved with the financial support of the deputy of research and technology of Tabriz University of Medical Sciences.

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Majid Purabdollah

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Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

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Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Akram Ghahramanian & Mostafa Ghasempour

Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

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M P: conceptualized the study, data collection, analysis and interpretation, drafting of manuscript; V Z: conceptualized the study, analysis and interpretation, drafting of manuscript; LV: conceptualized the study, data collection and analysis, manuscript revision; A Gh: conceptualized the study, data collection, analysis, and drafting of manuscript; S M: conceptualized the study, analysis, and drafting of manuscript; M Gh: data collection, analysis, and interpretation, drafting of manuscript; All authors read and approved the final manuscript.

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Purabdollah, M., Zamanzadeh, V., Ghahramanian, A. et al. Competency gap among graduating nursing students: what they have achieved and what is expected of them. BMC Med Educ 24 , 546 (2024). https://doi.org/10.1186/s12909-024-05532-w

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The predicting factors of chronic pain among nursing students: a national study in Iran

• Maryam Shaygan   ORCID: orcid.org/0000-0002-1456-9340 1 ,
• Banafsheh Tehranineshat   ORCID: orcid.org/0000-0002-2066-5689 2 ,
• Saeed Hosseini Teshnizi   ORCID: orcid.org/0000-0002-5575-6855 3 &
• Agrin Mohammadi 4  

BMC Psychology volume  12 , Article number:  297 ( 2024 ) Cite this article

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Nursing students are faced with a variety of challenges that demand effective cognitive and emotional resources. The physical and psychological well-being of the students plays a key part in the public health of the community. Despite the special lifestyle of nursing students, few studies have addressed chronic pain in this population. Accordingly, the present study aims to identify the predictors of chronic pain among nursing students.

This cross-sectional study was conducted on 1,719 nursing students aged 18–42 years, between February and November 2019. Sampling was carried out in several stages. Data were collected using seven instruments, namely a demographics survey, the characteristics of chronic pain form, Spielberger State-Trait Anxiety Inventory (STAI), the Patient Health Questionnaire-9 (PHQ-9), the Bar-on Emotional Quotient Inventory, Academic Satisfaction Scale, and Procidano and Heller Social Support Scale. Descriptive statistics, multinomial logistic regression, and regression models were used to describe the characteristics of the pain and its predictive factors.

The average age of the participants was 22.4 ± 2.96 years. The results of univariate analysis showed that gender ( P  = 0.506), mother’s education ( P  = 0.056, P  = 0.278, P  = 0.278), father’s education ( P  = 0.817, P  = 0.597, P  = 0.41), place of residence ( P  = 0.215), depression ( P  = 0.501), grade point average ( P  = 0.488), academic satisfaction ( P  = 0.183) and chronic pain weren’t significantly correlated with chronic pain in nursing students. The results of the multiple logistic regression models showed that chronic pain was positively correlated with age, social support, state anxiety, and trait anxiety (OR = 1.07, 95% CI: 1.02–1.12; OR = 0.95, 95% CI: 0.93–0.97; OR = 1.03, 95% CI: 1.02–1.05; and OR = 1.97, 95% CI: 0.95–1.99; respectively).

The prevalence of chronic pain was relatively high in these students. In addition, age, social support, and anxiety could be important factors in the development or persistence of chronic pain in nursing students. The results also provided basic and essential information about the contributing factors in this area. However, consideration of factors such as referral for treatment, home medications for pain relief, and outcomes of chronic pain are suggested in future longitudinal studies.

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Chronic pain is defined as pain persisting or recurring for more than three months [ 1 ] in one or more than one anatomical region of the body, accompanied by emotional distress or serious functional disabilities and disrupting one’s everyday tasks and participation in social activities [ 2 ]. Chronic pain not only affects individuals’ daily activities, e.g. jobs, home lives, recreation, and communications [ 3 ], but has an impact on their quality of life and physical and mental well-being [ 4 ]. The negative consequences of pain are probably more significant in young adults, who are exposed to various stressors, life changes, and challenges in their future. According to a study, pain in young adults is associated with disability, low quality of life, and diminished efficiency [ 5 ]. In addition, pain-related issues for individuals, especially university students, often lead to drug abuse, opioid addiction, and mental disorders, e.g. depression [ 6 ].

Several studies have addressed the prevalence of pain and its correlation with health complaints in students and reported that pain is a common issue among university students which causes a decline in their psychological and social functioning and general well-being [ 7 , 8 , 9 ]. Studies conducted in the universities of Norway and Spain found that the prevalence of pain among the students was 54.7% and 30% respectively [ 10 , 11 ]. The female students in Norway reported the highest incidence of pain (59.9%), and the students in Sweden were found to suffer from the highest rate of musculoskeletal signs of pain (63.8%) [ 10 , 12 ]. Abledu and Offei (2015) studied 157 first-year nursing students at a school in Ghana and found the highest point prevalence of skeletomuscular pains to be in the subjects’ hands and wrists (15.3%) and backs (15.3%) [ 13 ]. In another study of 264 nursing students in Turkey (2017), 52.3% of the students complained of headaches, 42.4% complained of stomach pains, and 33% complained of back pains [ 14 ].

A study in Iran reported the rate of musculoskeletal pains among medical students to be 29.4% in the neck region, 24.3% in the upper part of the back, and 37.2% in the lower part of the back. The study also found a significant correlation between musculoskeletal pains and pains in the neck and knees based on the number of hours the subjects used their smartphones [ 15 ]. In another study, 39.4% of the medical students reported pain in their necks. Among the studied risk factors, such factors as age, carrying heavy bags, length of sleep, and number of hours spent using a computer had a significant correlation with pain in the neck and shoulders [ 16 ]. According to a study conducted in the east of Iran, failure to comply with the principles of ergonomics in designing seats for nursing schools resulted in great dissatisfaction with the seats and a musculoskeletal pain rate of 21.4% [ 17 ]. The results of studies of nurses in practice in hospitals in the northern and southern regions of Iran showed that the most prevalent musculoskeletal disorders are as follows: back pain (69–81%), neck pain (50-56.2%), and knee pain (48.9–63.5%). These chronic pains were related to various factors, including frequent bending, transferring patients, lifting and carrying medical equipment, bathing the patients, and lack of knowledge of the principles of ergonomics [ 18 , 19 , 20 ]. In a study by Choobineh et al., serious psychological needs, poor decision making skills, and lack of social support were more common among the nurses with chronic pains [ 18 ]. Arsalani et al. reported that poor control over their excessive workload and low job satisfaction led to increased work stress, emotional/mental/social issues, and increased risk of musculoskeletal disorders among nurses [ 21 ].

Research shows that medical and nursing students are more prone to chronic musculoskeletal pains than other students, which is the result of the nature of medical education. To acquire professional knowledge and skills, medical and nursing students must go through clinical training courses in the hospital environment. These courses are known as the most stressful part of medical education [ 22 , 23 , 24 ]. The stress of clinical training, long periods of standing next to patients’ beds, wrong twisting of the body during medical examinations or caregiving, and moving the patients [ 22 , 24 , 25 ], in addition to reading, writing, and using computers for long periods make this group of students more prone to pains in the back and neck than non-medical students [ 26 , 27 ].

A variety of risk factors associated with chronic pain have been reported, among them demographic-social, psychological, clinical, and biological factors. Identification of these risk factors can help develop measures designed to prevent or manage the contributory factors in university students’ exposure to chronic pain [ 28 ].

One of the psychological risk factors is anxiety and depression, which was found to be more common among nursing students with chronic pains than those who did not suffer from these pains [ 29 ]. However, in some other studies, there was not a significant difference between the students with chronic pains and the students without chronic pains in terms of anxiety and depression [ 30 , 31 ]. Other studies reported that the academic and psychosocial performance of students with chronic pains was less satisfactory compared to other students and the former experienced higher levels of anxiety and depression [ 32 , 33 , 34 ]. According to some other studies, students who suffer from chronic pains are more prone to absenteeism [ 29 , 31 ].

Emotional intelligence may act as a protective factor against the negative outcomes of chronic pain [ 35 ]. Moreover, social support interventions as part of a multidisciplinary approach would be beneficial in coping with experiences of chronic pain [ 36 ]. However, a study by Feldman (2020) showed that, even though the students with chronic pains had less social support and support from their friends and other important people in their lives than the students who did not have chronic pains, the difference was not significant [ 37 ].

Yet, few studies have investigated influential factors in chronic pain among nursing students. There is need for more research into chronic pain in nursing students as the nature of practical training can aggravate the students’ chronic pain [ 38 ]. Although previous research has focused on the relationship between chronic pain with negative psychological characteristics, such as depression and anxiety, little is known about the relationship between chronic pain and positive psychological characteristics, such as emotional intelligence, academic satisfaction and social support in nursing students. One of the most important steps in pain management is identifying the contributory factors, and the physical and mental health of nursing students plays a key role in the future health of a country [ 39 ]. Accordingly, the present study was conducted to identify the predictors of chronic pain among nursing students.

Materials and methods

Study design.

The present study is a descriptive, cross-sectional work of research conducted on nursing students at the universities of medical sciences of Iran, between February and November 2019.

The setting of the study was all the nursing schools in Iran. The bachelor’s nursing program lasts four years, eight semesters, in Iran, during which period 130 credits are to be taken. From their second semester, nursing students can take courses which involve training in clinical environments. The master’s nursing program lasts two years, four semesters, during which period 32 credits are to be taken. From their first semester, postgraduate students undergo training in clinical environments.

Participants and sampling method

The population of the study consisted of all the nursing students in the nursing schools of Iran. Based on the findings of previous research and the assumption that at least 20% of nursing students suffer from chronic pain [ 39 ], and using a sample size formula and a loss to follow-up rate of 20%, the size of the sample was set at 1719.

Sampling was carried out in several stages. At first, all the nursing schools in Iran were divided into five regions based on their geographical location: north, south, east, west, and center. Next, each region was considered as a category and the categories with a larger share of the students had more subjects selected from them. Subsequently, from each region, two provinces were randomly selected via two-stage cluster sampling and then three nursing schools were randomly selected from those two provinces. Students were selected from each school on a random basis: the researchers acquired a list of the students’ names from the education department of each school and selected the students who met the inclusion criteria using a table of random numbers created by SPSS.

The inclusion criteria were being a student at a nursing school, being an undergraduate student from semester 2 to semester 8 or a postgraduate student from semester 1 to semester 4, and not having been on academic probation. The students who were not willing to participate in the study, had been transferred from another school, had been absent or on a break at the time of sampling, had a serious mental or physiological disease at the time of the study, or had a history of use of psychoactive drugs or sedatives were excluded. Drug abuse and abuse of psychoactive drugs and the resulting physiological and psychological dependence on these drugs can affect an individual’s perception of pain and chronic pain behaviors. Also, mental disorders can reinforce pain signals and make the symptoms more severe, resulting in a significant delay in diagnosing pain disorders. Moreover, Individuals with a chronic disease, including multiple sclerosis, diabetes, and cancer, are prone to chronic pain and it is possible that use of pain relievers, self-care activities, and other pain management interventions affect their perception of pain. Accordingly, these nursing students were excluded [ 40 , 41 ].

Data collection

The questionnaires were collected as follows: after getting permission from the dean of each nursing school, the fourth author (AM) went to the education department of the schools and acquired a list of the names of all the undergraduate students in semester 2 to semester 8 and the postgraduate students in semester 1 to semester 4. Next, a sample of the students who met the inclusion criteria was selected using a table of random numbers created by SPSS. The selected students received an envelope containing a paper about the objectives of the study, an informed consent form, and the self-report questionnaires. In addition, the students were informed face-to- face about the objectives of the study and asked to manually complete the demographics survey and the questionnaires if they were willing to participate in the study when they were at school and submit them to the secretary at the education department.

All the questionnaires were handed out and collected manually by the fourth author (AM). The questionnaires were completed in the middle of a semester. The present study was a national study and had been approved by the Iranian biomedical ethics committee website and the researchers had obtained the necessary permits from the university. Moreover, before manual distribution of the questionnaires, the required permits were obtained from the dean of each nursing school.

To minimize bias and contamination of data, the co-researcher was instructed to follow a standard protocol at the time of data collection and random sampling. Moreover, to minimize social desirability bias, the respondents were informed about the objectives of the study and assured that the questionnaires would be completed anonymously and all information would remain confidential throughout the study.

Data collection instruments

The demographic factors.

The collected data consisted of the students’ age, gender, marital status, education level, parents’ education level, place of residence, and grade point average (GPA).

The characteristics of chronic pain

In order to measure chronic pain, the researchers used a chronic pain questionnaire which consists of several parts. Initially, the nursing students were asked the following questions: Do you suffer from recurring or continuing pain? Have you been experiencing pain and discomfort for three months or more? Has the pain affected your life and daily activities? Affirmative responses to the previous screening questions showed that the participants suffered from chronic pain. In part two, the participants were asked to describe the frequency of their chronic pain by selecting one of the following choices: “constant and nonstop,” “once or a few times per day,” “once or a few times per week,” or “once or a few times per month.” The third part of the chronic pain questionnaire consisted of questions about the location of the participants’ pain: head, face, hands, feet, neck, shoulders, wrists, ears, back, abdomen, chest, eyes, arms, knees, and ankles. In the next part, the participants were asked to rate the intensity of their pain in the past two weeks on the Visual Analogue Scale (VAS) from 0 to 10. These items were developed according to the International Classification of Diseases, 11th Revision (ICD-11) criteria [ 1 ]. In a study by Shaygan et al. (2020) in Iran, the face validity and content validity of the items were assessed by 15 nursing, anesthesiology, and pain experts. All the items were found to be clear and comprehensible by 89% of the evaluators, and the impact score of the items was greater than 1.5. The CVI and CVR of the questionnaire were reported to be 0.87 and 0.82 respectively. The reliability of the items was tested using the test-retest method with a 2-week interval and the result was a Cronbach’s alpha of greater than 0.74 [ 35 ].

The visual analog scale (VAS) is an accurate and reliable tool for measuring the intensity of pain. Especially its vertical version was considered to be easier for the participants to understand and to be more effective for determining the intensity of pain [ 42 ]. A score of 1–3 indicates mild pain, 4–7 indicates moderate pain, and 8–10 indicates severe pain. The Test-retest reliability of VAS has been reported to be satisfactory (ICC = 0.71–0.99); its concurrent validity has been found to be moderate (0.71–0.78) as compared with the numeric pain rating scale (NPRS) [ 42 ]. According to a study by Rezvani et al. (2012) in Iran, VAS is sufficiently accurate and can be completed in a short time, making it a more appropriate tool for measuring chronic pain. The correlation coefficient between VAS and the short form of McGill Pain Questionnaire (SF-MPQ) was reported to be 0.86 [ 43 ].

Spielberger state-trait anxiety inventory [STAI]

Spielberger’s State-Trait Anxiety Inventory, commonly known as STAI, consists of separate self-assessment scales which measure state and trait anxiety. The sub-scale of state anxiety comprises of 20 statements which evaluate the respondent’s feelings “at the moment of responding.” The sub-scale of trait anxiety comprises of 20 statements which evaluate the respondent’s general and usual feelings. Each statement is scored on a 4-point Likert scale: (1) not at all, (2) somewhat, (3) moderately so, and (4) very much so. The anxiety-present items were scaled from 1 to 4. However, the anxiety-absent items were scaled in reverse from 4 to 1. A score of 4 indicates great anxiety, and 10 items from the state anxiety scale and 11 items from the trait anxiety scale are scored accordingly. As for scoring the other items, a high score indicates absence of anxiety, and this applies to 10 items related to state anxiety and nine items related to trait anxiety. To calculate a respondent’s score for each of the two subscales—some items are scored reversely—researchers add up the sums of the 20 items in each subscale. Thus, the score range of each subscale ranges from 20 to 80. Spielberger et al. (1983) reported the internal consistency of the scale to be 0.86–0.95; the test-retest reliability of the scale with a two-month interval was reported to be 0.65–0.75. The construct validity of the scale was found to be satisfactory [ 44 ]. Abdoli et al. (2020) measured the reliability and validity of the Persian version of Spielberger State-Trait Anxiety Inventory (STAI) using 492 students. As for the internal consistency of the scale, the Cronbach’s alphas of trait anxiety and state anxiety were found to equal 0.88 and 0.84 respectively. In evaluation of the construct validity of the scale by the convergent method, STAI was compared with Beck Anxiety Inventory and the Cronbach’s alphas of trait anxiety and state anxiety were found to equal 0.64 and 0.64 respectively [ 45 ]. In present study, the reliability of the scale was obtained 0.89.

Patient Health Questionnaire-9 (PHQ-9)

The Patient Health Questionnaire consists of nine items, each of which addresses one of the symptoms of depression according to DSM criteria [Diagnostic and Statistical Manual of Mental Disorders]. PHQ-9 is one of the most reliable instruments for diagnosing depression in chronic diseases. The items are scored on a 3-point Likert scale, ranging from always [3] to never [0]. The total score range is between 0 and 27. A score of under 5 indicates absence of depression, 5 to 9 indicates slight depression, 10 to 14 indicates moderate depression, and 15 and above indicates severe depression in the respondent. In 2010, Zuithoff et al. tested the construct validity and reliability of PHQ-9 on 1338 patients. The internal consistency of the questionnaire was found to be ICC = 0.88, and its test-retest reliability equaled r  = 0.94, confirming that the instrument is valid for detecting anxiety disorders [ 46 ]. Dadfar et al. (2017) tested the validity and reliability of the Persian version of PHQ-9 on 130 outpatients with a mental disorder. The total score of the Persian questionnaire ranged from 0 to 27. The internal consistency and test-retest reliability of the questionnaire were 0.88 and 0.79 respectively. Evaluation of the convergent validity of the questionnaire resulted in 0.7 with the brief version of Beck Depression Inventory-13 (BDI-13) and − 0.35 with the World Health Organization-five Well-Being Index (WHO5). Confirmatory factor analysis proved the good fit of the data: CFI=-0.94, TLF = 0.93, and RMSEA = 0.06 [ 47 ]. In present study, the reliability of the scale was obtained 0.84.

Bar-on emotional quotient inventory

This inventory comprises of 90 items and 15 sub-scales which measure emotional intelligence. Responses to the items are arranged on a 5-point Likert scale and, thus, each item earns a score from 1 to 5 (“Completely agree” =5 and “Completely disagree” =1). Some of the items with negative content are scored reversely. The total score for each scale is the sum of the scores for the items in that scale, and the total test score equals the sum of the scores for all the 15 scales. Higher scores on the test indicate the respondent’s greater success in the scale in question or the entire test and vice versa. The total score range is between 90 and 450. The validity and reliability of the inventory were tested by Dawada et al. (2009) on 243 university students in the U.S. The internal consistency of this instrument equaled a Cronbach’s alpha of 0.96; the consistency of the items ranged from 0.67 to 0.93. Evaluation of divergent validity and convergent validity showed that the construct validity of the inventory was satisfactory. This instrument has a significant direct correlation with the positive emotions scale and a significant inverse correlation with the negative emotions scale [ 48 ].

In a study by Nejati and Meshkat (2018), the validity and reliability of the Persian version of the Bar-on Emotional Quotient Inventory were tested using 600 university students. The translated inventory consisted of 90 items and 15 subscales. The items were scored on a 5-point Likert scale: Completely disagree = 1, Disagree = 2, Not sure = 3, Agree = 4, and Completely agree = 5. The range of the scores was from − 90 to 450. Evaluation of the content validity resulted in a CVR of 0.86 and CVI of 0.87. The results of confirmatory factor analysis proved the good fit of the data, and the Cronbach’s alpha of the instrument was 0.94. The study also reported the following: GFI = 0.95, CFI = 0.917, and RMSEA = 0.02. The reliability of the inventory equaled 0.89 [ 49 ]. In present study, the reliability of the scale was obtained 0.86.

Academic satisfaction scale

Developed by Atashkar et al. (2014) in Iran, the Academic Satisfaction Scale evaluates academic satisfaction in students of medical sciences. The questionnaire consists of 20 items which directly and indirectly address the student’s perception of his/her major, internal and external motives for selecting that major, and academic, professional, and financial prospects. The items are scored on a 5-point Likert scale (the minimum and maximum scores for each item are 1 and 5 respectively). The total score range is between 20 and 100. The content validity of the questionnaire was verified by five experts after revision of the items according to expert feedback. The content validity ratio(CVR) and content validity index (CVI) were 0.87 and 0.88 respectively. The reliability was found to equal a Cronbach’s alpha of 0.89 [ 50 ]. In the present study, the scale was distributed among 30 students, and then its reliability was calculated using Chronbach’s alpha, yielding a value of 0.84.

Procidano and Heller social support scale

Developed by Procidano and Heller in 1983, the Social Support Scale consists of 20 items which are scored based on three responses: “Yes”, “No”, and “I do not know”. The total score range is between 0 and 20. A higher score indicates greater social support for the respondent. A Cronbach’s alpha of 0.9 verifies that the scale possesses excellent internal consistency. This instrument also possesses satisfactory concurrent validity and correlates with psychological distress and social efficiency scores [ 51 ].

In a study by Aghamirli et al. (2020), the validity and reliability of the Persian version of Procidano and Heller Social Support Scale were tested. The 20-item scale consists of five subscales: support (5 items), caring (4 items), assistance (4 items), information (4 items), and feedback (3 items). The items are scored on a 6-point Likert scale, from Completely disagree = 1 to Completely agree = 6. The range of the scores is from 20 to 120, with higher scores indicating more social support from the respondents’ point of view. The results of confirmatory factor analysis showed that the construct of the scale had a good fit to the data and all the goodness of fit indexes were confirmed. The Cronbach’s alphas of the subscales of the instrument were reported to range between 0.87 and 0.88 [ 52 ]. In present study, the reliability of the scale equaled 0.87.

Data analysis

The categorical variables were described by number [n] and percentage (%) and the continuous variables were described by mean and standard deviation (SD). At first, a univariate logistic regression was done for each variable and then the variables with p-values of less than 0.2 were entered into the multiple logistic regression analysis. In multiple logistic analysis, changes in the significance level of some predicting variables are often detected. Therefore, those variables that had a p-value of smaller than 0.2 in univariate logistic regression are entered into multiple logistic analysis. In this manner, all the relevant and potential predictive variables are studied [ 53 , 54 ]. To determine which variables should be considered in the multivariate model of the study, the researchers used the above-mentioned criterion. Also, multivariate logistic regression analysis was used to investigate the adjusted association of explanatory variables with chronic pain. Because the dependent variable, i.e. chronic pain, was dichotomous, binary logistic regression was applied.

For univariate and multiple logistic regression odds ratios (OR) with 95% confidence intervals (CI) with p-value were reported. The Hosmer-Lemeshow statistic and was applied to assess goodness-of-fit model. P-value less than 0.05 was considered statistically significant. Figures were drawn in GraphPad Prism 8.0. All statistical analyses were performed with IBM SPSS Statistics 26 software (IBM Corporation, Armonk, NY, USA).

The study population’s demographic characteristics

A total of 1,719 students were studied. The average age of the participants was 22.4 ± 2.96 years and their grade point average was 16.03 ± 1.18. The majority of the participants were female (61.7%) and single (87%). All of the participants were university students at the time of the study, with the great majority being undergraduates (88.8%). None of the participants was a PhD candidate (Table  1 ).

The number of the nursing students who experienced chronic pain was higher in the 30–35 age group compared to the other age groups ( P  > 0.05), suggesting an increase in perceived chronic pain during adulthood. Moreover, there is not difference between male and female nursing students experienced more chronic pain in each age group ( P  > 0.05) ([Fig.  1 ).

Comparison of gender and age group variables between the nursing students with chronic pain

Prevalence and characteristics of chronic pain

The results showed that 544 of the participants suffered from chronic pain, accounting for 31.65% of the cases (95% CI, 35–43). Severe chronic pain, defined as pain intensity of 8–10 on a scale of 0 to 10, was reported by 7.4% of the participants (95% CI, 0.063–0.087). Prevalence of chronic pain was higher among female (33%, 95% CI, 30–36) than male nursing students (30.1%, 95% CI, 27–34), but the difference was not significant ( P  = 0.23). Out of a total of 1,719 participants who were surveyed, 1175(68.4%) individuals were found to be free of pain. Among the individuals who had pain, 6.43% were suffering from permanent pain. Of the participants who had pain, 29.1% felt pain in a specific location. Most nursing students complained of chronic pain in the head [31.21] and abdomen [11.98]. Figure  2 shows the frequency of chronic pain regions as reported by the nursing students.

Self-expressed sites of chronic pain in nursing students

Comparing the mean of educational-psycho-social variables showed that the nursing students who had chronic pain were significantly different from the healthy ones in terms of social support ( P  < 0.001) and emotional intelligence ( P  = 0.003). However, there was no significant difference in mean scores of depression, satisfaction with education, state anxiety, and trait anxiety between the two groups ( P  > 0.05) (Fig.  3 ).

Comparison of educational-psycho-social variables between the nursing students with chronic pain and healthy ones

Predictors of pain

In the univariate analysis, before assessing the predictors of chronic pain, the relationship between the demographic variables and educational-psycho-social factors, and the existence of chronic pain in nursing students were evaluated. The results showed that age, marital status, education level, social support, emotional intelligence, state anxiety, trait anxiety, and chronic pain were significantly associated in nursing students (Table  2 ). Then, at the third stage of analysis (multivariate analysis), binary logistic regression was performed. Between the three binary logistic regression models presented, the third model, with variables which included age, social support, state anxiety, and trait anxiety could predict chronic pain in the nursing students better than the other models (accuracy = 65.8%). The results of Hosmer-Lemeshow test (chi-square = 0.99 and p  = 0.87) showed the multiple logistic regression models for this data was calibrated.

In this model, chronic pain was positively associated with age, social support, state anxiety, and trait anxiety (OR = 1.07, 95% CI: 1.02–1.12; OR = 0.95, 95% CI: 0.93–0.97; OR = 1.03, 95% CI: 1.02–1.05; and OR = 1.97, 95% CI: 0.95–1.99; respectively). Afterwards, the multinomial logistic regression test demonstrated that by including the aforementioned variables as predictors, the overall model fitted considerably better compared to an empty model (with no predictors) ( P  < 0.001). The results of this test revealed that despite the significant correlation of age, marital status, education level, and emotional intelligence with chronic pain in nursing students based on the chi-square test, when they were entered in the regression model, the impact of these factors was suppressed by the effect of age, social support, and anxiety (Table  2 ).

In the present, the majority of the nursing students were female and single, were studying for their bachelor’s degree, and lived in dormitories. The results showed that 31.6% of the nursing students suffered from chronic pain. The most common areas which were affected by pain were the head and abdomen. Kodana et al., report the prevalence of chronic pain in nursing students to be 79.2% [ 55 ]. . In a study by Abledu et al., 70.1% of the nursing students had suffered from musculoskeletal disorders in the past 12 months and 56.1% had been affected by the incapacitating consequences of pain. In addition, 44.6% of the students complained of pain in their necks, backs, lower backs, and wrists [ 13 ]. These differences in findings mainly resulted from methodological differences rather than population differences, including research design, data collection method, localization and definition of pain, different definitions of point prevalence, and different age groups. In addition, In Iran, clinical training courses for undergraduate nursing students start from their second semester. During their clinical training, nursing students should care for their patients, which entails standing for long periods. Also, at school, they have to spend long hours sitting while attending classes or studying. Poor posture during clinical practice and long hours of sitting in classes and libraries can account for the occurrence of musculoskeletal pain in nursing students [ 56 ]. Another reason for the differences between studies’ reports on the prevalence of chronic pain can be the different cultural and religious contexts of different societies. Religious beliefs can have a significant impact on individuals’ perceptions, emotions, and behaviors, as well as their health and sensitivity to pain [ 57 ]. Different cultural groups also differ in their manner of expressing pain. Some cultural groups may refrain from moaning, crying, or grimacing when they are in pain, while others openly manifest their discomfort in response to pain stimuli [ 58 ].

One study compared female undergraduate nursing and physiotherapy students’ beliefs about back pain in three different countries: Australia, Taiwan, and Singapore. It was found that fear of physical activates was different among the students of different countries. Compared to white Australians and physiotherapy students, Taiwanese and Singaporean nursing students had more negative beliefs about the consequences of back pain and were more afraid of physical activities [ 59 ]. These differences may be due to the collectivist cultural context, as opposed to the individualistic culture, of these populations and their different training programs. The focus of physical exercises on back pain management among physiotherapy students may reduce their fear of exercising and increase their positive adaptive behaviors regarding back pain [ 60 ].

In the present study, the prevalence of chronic pain among nursing students was less than in other studies. The students who were surveyed in the present study were from Iran, mostly lived in dormitories, and belonged to a collectivist culture. Collectivism is the dominant attitude in most Asian countries, meaning that individuals prefer to communicate their discomforts, including chronic pain, only in their families, are more tolerant of pain in the workplace or school, and satisfy their emotional needs only through their families to achieve a sense of unity, belonging, and identity. On the other hand, in European and North American countries, individualism is the dominant culture [ 61 ]. Cultural differences between collectivist and individualistic societies affect their rate of depression, emotional response to pain [ 43 ], and adjustment to stress and inconveniences, which can have an impact on individuals’ experience of pain, expression of pain, and response to pain [ 60 ]. As integral parts of a culture, religion and spirituality can facilitate adaptation to pain and reduce negative feelings, such as depression, which potentially aggravate pain [ 62 ]. Collectivist cultural values may positively correlate with such key psychological processes as self-adjustment, which can affect both the perception of musculoskeletal chronic pains and the associated disabilities [ 60 ]. It appears that collectivism can be a protective factor against chronic back pain and neck pain. Therefore, the authorities at universities should consider students’ cultural background in investigating and managing their chronic pain.

The results of the multinomial logistic regression test revealed that, when demographic characteristics and educational-psycho-social variables were entered in the regression model, there was a significant correlation between the variables of age, social support, and anxiety on the one hand and chronic pain in nursing students on the other. However, the students’ other demographic characteristics (marital status, parents’ education, GPA, and place of residence) and depression, academic satisfaction, and emotional intelligence did not significantly correlate with their chronic pain.

It was found that there was a significant correlation between chronic pain and age in the nursing students: older students were more prone to chronic pain. According to a study by Houde et al. (2016), there was a significant positive correlation between age on the one hand and pain and debility on the other in individuals with back pain. The correlation was stronger in the youth than in the elderly [ 63 ]. However, in their study, Duke et al. (2013) did not find a significant correlation between the university students’ age and the severity of their perceived pain [ 64 ]. According to a national study by Henderson et al. (2013) conducted in Australia, the prevalence of chronic pain in the 15 to 24, 25 to 44, and above 75-year-old age groups was 5%, 14%, and 36% respectively [ 65 ]. However, Boggero et al. (2015) reported a smaller prevalence of pain among the elderly [ 66 ]. In a study in Iran, the number of the adolescents who experienced pain was higher in the 12–15 age group compared to the 16–21 age group [ 67 ]. The discrepancy between the findings of the above-mentioned studies can be attributed to the studies’ use of different pain scales. Nonetheless, research shows that the rate of chronic pain is increasing across different populations and age groups [ 68 ].

Another finding of the present study was the presence of a significant correlation between social support and chronic pain in the nursing students. Even though the correlation was not very strong, the students who received more social support reported less chronic pain. According to a study by Zoghipaidar et al. (2020), perceived social support played a significant role in predicting the rate of chronic muscular pains in married women [ 69 ]. In their study of the impact of family support on the extent of pain and depression in 2,411 patients with arthritis rheumatoid, Hung et al. (2017) found that the patients who enjoyed the support of their family members and spouses showed significantly fewer symptoms of depression ad pain [ 70 ]. According to another study, the individuals who live close to their families or belong to a large family are more competent in controlling and managing their pain [ 71 ]. These findings show that social support, including the support of one’s family, friends, and other people who are important in one’s life, is a potential source of energy for coping with one’s chronic pain. Therefore, the role of social support in managing chronic pain should be underscored.

The results of the present study showed that there was a significant correlation between chronic pain and anxiety in the nursing students. Even though the correlation between the variables of state anxiety and trait anxiety on the one hand and chronic pain on the other was not very strong, state anxiety was found to increase the risk of chronic pain in the nursing students more than the variables of depression, social support, academic satisfaction, and emotional intelligence did. In a study by Makovec (2015), there was a significant positive correlation between back pain and anxiety in the participants: the individuals who reported moderate anxiety suffered from more pain [ 72 ]. Several studies have reported that anxiety can reduce the quality of life of patients with chronic pain [ 69 , 73 , 74 ]. Moreover, most individuals with chronic pain have at least one anxiety-related disorder [ 69 ]. As anxiety is associated with an increase in chemical transmitters, especially noradrenaline and adrenaline, which cause tension and muscle spasm, it can contribute to pain [ 75 ]. Accordingly, educational interventions designed to help nursing students manage their anxiety can decrease the rate of pain in this population.

In the present study, the variable of depression did not correlate with chronic pain in the nursing students. However, previous research showed that the prevalence of depression was higher in patients with chronic back pain than in the general population [ 76 ]. In their study of the relationship between anxiety and depression and perception of pain in women after mastectomy, Hansdorfer-Korzon et al. (2016) found that such mental factors as depression, anxiety, and belief system played a significant part in the patients’ perceived severity of pain [ 77 ]. These findings were confirmed by another study [ 78 ]. Sometimes, depression in individuals with chronic pain remains undiagnosed and is, therefore, not treated [ 79 ]. In view of the inter-correlation between chronic pain on the one hand and anxiety and depression on the other, the significance of screening individuals with chronic pain for mental health problems should be underscored [ 80 ]. Differences between the screening instruments for depression employed in the above-mentioned studies and the present study may account for the discrepancy between the findings.

In the present study, it was also found that emotional intelligence did not significantly correlate with chronic pain in the nursing students. However, Wright and Schutte’s 2014 study of the moderating effect of emotional intelligence and self-efficacy in patients with arthritis who were visiting a pain a clinic in Australia because they were suffering from chronic pain showed that emotional intelligence and self-efficacy correlated with better pain management and reduced mental perception of pain [ 81 ]. The results of a study by Kopera et al. (2018) showed that, among the alcoholics who visited a rehab center in Poland, those who were better at moderating their emotions and had higher education experienced less pain [ 82 ]. According to another study (2020), emotional intelligence, self-confidence, and parental models were influential factors in the development and persistence of chronic pain in adolescents [ 35 ]. By reducing emotionality or negative moods, higher levels of emotional intelligence can decrease pain vulnerability or perception of pain [ 83 ]. It may emphasize the need for strategies to increase emotional intelligence in nursing students. Additional research is required to determine whether training in emotional intelligence could provide direct symptom relief or even potentially serve as a protective factor, reducing pain vulnerability in nursing students who may have other identified risk factors for the development of chronic pain.

One of the strengths of the present study was its large sample size, which confirmed the findings related to chronic pain changes. Another important strength of the study was that, in addition to assessing the prevalence of chronic pain in the nursing students, the educational-psycho-social factors contributing to the incidence of chronic pain were evaluated.

One of the limitations of the present study was personal differences between the nursing students, including differences in their physical, and family conditions, which may have affected the results of the study. In addition, lack of research on chronic pain and factors associated with it in the present study population restricted the possibility of comparing the findings of the present study with similar studies. Additionally, some factors such as sitting time, sitting straight, academic semester, and using assisting devices during reading in university, were not taken into account in the present study. Other limitations of the study were that completing the questionnaires was time consuming and the questionnaires were self-report instruments, in which participants may report their pain to be higher or lower than the real levels. Therefore, before distributing the questionnaires, the researchers informed the students about the objectives and purposes of the study and asked them to complete the questionnaires at their convenience.

The findings of the present study showed that social support can lessen nursing students’ vulnerability to chronic pain. On the other hand, increasing age and experiencing anxiety during their education increase the risk of chronic pain among nursing students. The findings of the study corroborate some evidence of the impact of age, psychological factors, and social support on chronic pain among nursing students. Thus, for effective prevention of the risk of developing chronic pain by nursing students, the role of social support and education-related anxiety must be taken into account. The findings of the present study can help university authorities take the necessary steps to manage chronic pain in students who suffer from pain and take preventive measures for students who are free from pain, which will contribute to the students’ academic performance and success. It is suggested that future research should use cohorts in order to identify the effective factors in pain and appropriate interventions for relieving nursing students’ chronic pain in other societies to add to the existing knowledge.

Data availability

The dataset generated and/or analysed during the current study are not publicly available due to promises of participant anonymity and confidentiality but are available from the corresponding author on reasonable request.

Abbreviations

Grade point average

Visual analog scale

The numeric pain rating scale

Patient Health Questionnaire-9

Confidence interval

Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003–7. https://doi.org/10.1097/j.pain.0000000000000160 .

Article   PubMed   PubMed Central   Google Scholar  

Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Chronic pain as a symptom or a disease: the IASP classification of Chronic Pain for the International classification of diseases (ICD-11). Pain. 2019;160(1):19–27. https://doi.org/10.1097/j.pain.0000000000001384 .

Article   PubMed   Google Scholar  

Jamieson-Lega K, Berry R, Brown CA, Pacing. A concept analysis of a chronic pain intervention. Pain Res Manag. 2013;18:207–13. https://doi.org/10.1155/2013/686179 .

Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. J pain Res. 2016;457–67. https://doi.org/10.2147/JPR.S105892 .

Kim HJ, Boo S, Meeker TJ. Pain prevalence, management and interference among university students in South Korea: an exploratory cross-sectional study. J Pain Res. 2021;2423–31. https://doi.org/10.2147/JPR.S324758 .

Rogers AH, Bakhshaie J, Ditre JW, Manning K, Mayorga NA, Viana AG, et al. Worry and rumination: explanatory roles in the relation between pain and anxiety and depressive symptoms among college students with pain. J Am Coll Health. 2019;67(3):275–82. https://doi.org/10.1080/07448481.2018.1481071 .

El Ansari W, Oskrochi R, Haghgoo G. Are students’ symptoms and health complaints associated with perceived stress at university? Perspectives from the United Kingdom and Egypt. Int J Environ Res Public Health. 2014;11(10):9981–10002. https://doi.org/10.3390/ijerph111009981 .

Robertson D, Kumbhare D, Nolet P, Srbely J, Newton G. Associations between low back pain and depression and somatization in a Canadian emerging adult population. J Can Chiropr Assoc. 2017;61(2):96. PMCID: PMC5596967.

PubMed   PubMed Central   Google Scholar  

Ansari WE, Stock C, Group USH, Snelgrove S, Hu X, Parke S, et al. Feeling healthy? A survey of physical and psychological wellbeing of students from seven universities in the UK. Int J Environ Res Public Health. 2011;8(5):1308–23. https://doi.org/10.3390/ijerph8051308 .

Grasdalsmoen M, Engdahl B, Fjeld MK, Steingrímsdóttir ÓA, Nielsen CS, Eriksen HR, et al. Physical exercise and chronic pain in university students. PLoS ONE. 2020;15(6):e0235419. https://doi.org/10.1371/journal.pone.0235419 .

Solé E, Racine M, Tomé-Pires C, Galán S, Jensen MP, Miró J. Social factors, disability, and depressive symptoms in adults with chronic pain. Clin J Pain. 2020;36(5):371–8. https://doi.org/10.1097/AJP.0000000000000815 .

Backåberg SRM, Brunt D, Gummesson C. Impact of musculoskeletal symptoms on general physical activity during nursing education. Nurse Educ Pract. 2014, 1;14(4):385 – 90. https://doi.org/10.1016/j.nepr.2014.02.003 .

Abledu JK, Offei EB. Musculoskeletal disorders among first-year Ghanaian students in a nursing college. Afr Health Sci. 2015;15(2):444-9. PMCID: PMC4480470.

Uzunçakmak T, Kılıç M. Pain experience of nursing students and the methods used to cope with pain. Agri. 2017;29(3):117–21. https://doi.org/10.5505/agri.2017.32650 .

Dehghan L, Dalvand H, Samadi S, Ebrahimi Monfared M, Rafiei F. Prevalence of Musculoskeletal pains among Rehabilitation, dentistry and nursing students. J Arak Uni Med Sci. 2020;23(4):462–71. https://doi.org/10.32598/jams.23.4.2441.5 .

Article   Google Scholar  

Sadat BE, Babaei-Ghazani A, Azizi R, Parizad M. Prevalence and risk factors of neck and shoulder pain in medical students of Tabriz University of Medical Sciences. Med J Tabriz Uni Med Sciences Health Services. 2013;35(3):12 – 7. https://mj.tbzmed.ac.ir/Article/8574 .

Hamed Hosseini M, Khodadadi M, Hoshiar H, Noorbakhsh AH. The effect of different classroom chairs on the prevalence of musculoskeletal problems and the rate of students’ satisfaction. Health Dev J. 2015;4(3):209–18. https://jhad.kmu.ac.ir/article_91388_2f9f1b47251a141961bd9940f8da2f3d.pdf .

Google Scholar  

Choobineh A, Museloo BK, Ghaem H, Daneshmandi H. Investigating association between job stress dimensions and prevalence of low back pain among hospital nurses. Work. 2021;69(1):307–14. https://doi.org/10.3233/WOR-213479 .

Sharif Nia S, Haghdoost A, Hajihosseini F, Hojjati H. Relationship between the musculoskeletal disorders with the ergonomic factors in nurses. Koomesh 1390; 12(4):372–8 http://koomeshjournal.semums.ac.ir/article-1-1347-en.html .

Saberipour B, Ghanbari S, Zarea K, Gheibizadeh M, Zahedian M. Investigating prevalence of musculoskeletal disorders among Iranian nurses: a systematic review and meta-analysis. Clin Epidemiol Global Health. 2019;7(3):513–8. https://doi.org/10.1016/j.cegh.2018.06.007 .

Arsalani N, Fallahi-Khoshknab M, Josephson M, Lagerström M. Musculoskeletal disorders and working conditions among Iranian nursing personnel. Int J Occup Saf Ergon. 2014;20(4):671–80. https://doi.org/10.1080/10803548.2014.11077073 .

Hasan MM, Yaqoob U, Ali SS, Siddiqui AA. Frequency of musculoskeletal pain and associated factors among undergraduate students. Case Rep Clin Med. 2018;7(2):131–45. https://doi.org/10.4236/crcm.2018.72011 .

Wong AY, Chan LL, Lo CW, Chan WW, Lam KC, Bao JC, et al. Prevalence/Incidence of low back Pain and Associated Risk factors among nursing and medical students: a systematic review and Meta-analysis. PM&R. 2021;13(11):1266–80. https://doi.org/10.1002/pmrj.12560 .

Iqbal M, Ahmad A, Khattak S, Hammad SM, Zeb GS, Daud M. Frequency of Low Back Pain in Under Graduate Students of Khyber Medical University: JRCRS. 2017; 5 (1): 25–28. J Riphah Coll. Rehabili. sci. 2017;5(1):25 – 8. https://journals.riphah.edu.pk/index.php/jrcrs/article/view/458 .

Kox J, Runhaar J, Bierma-Zeinstra S, Groenewoud H, Bakker E, Miedema H, et al. What sociodemographic and work characteristics are associated with musculoskeletal complaints in nursing students? A cross-sectional analysis of repeated measurements. Appl Ergon. 2022;101:103719. https://doi.org/10.1016/j.apergo.2022.103719 .

Gharib N, Hamid NS. Prevalence of mechanical neck pain in Taif university female students: a survey study. J Am Sci. 2013;9(6):347–54. Corpus ID: 73997510.

Yunn HT, Nadamurni NU, Wen PS. Prevalence and risk factors of Neck Pain among Medical and Health sciences Undergraduate students in Universiti Tunku Abdul Rahman (Utar): a cross-sectional study. URI: UTAR; 2013. http://eprints.utar.edu.my/id/eprint/1709 .

Serbic D, Friedrich C, Murray R. Psychological, social and academic functioning in university students with chronic pain: a systematic review. J Am Coll Health. 2023;71(9):2894–908. https://doi.org/10.1080/07448481 .

Serbic D, Zhao J, He J. The role of pain, disability and perceived social support in psychological and academic functioning of university students with pain: an observational study. Int J Adolesc Med Health. 2021;33(3):209–17. https://doi.org/10.1515/ijamh-2019-0032 .

Furtado RNV, Ribeiro LH, Abdo BA, Descio FJ, Martucci Junior CE, Serruya DC. Dor lombar inespecífica em adultos jovens: fatores de risco associados. Rev Bras Reumatol. 2014;54:371–7. https://doi.org/10.1016/j.rbr.2014.03.018 .

Thomas M, Roy R, Cook A, Marykuca S. Chronic pain in college students: Issues of management. Can Fam Physician. 1992;38:2597. PMCID: PMC2145891.

Jiang C, Xu Y, Sharma S, Zhang L, Wang H, Song J, et al. Psychosocial factors associated with irritable bowel syndrome development in Chinese college freshmen. J Neurogastroenterol Motil. 2019;25(2):233. https://doi.org/10.5056/jnm18028 .

Pesqueira AA, Zuim PR, Monteiro DR, Do Prado Ribeiro P, Garcia AR. Relationship between psychological factors and symptoms of TMD in university undergraduate students. Acta Odontol Latinoam. 2010;23(3):182–7. PMID: 21638957.

PubMed   Google Scholar  

Kato T. Effect of psychological inflexibility on depressive symptoms and sleep disturbance among Japanese young women with chronic pain. Int J Environ Res Public Health. 2020;17(20):7426. https://doi.org/10.3390/ijerph17207426 .

Shaygan M, Karami Z. Chronic pain in adolescents: the predictive role of emotional intelligence, self-esteem and parenting style. Int J Community Based Nurs Midwifery. 2020;8(3):253. https://doi.org/10.30476/ijcbnm.2020.83153.1129 .

Oraison HM, Kennedy GA. The effect of social support in chronic back pain: number of treatment sessions and reported level of disability. Disabil Rehabil. 2021;43(11):1526–31. https://doi.org/10.1080/09638288.2019.1668969 .

Feldman EC, Macaulay T, Tran ST, Miller SA, Buscemi J, Greenley RN. Relationships between disease factors and social support in college students with chronic physical illnesses. Child s Health Care. 2020;49(3):267–86. https://doi.org/10.1080/02739615.2020.1723100 .

Braga PCV, Souza LAF, Evangelista RA, Pereira LV. The occurrence of headaches and their effect upon nursing undergraduate students. Rev Esc Enferm USP. 2012;46:138–44. https://doi.org/10.1590/s0080-62342012000100019 .

Davis KM, Schwarz JE. The Prevalence and Impact of Chronic Pain in baccalaureate nursing students. 2016. http://ideaexchange.uakron.edu/honors_research_projects/297 .

Compton MA. Cold-Pressor pain tolerance in opiate and cocaine abusers: correlates of drug type and use status. J Pain Symptom Manage. 1994;9(7):462–73. https://doi.org/10.1016/0885-3924(94)90203-8 .

Thomas MV, van Ryckeghem DM, Schulz A, Müller R, Lambracht K, Adermann J, et al. Mental disorders in Chronic Pain patients seeking treatment at a Tertiary Pain Hospital. Eur J Health Psychol. 2024. https://doi.org/10.1027/2512-8442/a000142 .

Kahl C, Cleland JA. Visual analogue scale, numeric pain rating scale and the McGill pain questionnaire: an overview of psychometric properties. Phys Therapy Reviews. 2005;10(2):123–8. https://doi.org/10.1179/108331905X55776 .

Rezvani Amin MSM, Abadi A, Moradyan T. Correlation between Visual Analogue Scale and Short form of McGill Questionnaire in Patients with Chronic Low Back Pain. Qom Univ Med Sci J 2012; 6 (1) :31–34 http://www.journalmuqacir/article-1-583-fahtml .

Spielberger CD. State-trait anxiety inventory for adults. 1983. https://doi.org/10.1037/t06496-000 .

Abdoli N, Farnia V, Salemi S, Davarinejad O, Jouybari TA, Khanegi M, et al. Reliability and validity of Persian version of state-trait anxiety inventory among high school students. East Asian Arch Psychiatry. 2020;30(2):44–7. https://doi.org/10.12809/eaap1870 .

Zuithoff NP, et al. The Patient Health Questionnaire-9 for detection of major depressive disorder in primary care: consequences of current thresholds in a crosssectional study. BMC Fam Pract. 2010;11:1–7.

Dadfar M, Kalibatseva Z, Lester D. Confiabilidade E validade da versão persa do Patient Health Questionnaire-9 (PHQ-9) em pacientes psiquiátricos ambulatoriais iranianos. Trends Psychiatry Psychother. 2018;40:144–51.

Dawda D, Hart SD. Assessing emotional intelligence: reliability and validity of the Bar-On emotional quotient inventory (EQ-i) in university students. Pers Individ Differ. 2000;28(4):797–812. https://doi.org/10.1016/S0191-8869(99)00139-7 .

Nejati R, Meshkat M. The reliability and validity of Bar-On’s emotional quotient inventory for Iranian English language learners. JFLR. 2016;6(1):131–54. https://doi.org/10.22059/JFLR.2016.62813 .

Atashkar H, Sohrabi Z, Bigdeli S, Bahari F. The relationship between achievement motivation and Scholar satisfaction among medical, dentistry and pharmacy senior Students of Tehran University of Medical Sciences. Med Purif. 2014;23(1):21–34.

Procidano ME, Heller K. Measures of perceived social support from friends and from family: three validation studies. Am J Community Psychol. 1983;11(1):1–24. https://doi.org/10.1007/BF00898416 .

Aghamirali M, Kadivar P, EmamiPour S. Psychometric indicators of Social Support Questionnaire for Peers Procidano and Heller. Social Psychol Res. 2020;9(36):39–54. https://www.socialpsychology.ir/article_105541.html?lang=en .

Concato J, Feinstein AR, Holford TR. The risk of determining risk with multivariable models. Ann Intern Med. 1993;118(3):201–10. https://doi.org/10.7326/0003-4819-118-3-199302010-00009 .

Cecatto SB, Monteiro-Soares M, Henriques T, Monteiro E, Moura CIFP. Derivation of a clinical decision rule for predictive factors for the development of pharyngocutaneous fistula postlaryngectomy. Braz J Otorhinolaryngol. 2015;81:394–401. https://doi.org/10.1016/j.bjorl.2014.09.009 .

Kodama Y, Fukahori H, Tse M, Yamamoto-Mitani N. Pain prevalence, pain management, and the need for pain education in healthcare undergraduates. Pain Manag Nurs. 2021;22(3):408–13. https://doi.org/10.1016/j.pmn.2020.09.008 .

Shaygan M, Tehranineshat B, Mohammadi A, Foruhi Z. A National Survey of the Prevalence of Chronic Pain in Nursing Students and the Associated Factors. Invest Educ Enferm. 2022;40(1). PMCID: PMC9052710.

Najem C, Mukhtar NB, Ayoubi F, Van Oosterwijck J, Cagnie B, De Meulemeester K, et al. Religious beliefs and attitudes in relation to pain, pain-related beliefs, function, and coping in chronic musculoskeletal pain: a systematic review. Pain Physician. 2021;24(8):E1163. PMID: 34793635.

Narayan MC. Culture’s effects on pain assessment and management. Am J Nurs. 2010;110(4):38–47. https://doi.org/10.1097/01.NAJ.0000370157.33223.6d .

Burnett A, Sze CC, Tam SM, Yeung KM, Leong M, Wang WT, et al. A cross-cultural study of the back pain beliefs of female undergraduate healthcare students. Clin J Pain. 2009;25(1):20–8. https://doi.org/10.1097/AJP.0b013e3181805a1e .

Rajkumar RP. The influence of cultural and religious factors on cross-national variations in the prevalence of chronic back and neck. Front Pain Res (Lausanne). 2023;4:1189432. https://doi.org/10.3389/fpain.2023.1189432 . pain: an analysis of data from the global burden of disease 2019 study.

Tehranineshat B, Yektatalab S, Momennasab M, Bijani M, Mohammadi F. The experiences of multiple sclerosis patients’ family caregivers at the first hospitalization of their patients: a qualitative study. Patient Prefer Adherence. 2020;1159–72. https://doi.org/10.2147/PPA.S257746 .

Wachholtz AB, Pearce MJ. Does spirituality as a coping mechanism help or hinder coping with chronic pain? Curr Pain Headache Rep. 2009;13:127–32. https://doi.org/10.1007/s11916-009-0022-0 .

Houde F, Cabana F, Léonard G. Does age affect the relationship between pain and disability? A descriptive study in individuals suffering from chronic low back pain. J Geriatr Phys Ther. 2016;39(3):140–5. https://doi.org/10.1519/JPT.0000000000000055 .

Duke G, Haas BK, Yarbrough S, Northam S. Pain management knowledge and attitudes of baccalaureate nursing students and faculty. Pain Manage Nurs. 2013;14(1):11–9. https://doi.org/10.1186/1129-2377-14-79 .

Henderson JV, Harrison CM, Britt HC, Bayram CF, Miller GC. Prevalence, causes, severity, impact, and management of chronic pain in Australian general practice patients. Pain Med. 2013;14(9):1346–61. https://doi.org/10.1111/pme.12195 .

Boggero IA, Geiger PJ, Segerstrom SC, Carlson CR. Pain intensity moderates the relationship between age and pain interference in chronic orofacial pain patients. Exp Aging Res. 2015;41(4):463–74. https://doi.org/10.1080/0361073X.2015.1053770 .

Shaygan M, et al. Prevalence of chronic pain and contributing factors: a cross-sectional population-based study among 2,379 Iranian adolescents. Korean J Pain. 2023;36(2):230. https://doi.org/10.3344/kjp.22336 .

Silva CDd, Ferraz GC, Souza LAF, Cruz LVS, Stival MM, Pereira LV. Prevalência De Dor crônica em estudantes universitários de enfermagem. Texto Contexto-Enfermagem. 2011;20:519–25. https://doi.org/10.1590/S0104-07072011000300013 .

Kroenke K, Outcalt S, Krebs E, Bair MJ, Wu J, Chumbler N, et al. Association between anxiety, health-related quality of life and functional impairment in primary care patients with chronic pain. Gen Hosp Psychiatry. 2013;35(4):359–65. https://doi.org/10.1016/j.genhosppsych.2013.03.020 .

Hung M, Bounsanga J, Voss MW, Crum AB, Chen W, Birmingham WC. The relationship between family support; pain and depression in elderly with arthritis. Psychol Health Med. 2017;22(1):75–86. https://doi.org/10.1080/13548506.2016.1211293 .

Mawdsley L, Twiddy H, Longworth M. Involvement of family and friends in pain management interventions. J Observational Pain Med. 2015;1(5):12–21.

Makovec MR, Vintar N, Makovec S. Self–reported depression, anxiety and evaluation of own Pain in Clinical Sample of patients with different location of Chronic Pain/Samoocenjena Depresivnost in Anksioznost Ter Evalvacija Lastne Bolečine V Kliničnem Vzorcu Pacientov Z Različno Lokacijo Kronične Bolečine. Zdr Varst. 2015;54(1):1–10. https://doi.org/10.1515/sjph-2015-0001 .

Orenius T, Koskela T, Koho P, Pohjolainen T, Kautiainen H, Haanpää M, et al. Anxiety and depression are independent predictors of quality of life of patients with chronic musculoskeletal pain. J Health Psychol. 2013;18(2):167–75. https://doi.org/10.1177/1359105311434605 .

Rod K. Observing the effects of mindfulness-based meditation on anxiety and depression in chronic pain patients. Psychiatr Danub. 2015;27(suppl 1):209–11. PMID: 26417764.

Sauer S, Biancalana M. Trigger point therapy for low back pain. New Harbinger; 2010.

Donatti A, Alves ÉdS, Terassi M, Luchesi BM, Pavarini SCI, Inouye K. Relação entre a intensidade de dor lombar crônica e limitações geradas com os sintomas depressivos. BrJP. 2019;2:247–54. https://doi.org/10.5935/2595-0118.20190044 .

Hansdorfer-Korzon R, Chojnacka-Szawłowska G, Landowski J, Majkowicz M, Basiński K, Zdun-Ryżewska A, et al. Relationships of anxiety and depressive symptoms with pain perception in post-mastectomy women. An intragroup analysis. Arc Clin Psychiatr (São Paulo). 2016;43:74–8. https://doi.org/10.1590/0101-60830000000088 .

Mah K, Bezjak A, Loblaw DA, Gotowiec A, Devins GM. Measurement invariance of the illness intrusiveness ratings Scale’s three-factor structure in men and women with cancer. Rehabil Psychol. 2011;56(1):58. https://doi.org/10.1037/a0022490 .

Lee H-J, Choi EJ, Nahm FS, Yoon IY, Lee PB. Prevalence of unrecognized depression in patients with chronic pain without a history of psychiatric diseases. Korean J Pain. 2018;31(2):116. https://doi.org/10.3344/kjp.2018.31.2.116 .

Pereira FG, França MH, Paiva MCAd, Andrade LH, Viana MC. Prevalence and clinical profile of chronic pain and its association with mental disorders. Rev Saude Publica. 2017;51:96. https://doi.org/10.11606/S1518-8787.2017051007025 .

Wright CJ, Schutte NS. The relationship between greater mindfulness and less subjective experience of chronic pain: mediating functions of pain management self-efficacy and emotional intelligence. Aust J Psychol. 2014;66(3):181–6. https://doi.org/10.1111/ajpy.12041 .

Kopera M, Jakubczyk A, Klimkiewicz A, Suszek H, Krasowska A, Brower KJ, et al. Relationships between components of emotional intelligence and suicidal behavior in alcohol-dependent patients. J Addict Med. 2018;12(1):24–30. https://doi.org/10.1097/ADM.0000000000000358 .

Koechlin H, Coakley R, Schechter N, Werner C, Kossowsky J. The role of emotion regulation in chronic pain: a systematic literature review. J Psychosom Res. 2018;107:38–45. https://doi.org/10.1016/j.jpsychores.2018.02.002 .

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This article is the result of a research project registered at Shiraz University of Medical Sciences, Shiraz, Iran (no. 13666). The authors would like to express their gratitude to all the nursing students who participated in this study.

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1  M.SH. is responsible for the study design, analysis, and interpretation of data, drafted, and revised the article critically, and approved the version to be published. 2 B.T. has made a substantial contribution to the interpretation of data, drafted, revised the article critically, and approved the version to be published. 3  S.H.T. has made a substantial contribution to the data analysis and interpretation of data. 4 A.M. has made a substantial contribution to the acquisition of data.

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Shaygan, M., Tehranineshat, B., Teshnizi, S.H. et al. The predicting factors of chronic pain among nursing students: a national study in Iran. BMC Psychol 12 , 297 (2024). https://doi.org/10.1186/s40359-024-01803-9

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Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

Metrics details

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

Nicol J, Tiedemann M. Legislative Summary: Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). Available from: https://lop.parl.ca/staticfiles/PublicWebsite/Home/ResearchPublications/LegislativeSummaries/PDF/42-1/c14-e.pdf .

Downie J, Scallion K. Foreseeably unclear. The meaning of the “reasonably foreseeable” criterion for access to medical assistance in dying in Canada. Dalhousie Law J. 2018;41(1):23–57.

Nicol J, Tiedeman M. Legislative summary of Bill C-7: an act to amend the criminal code (medical assistance in dying). Ottawa: Government of Canada; 2021.

Google Scholar  

Council of Canadian Academies. The state of knowledge on medical assistance in dying where a mental disorder is the sole underlying medical condition. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-Where-a-Mental-Disorder-is-the-Sole-Underlying-Medical-Condition.pdf .

Council of Canadian Academies. The state of knowledge on advance requests for medical assistance in dying. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2019/02/The-State-of-Knowledge-on-Advance-Requests-for-Medical-Assistance-in-Dying.pdf .

Council of Canadian Academies. The state of knowledge on medical assistance in dying for mature minors. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-for-Mature-Minors.pdf .

Health Canada. Third annual report on medical assistance in dying in Canada 2021. Ottawa; 2022. [cited 2023 Oct 23]. Available from: https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2021.html .

Banner D, Schiller CJ, Freeman S. Medical assistance in dying: a political issue for nurses and nursing in Canada. Nurs Philos. 2019;20(4): e12281.

Article   PubMed   Google Scholar  

Pesut B, Thorne S, Stager ML, Schiller CJ, Penney C, Hoffman C, et al. Medical assistance in dying: a review of Canadian nursing regulatory documents. Policy Polit Nurs Pract. 2019;20(3):113–30.

Article   PubMed   PubMed Central   Google Scholar  

College of Registered Nurses of British Columbia. Scope of practice for registered nurses [Internet]. Vancouver; 2018. Available from: https://www.bccnm.ca/Documents/standards_practice/rn/RN_ScopeofPractice.pdf .

Pesut B, Thorne S, Schiller C, Greig M, Roussel J, Tishelman C. Constructing good nursing practice for medical assistance in dying in Canada: an interpretive descriptive study. Global Qual Nurs Res. 2020;7:2333393620938686. https://doi.org/10.1177/2333393620938686 .

Article   Google Scholar  

Pesut B, Thorne S, Schiller CJ, Greig M, Roussel J. The rocks and hard places of MAiD: a qualitative study of nursing practice in the context of legislated assisted death. BMC Nurs. 2020;19:12. https://doi.org/10.1186/s12912-020-0404-5 .

Pesut B, Greig M, Thorne S, Burgess M, Storch JL, Tishelman C, et al. Nursing and euthanasia: a narrative review of the nursing ethics literature. Nurs Ethics. 2020;27(1):152–67.

Pesut B, Thorne S, Storch J, Chambaere K, Greig M, Burgess M. Riding an elephant: a qualitative study of nurses’ moral journeys in the context of Medical Assistance in Dying (MAiD). Journal Clin Nurs. 2020;29(19–20):3870–81.

Lamb C, Babenko-Mould Y, Evans M, Wong CA, Kirkwood KW. Conscientious objection and nurses: results of an interpretive phenomenological study. Nurs Ethics. 2018;26(5):1337–49.

Wright DK, Chan LS, Fishman JR, Macdonald ME. “Reflection and soul searching:” Negotiating nursing identity at the fault lines of palliative care and medical assistance in dying. Social Sci & Med. 2021;289: 114366.

Beuthin R, Bruce A, Scaia M. Medical assistance in dying (MAiD): Canadian nurses’ experiences. Nurs Forum. 2018;54(4):511–20.

Bruce A, Beuthin R. Medically assisted dying in Canada: "Beautiful Death" is transforming nurses' experiences of suffering. The Canadian J Nurs Res | Revue Canadienne de Recherche en Sci Infirmieres. 2020;52(4):268–77. https://doi.org/10.1177/0844562119856234 .

Canadian Nurses Association. Code of ethics for registered nurses. Ottawa; 2017. Available from: https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics .

Canadian Nurses Association. National nursing framework on Medical Assistance in Dying in Canada. Ottawa: 2017. Available from: https://www.virtualhospice.ca/Assets/cna-national-nursing-framework-on-maidEng_20170216155827.pdf .

Pesut B, Thorne S, Greig M. Shades of gray: conscientious objection in medical assistance in dying. Nursing Inq. 2020;27(1): e12308.

Durojaiye A, Ryan R, Doody O. Student nurse education and preparation for palliative care: a scoping review. PLoS ONE. 2023. https://doi.org/10.1371/journal.pone.0286678 .

McMechan C, Bruce A, Beuthin R. Canadian nursing students’ experiences with medical assistance in dying | Les expériences d’étudiantes en sciences infirmières au regard de l’aide médicale à mourir. Qual Adv Nurs Educ - Avancées en Formation Infirmière. 2019;5(1). https://doi.org/10.17483/2368-6669.1179 .

Adler M, Ziglio E. Gazing into the oracle. The Delphi method and its application to social policy and public health. London: Jessica Kingsley Publishers; 1996

Keeney S, Hasson F, McKenna H. Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J Adv Nurs. 2006;53(2):205–12.

Keeney S, Hasson F, McKenna H. The Delphi technique in nursing and health research. 1st ed. City: Wiley; 2011.

Willis GB. Cognitive interviewing: a tool for improving questionnaire design. 1st ed. Thousand Oaks, Calif: Sage; 2005. ISBN: 9780761928041

Lamb C, Evans M, Babenko-Mould Y, Wong CA, Kirkwood EW. Conscience, conscientious objection, and nursing: a concept analysis. Nurs Ethics. 2017;26(1):37–49.

Lamb C, Evans M, Babenko-Mould Y, Wong CA, Kirkwood K. Nurses’ use of conscientious objection and the implications of conscience. J Adv Nurs. 2018;75(3):594–602.

de Vaus D. Surveys in social research. 6th ed. Abingdon, Oxon: Routledge; 2014.

Boateng GO, Neilands TB, Frongillo EA, Melgar-Quiñonez HR, Young SL. Best practices for developing and validating scales for health, social, and behavioral research: A primer. Front Public Health. 2018;6:149. https://doi.org/10.3389/fpubh.2018.00149 .

Puchta C, Potter J. Focus group practice. 1st ed. London: Sage; 2004.

Book   Google Scholar  

Streiner DL, Norman GR, Cairney J. Health measurement scales: a practical guide to their development and use. 5th ed. Oxford: Oxford University Press; 2015.

Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.

Adesina O, DeBellis A, Zannettino L. Third-year Australian nursing students’ attitudes, experiences, knowledge, and education concerning end-of-life care. Int J of Palliative Nurs. 2014;20(8):395–401.

Bator EX, Philpott B, Costa AP. This moral coil: a cross-sectional survey of Canadian medical student attitudes toward medical assistance in dying. BMC Med Ethics. 2017;18(1):58.

Beuthin R, Bruce A, Scaia M. Medical assistance in dying (MAiD): Canadian nurses’ experiences. Nurs Forum. 2018;53(4):511–20.

Brown J, Goodridge D, Thorpe L, Crizzle A. What is right for me, is not necessarily right for you: the endogenous factors influencing nonparticipation in medical assistance in dying. Qual Health Res. 2021;31(10):1786–1800.

Falconer J, Couture F, Demir KK, Lang M, Shefman Z, Woo M. Perceptions and intentions toward medical assistance in dying among Canadian medical students. BMC Med Ethics. 2019;20(1):22.

Green G, Reicher S, Herman M, Raspaolo A, Spero T, Blau A. Attitudes toward euthanasia—dual view: Nursing students and nurses. Death Stud. 2022;46(1):124–31.

Hosseinzadeh K, Rafiei H. Nursing student attitudes toward euthanasia: a cross-sectional study. Nurs Ethics. 2019;26(2):496–503.

Ozcelik H, Tekir O, Samancioglu S, Fadiloglu C, Ozkara E. Nursing students’ approaches toward euthanasia. Omega (Westport). 2014;69(1):93–103.

Canning SE, Drew C. Canadian nursing students’ understanding, and comfort levels related to medical assistance in dying. Qual Adv Nurs Educ - Avancées en Formation Infirmière. 2022;8(2). https://doi.org/10.17483/2368-6669.1326 .

Edo-Gual M, Tomás-Sábado J, Bardallo-Porras D, Monforte-Royo C. The impact of death and dying on nursing students: an explanatory model. J Clin Nurs. 2014;23(23–24):3501–12.

Freeman LA, Pfaff KA, Kopchek L, Liebman J. Investigating palliative care nurse attitudes towards medical assistance in dying: an exploratory cross-sectional study. J Adv Nurs. 2020;76(2):535–45.

Brown J, Goodridge D, Thorpe L, Crizzle A. “I am okay with it, but I am not going to do it:” the exogenous factors influencing non-participation in medical assistance in dying. Qual Health Res. 2021;31(12):2274–89.

Dimoula M, Kotronoulas G, Katsaragakis S, Christou M, Sgourou S, Patiraki E. Undergraduate nursing students’ knowledge about palliative care and attitudes towards end-of-life care: A three-cohort, cross-sectional survey. Nurs Educ Today. 2019;74:7–14.

Matchim Y, Raetong P. Thai nursing students’ experiences of caring for patients at the end of life: a phenomenological study. Int J Palliative Nurs. 2018;24(5):220–9.

Canadian Institute for Health Research. Sex and gender in health research [Internet]. Ottawa: CIHR; 2021 [cited 2023 Oct 23]. Available from: https://cihr-irsc.gc.ca/e/50833.html .

Canadian Nurses’ Association. Nursing statistics. Ottawa: CNA; 2023 [cited 2023 Oct 23]. Available from: https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-statistics .

Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47(4):2025–47. https://doi.org/10.1007/s11135-011-9640-9 .

Ferri P, Di Lorenzo R, Stifani S, Morotti E, Vagnini M, Jiménez Herrera MF, et al. Nursing student attitudes toward dying patient care: a European multicenter cross-sectional study. Acta Bio Medica Atenei Parmensis. 2021;92(S2): e2021018.

PubMed   PubMed Central   Google Scholar  

Beuthin R, Bruce A. Medical assistance in dying (MAiD): Ten things leaders need to know. Nurs Leadership. 2018;31(4):74–81.

Thiele T, Dunsford J. Nurse leaders’ role in medical assistance in dying: a relational ethics approach. Nurs Ethics. 2019;26(4):993–9.

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We would like to acknowledge the faculty and students who generously contributed their time to this work.

JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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Stress and Coping Among Nursing Students During Clinical Training: An Integrative Review

• PMID: 31039260
• DOI: 10.3928/01484834-20190422-04

Background: Nursing students perceive stress during clinical trainings and use various coping strategies to manage it. This integrative review critically appraises previous literature on stress and coping strategies among undergraduate nursing students during clinical training.

Method: An integrative review procedure was followed. Five electronic databases were searched with various search terms. A total of 1,170 publications were screened, 13 of which were included in the review.

Results: Most studies applied a cross-sectional, descriptive approach. Students perceived moderate to high levels of stress during their clinical trainings, with problem solving and transference the most common coping techniques. Teachers and nursing staff were a strong stressor because students felt they were constantly being observed and evaluated.

Conclusion: The findings may provide guidance for how nursing staff can mentor students during clinical practice and establish a more supportive clinical environment. [J Nurs Educ. 2019;58(5):266-272.].

Copyright 2019, SLACK Incorporated.

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• Adaptation, Psychological*
• Cross-Sectional Studies
• Education, Nursing, Baccalaureate*
• Stress, Psychological / psychology*
• Students, Nursing / psychology*

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Stress and Coping Strategies among Nursing Students in Clinical Practice during COVID-19

Hanadi y hamadi.

1 Brooks College of Health, University of North Florida, Jacksonville, FL 32224, USA

Nazik M. A. Zakari

2 College of Applied Sciences, Al Maarefa University, Riyadh 11597, Saudi Arabia; as.ude.tscm@irakazn (N.M.A.Z.); as.dem.cmfk@imanlanf (F.N.A.N.); as.ude.tscm@adimsj (J.A.S.S.)

Ebtesam Jibreel

Faisal n. al nami, jamel a. s. smida, hedi h. ben haddad.

3 Department of Finance and Investment, College of Economics and Administrative Sciences, Imam Mohammad Ibn Saud Islamic University, Riyadh 13318, Saudi Arabia; as.ude.umami@daddahlahh

Associated Data

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Stress is common among nursing students and it has been exacerbated during the COVID-19 pandemic. This study examined nursing students’ stress levels and their coping strategies in clinical practice before and during the COVID-19 pandemic. A repeated-measures study design was used to examine the relationship between nursing students’ stress levels and coping strategies before and during the pandemic. Confirmatory factor analyses were conducted to validate the survey and a student T-test was used to compare the level of stress and coping strategies among 131 nursing students. The STROBE checklist was used. During COVID-19, there was a reliable and accurate relationship between stress and coping strategies. Furthermore, both stress and coping strategy scores were lower before COVID-19 and higher during COVID-19. Nursing students are struggling to achieve a healthy stress-coping strategy during the pandemic. There is a need for the introduction of stress management programs to help foster healthy coping skills. Students are important resources for our health system and society and will continue to be vital long term. It is now up to both nursing educators and health administrators to identify and implement the needed improvements in training and safety measures because they are essential for the health of the patient as well as future pandemics.

1. Introduction

Nursing is a practice-based profession, in the sense that the performance of nursing students depends largely on their clinical practicum; therefore, the quality of clinical training practice is crucial to the nursing education and profession. Furthermore, nursing students’ opinions regarding the quality of clinical training practices need to be strongly taken into consideration because of the demanding nature of the occupation. Nursing students are exposed to many sources of stress during clinical training and must handle stressful situations accordingly. Stressful situations can vary, including working with and handling breakout infections, where students assume an integral role in infection control measures and come into direct contact with infectious microorganisms. Becoming aware of and understanding students’ clinical practice stressors and coping strategies during clinical training in different situations provides educators with valuable information to maximize their students’ learning opportunities [ 1 ].

During a(n) pandemic/endemic, nursing students find themselves under additional stress factors such as the fear of being infected and infecting their close family members [ 2 ]. Two studies during the SARS (2003) and MERS outbreaks (2016) found that nursing students perceived themselves to be at a higher risk of infection and were reluctant to work in healthcare facilities due to inadequate safety and disease control measures [ 3 , 4 ]. Increased stress levels during the 2003 MERS outbreak in South Korea were negatively linked with nursing students’ intention to provide care to patients during future emerging infectious diseases [ 5 ].

Nursing students and staff are situated on the frontlines to combat infectious diseases and provide care and support to patients. They play a crucial role in providing effective infection control measures and ensuring the de-escalation of the spread of infectious microorganisms. Therefore, along with other medical staff and healthcare workers, nursing students and staff rushed to aid patients suffering from the most recent, fast-emerging, and rapidly spreading virus COVID-19 [ 6 ].

The COVID-19 pandemic spread to hospitals and nurses, putting them under enormous pressure in terms of workload and healthcare duties [ 7 ]. As a result, the lives and health of nurses and nursing students on the frontline, who are actively fighting the virus and are under great risk of contracting the disease, face dangerous repercussions [ 8 ]. COVID-19 studies and findings provide further evidence in regard to the anxiety experienced by nursing students and their response to treating this global pandemic [ 9 ].

Due to its extremely infectious and hazardous features, and the drastic lack of medication and treatment for the virus, COVID-19 has resulted in increased stress levels for nursing students and staff, which has consequently affected their coping strategies [ 8 ]. Therefore, understanding the relationship between stress levels and coping strategies of nursing students is critical. In non-pandemic times, the findings in Khater, Akhu-Zaheya [ 10 ], and Hamaideh [ 11 ] suggested that the most common coping behavior utilized by nursing students was problem-solving, followed by staying optimistic and transference.

It is essential to evaluate the quality of the clinical practices and identify stressors that arise from different clinical settings according to nursing students’ perspectives. Therefore, this study aimed to examine nursing students’ stress levels and their coping strategies in clinical practice before and during the COVID-19 pandemic.

Theoretical Framework

Stress has different definitions related to formulated theoretical models. It can be defined either as a stimulus, a response, or a combination of the two [ 12 , 13 ]. The definition of stress as a response was discovered by Selye (1976), who defines stress as the non-specific response of the body to any kind of demand [ 14 , 15 ]. On the other hand, Holmes and Rahes define stress as a stimulus without consideration to any response [ 16 ], stating that stress is: “an independent variable stimulus or load produced in an organism, creating discomfort, in such a way that whether tolerance limits are surpassed, stress becomes insufferable, appearing then psychological and physical problems”.

The definition that is most relevant to and can be appropriately adopted in this study to explain the reality of nursing student’s stress during clinical practice is Lazarus and Folkman’s theoretical framework. Based on Lazarus’ theory regarding the difficulty in differentiating between response and stimulus as the definition of stress, he conceptualizes an apparent stress definition that can reconcile differences between the separate theories of stress as a response or stress as a stimulus. He defines stress as “A particular relationship between the person and the environment that is appraised by the person as taxing and/or exceeding his or her resources and endangering his or her well-being” [ 17 ]. This is because it describes stress as a transactional relationship between the person and their surrounding environment [ 17 ]. Stress is not a singular facet, but rather arises due to influencing factors that affect the individual and, in turn, impact their response in such situations. For example, one of these stressful situations can occur during students’ clinical practice once the students face a new environment and establish new relationships with staff nurses, patients, and an instructor and/or supervisor [ 18 ]. A study found that the most stressful clinical settings identified by the study were the intensive care unit followed by the emergency room, then the surgical units, while the area that was considered the least stressful was the medical units [ 19 ]. Therefore, this study uses this working definition of stress to examine nursing students’ stress levels and their coping strategies in clinical practice before and during the COVID-19 pandemic.

2. Materials and Methods

2.1. setting.

The study was conducted in the nursing department at a private University to evaluate and compare the students’ perspectives of clinical practice stressors and the coping strategies used to respond to these stressors before the COVID-19 pandemic and during the first wave of the COVID-19 pandemic. The findings from this study will be utilized to improve the learning and the educational process in their current situation, reflecting on the level of the students who will graduate from nursing school in the future.

2.2. Design and Sample

A repeated-measures study design was used. The sample nursing students were all undergraduate academic nursing students studying at a private University who are participating in clinical training. Students not in clinical training were excluded from the study.

2.3. Data Collection Tool

This survey was developed using two previously validated surveys, the Perceived Stress Scale (PSS) and the Coping Behavior Inventory (CBI) survey. The PSS was developed by Sheu and Lin [ 20 ] and measures both the types of stressful events and the degree of stressors within clinical practices. This survey also included three demographic questions: The gender of the participant, their clinical training area, and their academic year of study. The PSS consists of 29 items (See Table 1 ) on a 5-point Likert scale (from 0 to 4) that are grouped into 6 stress/stressor categories. Those groups are stress from taking care of patients; teachers, and nursing personnel; assignments and workload; peers and daily life; the clinical environment; and lack of professional knowledge and skills.

The Perceived Stress Scale (PSS) and Coping Behavior Inventory (CBI) questions.

A score of 2.67 and higher was indicative of a high level of stress, a score between 1.34 and 2.66 was indicative of a moderate level of stress, and a score of less than 1.34 indicated a low level of stress [ 21 ]. The instrument’s reliability showed Cronbach’s alpha values of 0.86 and 0.89 [ 20 , 22 ] and a content validity index of 0.94 [ 22 ].

The CBI survey was first developed by Sheu and Lin [ 20 ] and measures the coping methods nursing students are more likely to utilize and their perceived effectiveness. The CBI survey consists of 19 items (See Table 1 ) all on a 5-point Likert Scale (from 0 to 4) that are grouped into 4 categories: Avoidance, Transference, Problem-solving, and Stay optimistic. A score of 2.67 and higher was indicative of a high level of coping strategies, a score between 1.34 and 2.66 was indicative of a moderate level of coping strategies, and a score of less than 1.34 indicated a low level of coping strategies. The instrument’s reliability showed a Cronbach’s alpha coefficient ranging from 0.76 to 0.80 [ 20 , 22 ].

2.4. Data Collection Procedure

Prior to data collection, the study protocol was approved by the Institutional Review Board (IRB) of the university. A researcher approached all eligible nursing students at the end of in-person lectures and explained to them the purpose of the study. They were informed that participation in this study is voluntary, and they could withdraw from it at any time. A refusal to participate would not affect their learning process and academic results. Students who were interested in the study were asked to sign a paper or digital consent form, fill in the questionnaire, and immediately return it to the researcher. Other eligible students who did not have in-person lectures were sent the survey via a Google Form to invite them to participate and complete the survey. The survey was sent out to a total of 180 students. Nursing students completed the survey on paper and online between 1 January 2019, and 2 February 2019, for the period before COVID-19 and 30 September 2020, and 30 October 2020, for the period during COVID-19.

2.5. Participants

Overall, 75 students were enrolled in clinical practice before and during COVID-19. One hundred and thirty-one nursing student responses were provided, resulting in about an 82% response rate before and during COVID-19. Out of the responses, 99 (75.6%) identified as female and 32 (24.4%) identified as male (See Table 2 ). The majority (60.3%) of the nursing students were in the Medical-Surgical clinical training area. In addition, 36 (27.5%) nursing students were in Level 5 (first year of clinical practice) of their academic year, and 32 (24.4%) were in Level 10 (last year of clinical practice also known as internship year) of their academic year. Nursing students in Level 5 participate in up to 2 clinical practice courses while Level 9 and 10 nursing students are in full clinical practice internships. The higher the level, the higher the clinical practice competency needed and the higher the necessary complexity. Only surveys that were fully completed were calculated in our response rate, therefore we had no missing data within the response for our analysis.

Nursing student demographic characteristics, n = 131.

2.6. Ethical Considerations

Before using the PSS and CBI tools, the researcher obtained permission from the original authors. The data collection tool contained a cover page that explained the aim of the study. All principles of ethics were adhered during the study. Therefore, anonymity and confidentiality of each individual’s data were also assured during the data collection stage. Participation in the survey was entirely optional and was at the discretion of each receiving the survey.

2.7. Statistical Analysis

The nursing student sample in this study was used to test the reliability and validity of the combined survey using confirmatory factor analysis. To analyze the results of the survey, means and standard deviations were utilized to examine the level of stress and coping strategies subscales and total scores. The Student T-test was used to compare the subscales and mean scores for the level of stress and coping strategies before and during the COVID-19 pandemic. We also used the Kolmogorov–Smirnov test to check the cumulative distributions of our two samples. All analyses were conducted in Stata 16, and significance was determined at p < 0.05.

The results from the comprehensive confirmatory factor analysis based on the varimax rotation factors of the entire sample results, the sample results before COVID-19, and the sample results after COVID-19 can be viewed in Table 2 . Although not shown, the covariance between stress and coping strategies was positive and significant for all the sample (covariance = 0.4; p < 0.001), both the sample results before (covariance = 0.28; p < 0.001) and after (covariance = 0.58; p < 0.001) COVID-19. When examining the entire sample responses factor loading show in Table 3 , all factor loadings were above 0.40 [ 23 ].

Unstandardized estimated for all-sample, before and after COVID-19.

Notes: LR test is the Wheaton et al. (1977) relative/normed chi-square (χ 2 /df), mc is the correlation between the dependent variable and its prediction, and mc 2 = mc^2 is the Bentler-Raykov squared multiple correlation coefficient.

The overall average score of stress before COVID-19 was 1.32 (low stress) and 1.95 (moderate stress) during COVID-19 (See Table 4 ). Across all six stress categories, the average stress score was lower before COVID-19 than during COVID-19. The largest change was found in the stress category “lack of professional knowledge and skills” where the average stress score before COVID-19 was 0.95 (low stress) and 1.78 (moderate stress) during COVID-19 with a 0.83 change. The smallest change was found in the stress category “the environment” from an average stress level of 1.16 (low stress) before COVID-19 and 1.70 (moderate stress) during COVID-19. The overall average score of coping strategies before COVID-19 was 1.84 (moderate coping) and 2.17 (moderate coping) during COVID-19. Across all four coping strategies categories, the average coping strategies score is lower before COVID-19 than during COVID-19. The largest change was found in the coping strategy category “Transference” where the average coping strategy score before COVID-19 was 1.87 (moderate) and 12.41 (moderate) during COVID-19 with a 0.54 change. The smallest change was found in the coping strategy category “stay optimistic” from an average coping strategy level of 2.06 (low) before COVID-19 and 2.15 (moderate) during COVID-19.

Means and std. deviation and T-test for subscales items of stress experienced by nursing students and coping strategies in their clinical practice before and during the COVID-19 pandemic.

* p -value for Chi-squared test < 0.05.

The results from the T-tests (See Table 4 ) show that there are statistically significant differences in both average stress scores and average coping strategies before and during COVID-19 across the majority of the categories. This statistical difference shows that both stress and coping strategy scores were lower before COVID-19 and higher during COVID-19. However, there was no statistically significant difference in the coping strategy category “Problem-solving” and “Stay optimistic” with a before-COVID-19 average coping strategy score of 2.09 and 2.06, and during scores of 2.32 and 2.15, respectively.

4. Discussion

Through the development of this survey, we have built upon previous research indicating the importance of understanding nursing students’ well-being through examining their stress levels and coping strategies. We have developed and tested a measurement scale that is reliable and accurately measures all identified in the Perceived Stress Scale (PSS) and the Coping Behavior Inventory (CBI) survey individually. However, our findings show that when the study is conducted on nurses in Saudi Arabia, there is not a strong reliable relationship between perceived stress and coping strategies (loading factor 0.4 and less) for the entire sample and the before COVID-19 sample. However, interestingly during COVID-19, there was a reliable and accurate relationship between stress and the use of coping strategies. A recent 2020 article regarding students’ coping strategies during the COVID-19 pandemic found that approximately 35% of students experienced some level of anxiety and used four types of coping strategies: Seeking social support, avoidance/acceptance, mental disengagement, and humanitarian [ 24 ].

The current study aimed to analyze the impact of the COVID-19 pandemic on nursing students’ stress levels and coping strategies. Through the combination of these two surveys, were have built upon previous research indicating the importance of stress and coping strategies among nursing students during unprecedented times. We have utilized a measurement scale that reliably and accurately measures stress and coping strategies before and during the COVID-19 pandemic. These findings can help inform nursing curricula developers on how to incorporate the needed skills and resources to prepare nurses for future infectious outbreaks. This is important as the Saudi Vision 2030 framework, released in 2017, has set a path to increase nurse graduates over the next 10 years and enhance the health delivery system to be community-focused. To meet this goal, Saudi Arabia has committed to increasing the nursing workforce by graduating and hiring 10,000 new nurses annually [ 25 ].

While multiple studies have reported on the psychological well-being of healthcare workers during COVID-19 [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ], our study is one of the first to examine the influence of the pandemic by controlling for before the pandemic in nursing students in Saudi Arabia. Data collection occurred during the first wave of the pandemic in the country. The results of this study reflect an increased level of stress and coping strategies among nursing students during the continuing COVID-19 pandemic than before the pandemic. We found that, overall, across all subscales of stress there was a significant increase in stress relating to taking care of patients, teachers and nursing staff, assignments and workload, peers and daily life, lack of professional knowledge and skills, and the environment. These stressors can be attributed to multiple factors such as the unpreparedness to care for COVID-19 patients, increases in safety protocols in the clinical setting and decreases in safety personal protective equipment, relying heavily on simulation for training, and added assignments in an online learning environment to keep up with skill development. The stressful learning environment hinders student success. The completion of clinical practice and a precursor to licensure adds even more added pressure on students to complete an excessive workload to meet the non-direct care hours required [ 34 ].

According to previous research, even in normal circumstances, nursing students experience stress and must utilize several coping strategies to reduce both stress and anxiety. A study conducted in Bahrain found that almost all nursing students experience moderate to severe levels of stress while in their clinical practice [ 35 ]. Furthermore, another study found that over 99% of nursing students reported the level of perceived stress moderate or high. Several studies have revealed that the cause of clinical stress can be attributed to fear and uncertainty of unknown events, fear of medical errors, working with unfamiliar equipment, and gaps between theory and practice [ 36 ]. The additional increase in the level of stress among nursing students due to COVID-19 can have both internal and external consequences [ 37 ]. It can cause students to perform poorly and may lead to a withdraw from the program as self-doubt sets in, changes in mental and physical health, and can eventually affect the quality of care provided to patients. Several studies have shown that due to the demand and utilization of personal protective equipment across the globe, many direct care workers such as nurses and nursing students lacked the proper protective equipment, which increased their vulnerability to contracting COVID-19 [ 38 , 39 ]. As a result, many nurses have lost their lives to COVID-19, while others continue to fight against the deadly virus. Consequently, nurses perceive an increased risk of catching COVID-19 [ 40 ], which has increased turnover intentions [ 41 ]. However, a study conducted in China during the COVID-19 pandemic found that only 3% of their sample believed clinical nursing work to be “too dangerous to engage in” and have an increased intention of leaving the nursing profession [ 42 ].

The COVID-19 pandemic is currently the biggest threat to the lives and health of nurses and nursing students and has been shown to impact their emotional response and coping strategies. Our study shows that nursing students’ use of Avoidance and Transference as coping strategies and overall coping strategies increased during the COVID-19 pandemic in comparison to before the pandemic. However, our study did not identify a statistical difference between nursing students’ use of problem-solving or staying optimistic as coping strategies. This is in contradiction to a recent study that found that nursing students were more willing to use coping strategies that focused on problem-solving [ 8 ]. Our study findings can be explained by examining Gan and Liu's [ 43 ] study, which found that undergraduate students who regarded stressful events as controllable were more likely to apply problem-focused coping strategies; however, since COVID-related events were uncontrollable during the study period, students might have relied on emotion-focused coping strategies such as Avoidance and Transference, which contradict some priory studies [ 44 , 45 ]. A study conducted before the pandemic found that the most common coping behavior used by nursing students was transference, followed by staying optimistic and problem-solving, while the least used was Avoidance [ 46 ]. These findings are important for both nursing schools and hospitals, where they must focus on providing psychological support to nurses as well as training them in all available coping strategies to improve their ability to manage their emotions and effective coping tools to improve the lives of the nursing student, their families, and ultimately their patients.

Limitations

The study focused on nursing students in Saudi Arabia from a single private university. Due to the correlational nature of our study, no causal conclusions can be made; however, our findings may lead to a greater understanding of stress and coping strategies of nursing students involved in the COVID-19 pandemic. Hence, the findings should not be generalized to the overall student population.

5. Conclusions

The psychological impact of the pandemic on nursing students should not be ignored. The well-being of these students is affected by high levels of stress and emotional-based coping strategies. To alleviate the degree of impact, guidelines and strategies should be adopted into current nursing curricula even before the student is in clinical practice. Prioritizing research and policy effort on mental health, stress, and coping strategies of students needs to occur to equip future nursing students with the tools needed to be successful in the field of nursing. However, future research needs to replicate this study on a greater scale across multiple universities across multiple countries. Moreover, using in-depth data collection strategies, such as qualitative interviews or focus groups, in future research would significantly help explain the rationales behind why students adopted one coping strategies over another.

Relevance to Clinical Practice

Our study highlights that there was a strong, reliable, and accurate relationship between stress and the use of coping strategies during the COVID-19 pandemic compared to before. We anticipate that this relationship will only continue. Students are important resources for our health system and society and will continue to be vital long term. It is now up to both nursing educators and health administrators to identify and implement the needed improvements in training and safety measures because they are essential for the health of the patient, but also future pandemics.

Acknowledgments

The authors would like to thank Almaarefa University for its financial support of this research. The authors would also like to thank the University of North Florida, and all the participants in who took part of the study.

Author Contributions

Study design: H.Y.H., E.J., N.M.A.Z., and J.A.S.S.; data collection and analysis: F.N.A.N. and H.H.B.H.; manuscript writing: H.Y.H., E.J., N.M.A.Z., F.N.A.N., H.H.B.H., and J.A.S.S.; agrees to be accountable for all aspects of work: H.Y.H., E.J., N.M.A.Z., F.N.A.N., H.H.B.H., and J.A.S.S. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of AlMaarefa University (protocol code 07-20062021 and 21 June 2019).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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