This literature review examined 13 studies on stress and coping strategies among nursing students. The studies found that nursing students experience moderate to high levels of stress, with their main stressors being academic demands like exams, assignments, and workloads, as well as clinical stressors such as caring for patients and negative interactions with staff. Common coping strategies utilized by nursing students included problem-solving approaches like developing objectives to resolve issues, adopting various strategies to solve problems, and finding meaning in stressful events. Nurse educators are encouraged to implement interventions to help students reduce stress and improve their coping skills.

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A literature review on stress and coping strategies
in nursing students
Leodoro J. Labrague, Denise M. McEnroe-Petitte, Donna Gloe, Loretta
Thomas, Ioanna V. Papathanasiou & Konstantinos Tsaras
To cite this article: Leodoro J. Labrague, Denise M. McEnroe-Petitte, Donna Gloe, Loretta
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! 2016 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2016.1244721
REVIEW ARTICLE
A literature review on stress and coping strategies in nursing students
Leodoro J. Labrague1
, Denise M. McEnroe-Petitte2
, Donna Gloe3
, Loretta Thomas4
, Ioanna V. Papathanasiou5
, and
Konstantinos Tsaras5
1
College of Nursing, Sultan Qaboos University, Muscat, Oman, 2
College of Nursing, Kent State University, Kent, OH, USA, 3
Southwest Baptist
University, USA, 4
Research Consultant, Self - Employed, and 5
Technological Educational Institute of Thessaly, Thessaly, Greece
Abstract
Background: While stress is gaining attention as an important subject of research in nursing
literature, coping strategies, as an important construct, has never been comprehensively
reviewed.
Aim: The aims of this review were: (1) to identify the level of stress, its sources, and (2) to
explore coping methods used by student nurses during nursing education.
Methods: This is a systematic review of studies conducted from 2000 to 2015 on stress and
coping strategies in nursing students. CINAHL, MEDLINE, PsycINFO and PubMed were the
primary databases for the search of literature. Keywords including ‘‘stress’’, ‘‘coping strategy’’,
‘‘nursing students’’ and ‘‘clinical practice’’ in 13 studies met the criteria.
Findings: Stress levels in nursing students range from moderate to high. Main stressors
identified included stress through the caring of patients, assignments and workloads, and
negative interactions with staff and faculty. Common coping strategies utilized by nursing
students included problem-solving strategies such as developing objectives to resolve
problems, adopting various strategies to solve problems, and finding the meaning of stressful
events.
Conclusion: Nurse educators may consider the use of formulation and implementation of
empirically tested interventions to reduce stress while enhancing coping skills.
Keywords
stress, coping strategy, nursing students and
clinical practice
History
Received 24 July 2016
Accepted 16 September 2016
Published online 8 December 2016
Introduction
Stress is a common factor in everyday life and, specifically, is
related to those in the nursing profession (Lim et al., 2010).
Lazarus & Folkman (1987) stated that stress is a ‘‘situation in
which internal demands, external demands, or both, are
appraised as taxing or exceeding the adaptive or coping
resources of an individual or group’’ (p. 19). Gorostidi et al.
(2007) suggested in nursing education, stress is influenced by
a number of issues especially growing into the role of the
nurse, meeting of the demands of the role and dealing with the
uncertainties the role elicits. Causes of stress can be many.
These include illness, pain, medications, unpleasant or
unpredicted events, internal and external conflicts, fear of
the unknown, cultural and environmental issues to name a few
(Labrague, 2014; Papathanasiou et al., 2014). Any of these
causes can affect the nursing student and can interfere with
their performance in all aspects of the educational process.
When in a nursing education program, students are often
exposed to high levels of stress when compared to other
students in other formalized programs (Al-Zayyat & Al-
Gamal, 2014a; Stecker, 2004). In particular, the clinical
component of the nursing program which is meant to prepare
nursing students for professional nursing roles and enhance
their critical thinking and decision making skills in the
clinical settings produces high levels of discomfort, stress and
anxiety (Dunn & Burnett, 1995).
Existing evidence showed that there are two major sources
of stress among nursing students: academic and clinical
stressors, with the latter being perceived more intensely by
nursing students at all levels (Jimenez et al., 2010; Pulido-
Martos et al., 2012). Stressors related to academia include: the
academic process (Tully, 2004), heavy assignments and
workloads (Al-Zayyat & Al-Gamal, 2014b; Labrague, 2014;
Suresh et al., 2012) and examinations (Burnard et al., 2008;
Gibbons, 2010; Nolan & Ryan, 2008; Pulido-Martos et al.,
2012). Studies consistently show that nursing students
experience moderate to severe levels of stress during clinical
practice (Blomberg et al., 2014; Burnard et al., 2008;
Labrague, 2014; Tully, 2004).
Clinical sources of stress include: fear of the unknown
(Pulido-Martos et al., 2012), new clinical environments (Kim,
2003), engaging in various clinical activities (Yamashita
et al., 2012), taking care of patients (Jimenez et al., 2010;
Khater et al., 2014; Sheu et al., 2002), lack of professional
knowledge or nursing skills (Gorostidi et al., 2007; Jimenez
et al., 2010; Labrague, 2014; Sheu et al., 2002), fear of failure,
clinical incompetence (Labrague, 2014), experience of death
and dying (Burnard et al., 2008; Suresh et al., 2012; Timmins
& Kaliszer, 2002), unfamiliarity with patients’ medical
Correspondence: Leodoro J. Labrague, Al Khoudh, Muscat, Oman.
Mobile: +96891273073. E-mail: Leo7_ci@yahoo.com

3. history (Sheu et al., 2002), unfamiliar patients’ diagnoses and
treatments (Sheu et al., 2002), fear of making mistakes (Kim,
2003; Pulido-Martos et al., 2012), giving medication to
children (Oermann & Lukomski, 2001) and lack of control in
relationships with patients (Gorostidi et al., 2007).
Other reported stressors include: peers, daily life and the
environment (Shaban et al., 2012), nursing staff and nurse
educators (Khater et al., 2014) finding of new friends,
learning of new responsibilities (Seyedfatemi et al., 2007),
being placed in unfamiliar situations, working with people
they do not know, financial strain (Tully, 2004), relationships
with friends, tutors and companions (Gorostidi et al., 2007),
negative interactions with instructor’s (Timmins & Kaliszer,
2002), being observed by instructors, being late (Kim, 2003)
and poor relationships with clinical staff (Nolan & Ryan,
2008).
Coping mechanisms are a necessity when dealing with
stress and accompanying stressors. Lazarus & Folkman
(1987) classified coping ways as problem-based and emo-
tion-based. Several studies highlighted problem-solving
approach as the most common coping behaviors in nursing
students while the avoidance approach as the least utilized
coping behaviors in nursing students (Al-Zayyat & Al-Gamal,
2014a,b,c; Labrague, 2014; Shaban et al., 2012; Sheu et al.,
2002). Problem-based coping ways are known to be beneficial
to students’ learning, clinical performance and well-being,
while emotion based coping ways were found to be harmful to
their health (Chang et al., 2007; Tully, 2004).
Stress is considered beneficial in minimal amounts as it
increases excitement and motivation (Gibbons, 2010).
However, unmanaged stress or failure to cope with chronic
stress may be harmful to the health and well-being of an
individual (Watson et al., 2008). Chronic stress may affect the
learning, decision-making, thinking and eventually the aca-
demic performance of the nursing student (Sheu et al., 2002).
Stress may even be a reason why they choose to leave the
nursing program (Watson et al., 2008). Unmanaged stress may
also cause the nursing student to experience negative
emotional states such as sadness, apprehension, anxiety,
worry, anger, lack of self-esteem, guilt, grief, nervous
breakdown, depression, feeling of loneliness, listlessness or
sleeplessness (Labrague, 2014).
To date, only two papers exist which summarize sources of
stress in nursing students (Al-Zayyat & Al-Gamal, 2014b;
Pulido-Martos et al., 2012). Both papers critically evaluated
existing studies on nursing students’ levels of stress. Coping
strategies, as an important construct, has never been reviewed,
thus this study is the pioneer and contribute significantly to
the existing knowledge on stress and coping among nursing
students.
Aim
The aims of this review were: (1) to identify the level of
stress, its sources, and (2) to explore coping methods used by
student nurses during nursing education.
Methods
The narrative conceptual synthesis method was used to review
quantitative studies reporting sources of stress in nursing
students and their coping mechanisms. A two-part analysis is
presented. Stress levels and its sources were the main focus of
the first analysis. Identifying nursing students coping mech-
anisms were the emphasis of the second analysis.
Search strategy
CINAHL, MEDLINE, PsycINFO and PubMed were the
primary databases for the search of the literature as they
contained vast numbers of journals including nursing research
journals. Keywords include ‘‘stress’’, ‘‘coping strategy’’,
‘‘nursing students’’ and ‘‘clinical practice’’ in various
combinations. To ensure rigorous and comprehensive search
of the literature, a manual search of nursing research journals
was conducted. In order to ensure the quality of the findings, a
systematic method of appraising the article was utilized. The
quality of the findings was evaluated using the Critical
Appraisal Checklist of the Center for Evidence-Based
Management (2014) to select the articles that would be
reviewed. The following flow diagram (see Figure 1) shows
the process used to identify articles for the systematic review.
Inclusion and exclusion criteria
This review of the literature included articles based on the
following criteria: (1) studies published from 2000 to 2015,
(2) studies including only nursing students, (3) studies in the
English language and published in scientific journals, (4)
studies that explored stress and its sources along with coping
strategies and (5) studies with quantitative design. Finally, 32
studies were identified, of which, 13 met the set criteria.
Results
Setting
Thirteen studies were included in the review (Table 1).
Five studies reviewed were from Asia: Hong Kong (Chan
et al., 2009), China (Zhao et al., 2014), Japan (Yamashita
et al., 2012), Taiwan (Chen & Hung, 2013) and India (Shukla
et al., 2013). Three studies were from the Middle East
(Al-Zayyat & Al-Gamal, 2014c; Seyedfatemi et al., 2007;
Shaban et al.,2012), two from the United States (Reeve et al.,
2013; Wolf et al., 2015) and others were from various other
parts of the world (Bam et al., 2015; Evans & Kelly, 2004; Lo,
2002).
Design and sample size
A majority of the studies reviewed were descriptive, cross-
sectional studies (Al-Zayyat & Al-Gamal, 2014c; Bam et al.,
2015; Chan et al., 2009; Chen & Hung, 2013; Evans & Kelly,
2004; Seyedfatemi et al., 2007; Shaban et al., 2012; Shukla
et al., 2013; Yamashita et al., 2012; Zhao et al., 2014) with
sample sizes that ranged from 52 to 1370 nursing students.
One study used a longitudinal design (Lo, 2002) and two
studies utilized a mixed method research design (Reeve et al.,
2013; Wolf et al., 2015).
Instrument
Most of the studies utilized the Perceived Stress Scale (PSS)
developed by Sheu et al. (1997), to measure stress and
2 L. J. Labrague et al. J Ment Health, Early Online: 1–10

4. identify specific stressors in nursing students. Other instru-
ments used to measure stress included the Student Stress
Survey (SSS) (Seyedfatemi et al., 2007), General Health
Questionnaire (GHQ) (Lo, 2002; Yamashita et al., 2012),
Student Nurse Stress Index (SNSI), Student Life Stress
Inventory (Reeve et al., 2013) and Perceived Stress
Questionnaire (PSQ) (Wolf et al., 2015). One study utilized
a questionnaire developed by Lindop (1999) which consisted
of six sections: clinical stress, academic stress, emotional
response to stress, coping and personal factors.
Coping strategies were measured primarily using the
Coping Behavior Inventory (CBI) (Sheu et al., 2002) with
the remaining studies utilizing the Adolescent Coping orien-
tation for Problem Experiences (ACOPE) (Seyedfatemi et al.,
2007), Brief Coping Orientations to Problems Experienced
(COPE) (Bam et al., 2015; Yamashita et al., 2012), Ways of
Coping Instrument (Lazarus & Folkman, 1987), Modified
Ways of Coping Scale (Carver, 1997) and the Deakin Coping
Scale (Moore, 2003).
Some of the studies utilized stress and coping scales in
combination with other scales to measure self-efficacy (Zhao
et al., 2014), responses to stress (Chen & Hung, 2013), self-
esteem (Lo, 2002; Wolf et al., 2015) and perceived social
support (Reeve et al., 2013; Wolf et al., 2015).
Stress
Of the 13 studies, six reviewed reported levels of stress in
student nurses. High levels of stress were reported in one
study (Shukla et al., 2013) and moderate levels of stress in
five studies (Al-Zayyat & Al-Gamal, 2014c; Bam et al., 2015;
Chan et al., 2009; Shaban et al., 2012; Zhao et al., 2014).
All of the studies reviewed identified sources of stress, of
which, three studies reported taking examinations as the main
source. Yamashita et al. (2012), used the GHQ with the most
frequently reported stressors were examinations, followed by
relations with friends, clinical practice and reports. In a cross-
sectional study in India, Shukla et al. (2013) assessed the level
and sources of stress and explored coping strategies of the
nursing students. Utilizing the SNSI, item analysis revealed
the majority of nursing students or 87% perceived fear of
examinations as extremely stressful. Evans & Kelly (2004)
conducted a study to explore the stress experience and coping
skills in Diploma nursing students in Ireland. A self-reported
instrument was used to measure stress and coping abilities.
Analysis of the mean scores revealed that the highest ranked
stressors were taking examinations and high workloads with
mean scores of 4.60 and 4.40, respectively.
Three studies reported taking care of patients as the main
source of stress in students (Al-Zayyat & Al-Gamal, 2014c;
Chen & Hung, 2013). Chen & Hung (2013) reported a cross-
sectional study with 101 nursing students enrolled in a
nursing program in Taiwan. The PSS, a standardized scale
developed by Sheu et al. (2002) was used to collect
information on stress and its sources. This study’s findings
showed that the most common stressors encountered by
students were caring for patients followed by assignments and
workloads, instructors and staff. Recently, Al-Zayyat & Al-
Gamal (2014a,b,c) conducted a longitudinal study to measure
the degrees of stress, sources of stress and coping methods in
Jordanian students. Analyzing the subscales of the PSS,
findings revealed the highest means obtained were from the
caring for patients’ subscale. The author explained this may
be due to the fact that students in the study were training in
the Mental Health Nursing Course which focuses on funda-
mental mental health nursing and therapeutic communication
techniques. However, during their practicum, nursing students
encountered other patients requiring complex nursing care,
which caused them to feel stressed.
Two studies reviewed reported stress from assignments
and workloads (Shaban et al., 2012; Zhao et al., 2014). In a
study by Zhao et al. (2014) among 231 nursing students in
China, workloads and assignments were reported as the main
sources of stress followed by stress from peers and daily life.
In a cross-sectional study conducted in Jordan, baccalaureate
nursing students reported stressors mainly from assignments
Figure 1. Flow diagram of the process used to
identify references for the systematic review.
CINAHL, MEDLINE, PsycINFO and
PubMed 331 titles
177 papers excluded (title not relevant to
the subject
Abstract Screening
154 papers
78 papers excluded (abstract irrelevant
to the
Full Text Screening
76 papers
44 papers excluded (full text irrelevant to
the study)
32 articles
19 papers with methodological problem
(design, response rate)
13 articles included for review
DOI: 10.1080/09638237.2016.1244721 Stress and coping in nursing students 3

5. Table 1. Studies on stress and coping strategies among nursing students.
Author (s) Country Research question/aim Sample Research design Instrument/tool
Type of clinical
stressors Level of stress
Type of coping
strategies
1. Chan et al.
(2009)
Hong Kong To examine the stu-
dents’ stress and the
types of coping stra-
tegies they utilized.
205
All year level
except first
year
Cross-sectional
descriptive
Perceived Stress Scale
(PSS) (Sheu et al., 1997)
Content validity index was
0.94. Cronbach’s alpha
was 0.89
Coping Behavior Inventory
(CBI) (Sheu et al., 1997)
Cronbach’s alpha was 0.80
Deficiency of nur-
sing knowledge
and skills
Assignments and
workload, caring
for patients
Moderate Transference (sleeping,
watching TV or
movies, having a
shower or participat-
ing physical exer-
cise), being
optimistic, problem
solving and avoidance
2. Zhao et al.
(2014)
China To examine the stress,
coping strategy, self-
efficacy as well as
the predictingeffects
of stress and self-
efficacy on fre-
quency of use of
coping strategy of
nursing students in
China.
231
Final year
Cross-sectional
survey
Perceived Stress Scale
(PSS) (Sheu et al., 1997)
Cronbach’s alpha was 0.92
Coping Behavior Inventory
(CBI) (Sheu et al., 1997)
Cronbach’s alpha in the
sample is 0.81
Assignments and
workload, peers
and daily life,
caring for patients
Moderate Transference, staying
optimistic and prob-
lem solving
3. Seyedfatemi
et al. (2007)
Iran To determine sources of
stress and coping
strategies in nursing
students studying at
the Iran Faculty of
Nursing &
Midwifery.
366 Descriptive
cross-sec-
tional study
Student Stress Survey (SSS)
(Insel & Roth, 1985).
Cronbach’s alpha was 0.78
Adolescent Coping
Orientation for
ProblemExperiences
Inventory (ACOPE)
(Patterson & McCubbin,
1987).
Cronbach’s alpha was 0.85
Finding new friends,
working with
unknown, class
workload,
unfamiliar
situations
Level of stress –
not measured
in this study
Going along with one’s
parents requests and
rules, praying,
making one’s own
decisions, apologiz-
ing, helping other
people to solve prob-
lems, keeping friend-
ships and
daydreaming
4. Yamashita
et al. (2012)
Japan To describe the sources
of nursing students’
stressors,examine
coping styles during
events of stress
andcompare coping
styles between dis-
tressed and non-dis-
tressed nursing
students.
1370 Cross-sectional
survey
General Health
Questionnaire(GHQ)
(Doi & Minowa 2003)
Doi & Minowa (2003)
reported that GHQ had
reliability coefficient of
0.83
Brief Coping Orientations
to Problems Experienced
(COPE) scale.
Cronbach’s alpha for the-
present study was 0.79
Examinations,
friends, clinical
practice, reports
Level of stress
not measured
in this study
Acceptance, self-dis-
traction andusing
instrumental support
5. Al-Zayyat &
Al-Gamal
(2014a,b,c)
Jordan To determine the
degrees of stress, the
types of stressors,
and the copingstrate-
gies perceived by
nursing students
during pre- and post-
clinical periods in
PMHN courses.
65
All students
having
clinical
Descriptive, lon-
gitudinal
design
Perceived Stress Scale
(PSS) (Sheu et al., 1997)
Cronbach’s alpha coeffi-
cient was 0.89
Coping Behavior Inventory
(CBI) (Sheu et al., 1997)
Cronbach’s alpha was 0.74
Caring for patients,
assignments and
workloads, tea-
chers and staff
nurses
Moderate Problem-solving strat-
egy and staying opti-
mistic strategy
(continued )
4
L.
J.
Labrague
et
al.
J
Ment
Health,
Early
Online:
1–10

6. Author (s) Country Research question/aim Sample Research design Instrument/tool
Type of clinical
stressors Level of stress
Type of coping
strategies
6. Shaban et al.
(2012)
Jordan To identify the level and
types of stress per-
ceived by baccalaur-
eate nursing students
in Jordan in their
initial period of clin-
icalpractice and to
identify the coping
strategies that stu-
dents used to relieve
their stress.
181 Descriptive
cross-sec-
tional design
Perceived Stress Scale
(PSS) (Sheu et al., 1997)
Cronbach’s alpha coeffi-
cient was 0.87
Coping Behaviour
Inventory (CBI) (Sheu
et al., 2002).
Cronbach’s alpha coeffi-
cient was 0.73
Content validity of the PSS
and CBI was established
by a panel of experts
Assignment, clinical
environment,
staff nurses and
teachers
Moderate Problem solving, stay-
ing optimistic and
transference
7. Chen &
Hung (2013)
Taiwan To examine student
nurses’ perceived
stress, coping behav-
iors, personality
traits, and physio-
psycho-social
responses in clinical
practicum and to
identify predictors
for physio-psycho-
social responses in
the clinical
practicum.
101 Cross-sectional
design
Perceived Stress Scale
(PSS) (Sheu et al., 1997)
Cronbach’s alpha was 0.91
Coping Behaviour
Inventory (CBI) (Sheu
et al., 2002).
Cronbach’s alpha in the
present study was 0.80
Caring for patients,
assignment work-
load, and staff
nurses and
teachers
Level of stress
not measured
in this study
Problem-solving, opti-
mism, and
transference
8. Shukla et al.
(2013)
India To assess the level and
source of stress,
coping mechanisms
and influencing fac-
tors in student nurses.
59 Cross-sectional
design
Student Nurse Stress Index
(SNSI) (22 items)
Cronbach’s alpha was 0.76
Moo’s Coping Response
Inventory – adult (48
item)
Cronbach’s alpha was 0.79
Examination, being
unsure of what is
expected from
them in both aca-
demic activity
and clinical work,
lack of timely
feedback from
teachers, lack of
free time for self
High Approach coping and
avoidance coping
9. Evans &
Kelly (2004)
Ireland To examine the stress
experiences and
coping abilities of
student nurses.
52 Survey design 109-item questionnaire with
a Likert scale designed
by Lindop (1999).
Consists of six sections;
clinical stress, academic
stress, emotional
response to stress,
coping, and personal
factors
Validity and reliability of
the questionnaire had
been demonstrated in the
previous studies
(Lindop, 1999).
Examinations, aca-
demic work,
theory – clinical
gap, unfriendly
atmosphere on
the ward, teachers
Level of stress
not measured
in this study
Talking to relatives and
friends, talking to
peers, thinking to
carry on, and trying
to stay out of trouble
(continued )
DOI:
10.1080/09638237.2016.1244721
Stress
and
coping
in
nursing
students
5

7. Table 1. Continued
Author (s) Country Research question/aim Sample Research design Instrument/tool
Type of clinical
stressors Level of stress
Type of coping
strategies
10. Lo (2002) Australia To investigate the per-
ception and sources
of stress,coping
mechanisms used,
and self-esteem in
nursing students
during 3 years of
their undergraduate
nursing program.
333
First three years
of study
Descriptive ana-
lyses
Longitudinal
Study
General Health
Questionnaire
(GHQ) (Goldberg & Hillier,
1979)
Reliability and validity stu-
dies with a range of
populations
are described by Goldberg
& Hillier (1979)
Ways of Coping Instrument
(Lazarus & Folkman’s,
1987)
Construct validity was con-
firmed by factor analysis
Content validity of coping
strategies was assessed
by two nurse
academicians
Academic studies,
financial, family,
health
Level of stress
not measured
in this study
Problem-focused coping
(problem solving,
recreation and sport,
social support) emo-
tion-focused coping
(tension reduction
strategies)
11. Bam et al.
(2015)
Ghana To identify the stressors
in clinical practice
for nursing students
and the coping
mechanisms used.
322
2nd to 4th year
level
Descriptive
design
Perceived Stress Scale(PSS)
(Cohen et al., 1983)
Modified ways of coping
scale (Carver, 1997).
Reliability and validity of
the PSS and Brief COPE
Scale have been vali-
dated by earlier
studies (Lee, 2012)
Clinical-theory gap,
staff nurses,
standing through-
out clinical prac-
tice hours
Moderate to high Receiving moral sup-
port from their
family, establishing
cordial relationship
with nurses during
clinical practice, and
praying toGod about
the difficulties faced
at the clinical setting
12. Wolf et al.
(2015)
USA To describe stressors
and coping strategies
used by accelerated
students in compari-
son with generic
students.
210
3rd and 4th year
students
Mixed method
design
Perceived Stress
Questionnaire (PSQ)
(Levenstein et al., 1993)
Rosenberg Self-Esteem
Scale (R-SE) (Rosenberg
et al., 1989)
Multidimensional Scale of
Perceived Social Support
(MSPSS) (Zimet et al.,
1988)
Validity and reliability of
the scales not reported in
the study
Fear of failure in
classroom and
clinical, problems
with faculty, time
management
problems
Thinking positively,
seeking social sup-
port from family and
friends
13. Reeve et al.
(2013)
USA To identify the stress
experience and use of
social support as a
coping mechanism in
traditional and
second degree nur-
sing students’ educa-
tional experiences.
107
Traditional – 49
Second degree –
58
Mixed method
design
Multidimensional Scale of
Perceived Social Support
(Zimet et al., 1988)
Deakin Coping Scale
(Moore, 2003)
Social Support
Questionnaire (Sarason
et al., 1987)
Student Life Stress
Inventory
(Gadzella & Baloglu, 2001)
Validity and reliability of
the scales not reported in
the study
Negative inter-
actions with tea-
chers and staff
nurses, inad-
equate clinical
knowledge and
skills
Level of stress
not measured
in this study
Talking to friends,
hanging out with
friends, talking to
family members,
ignoring their stress,
crying, separating
self from others
6
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J.
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et
al.
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Online:
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8. and the clinical environment (Shaban et al., 2012). Two
studies reported inadequate interactions with the staff and
faculty as well as a lack of clinical competence (Reeve et al.,
2013; Wolf et al., 2015).
One study reported academic studies, financial, family and
health as the main sources of stress (Lo, 2002). In the study by
Bam et al. (2015), nursing students reported being stressed
when the clinical instruction varied from the class instruction.
Peer pressure, being disregarded and ignored by on-duty staff
created an unhealthy work setting for the nursing students. A
lack of professional knowledge and skills was reported as the
main source of stress in one study (Chan et al., 2009).
Determinants of stress were additionally reported in some
of the studies. For instance, in a study by Shaban et al. (2012),
female nursing students experienced higher levels of stress as
compared to their male counterparts. Shukla et al. (2013) and
Shaban et al. (2012) revealed that some nursing students with
no interest in nursing experienced high degrees of stress. In
another study, older nursing students and those who had been
in the nursing program for a period of time, tended to have a
lower level of stress (Bam et al., 2015). In a study by Wolf
et al. (2015), a history of depression, year in the program,
self-esteem and social support predicted stress in students.
Four studies examined the association between stress and
other psychological constructs, aside from coping. For
example, Zhao et al. (2014) examined the moderating effects
of self-efficacy on stress levels and coping mechanisms in a
group of nursing students who were practicing in three
hospitals in China. Student self-efficacy moderated the effects
of stress on coping strategies. Chen & Hung (2013) and Evans
& Kelly (2004) examined nursing students’ responses to stress
such as emotional responses (e.g. feeling exhausted and under
pressure) and physical symptoms (e.g. gastrointestinal upset).
In Reeve et al.’s study (2013), students reported feelings that
they experienced during a stressful event such as fear, anxiety,
worry, anger, guilt, grief or depression. In one study, self-
esteem was measured where it correlated significantly with
stress and coping behaviors (Lo, 2002).
Coping
This review identified coping strategies employed by nursing
students during stressful events. Six studies reported problem-
solving strategies as an approach in dealing with stress (Al-
Zayyat & Al-Gamal, 2014c; Lo, 2002; Shaban et al., 2012;
Shukla et al., 2013; Wolf et al., 2015). For example, Jordanian
nursing students who were attending clinical practice in a
mental health setting utilized problem-solving as the main
approach in coping with stress (Al-Zayyat & Al-Gamal,
2014c). Previous clinical experiences of nursing students
were seen by the authors as the main reason why nursing
students utilized this coping approach. A cross-sectional study
was conducted by Chen & Hung (2013) in 101 junior nursing
students in Taiwan. Students revealed they engaged in positive
coping strategies through the use of a problem-solving
approach.
Three studies reported the transference approach as the
main strategy in dealing with stress (Chan et al., 2009;
Yamashita et al., 2012; Zhao et al., 2014). Chan et al. (2009)
reported that the most frequently utilized coping strategy in
nursing students was transference such as performing exer-
cises, watching movies, taking a shower and sleeping. Authors
argued that nursing students in the study may not have learned
the different types of coping strategies aside from the fact that
this type of coping is easier and more convenient. Yamashita
et al. (2012) found nursing students, when faced by stress,
engaged in the coping strategies such as sleeping, eating and
talking to someone. Other remaining studies reported a
mixture of coping approaches such as praying, talking to
relatives and friends, ignoring their stress, crying and
separating themselves from others (Bam et al., 2015; Evans
& Kelly, 2004; Reeve et al., 2013; Seyedfatemi et al., 2007).
Few determinants of coping were reported in the studies
reviewed. For example, nursing students in their senior level
(Chan et al., 2009) and those with a high level of self-efficacy
(Zhao et al., 2014) tended to use a problem-solving approach.
Use of an avoidance method of coping was common in
nursing students who experienced stress from their teachers
and staff nurses (Chan et al., 2009). In one study, high levels
of self-efficacy in nursing students influenced their frequency
in using coping strategies (Zhao et al., 2014).
Discussion
This review identified the levels of stress, its sources, and
explored coping strategies used by student nurses when faced
by stress during the nursing education process. It is very
evident in the review that majority of the studies were cross-
sectional in nature (Al-Zayyat & Al-Gamal, 2014c; Bam
et al., 2015; Chan et al., 2009; Chen & Hung, 2013; Evans &
Kelly, 2004; Seyedfatemi et al., 2007; Shaban et al., 2012;
Shukla et al., 2013; Yamashita et al., 2012; Zhao et al., 2014)
with only one study using the longitudinal design (Lo, 2002)
and two studies utilized a mixed method research design
(Reeve et al., 2013; Wolf et al., 2015). This may be because
this design is more convenient and easy to complete when
compared to other types of research designs. However, this
might have some effects on the responses of the nursing
students considering the nature of stress. According to
Lazarus & Folkman (1987), stress levels change across time
and since they were asked to recall their previous clinical
experiences, they may not be able to recall some of these
stressful experiences. The use of a longitudinal study may be
necessary to detect changes in the levels for stress and coping
abilities across school years.
It is also worth noting that all studies but one (Yamashita
et al., 2012) evaluated utilized samples from one site only,
thus limiting generalizability of findings. Inclusion of other
students from other sites may provide a more generalizable
result. Therefore, future studies should be conducted utilizing
representative samples from other sites. In addition, all
studies reviewed, power analysis was not performed to
determine sample size. Validity of the conclusions therefore
is in question. This suggests future research should include
power calculation or sample size calculation to ensure the
validity of the research findings.
Comparing findings among studies reviewed was a chal-
lenge in the review considering the variety of tools used to
measure stress and coping in nursing students. Most of the
studies examined used tools which vary in the number of
DOI: 10.1080/09638237.2016.1244721 Stress and coping in nursing students 7

9. items, content and even in the structure. This may hinder
researchers in comparing and contrasting research studies.
Nevertheless, evidence from the studies reviewed suggested
that nursing students experience moderate levels of stress
during nursing education. This finding is in keeping with the
results obtained by previous authors (Hamaideh et al., 2016;
Jimenez et al., 2010; Labrague, 2014). Although stress in
minimal amounts can be beneficial, stress beyond a tolerant
level may have profound effects on the individual. Further,
most studies suggested that nursing students encountered
multiple stressors such as caring for patients, assignments and
workloads, negative interactions with staff and faculty, lack of
clinical competence, and taking of examinations.
Several interventions were mentioned to address stress in
nursing students. This included improving the clinical edu-
cation program (Al-Zayyat & Al-Gamal, 2014c), inclusion of
stress management during orientation of activities (Bam et al.,
2015; Seyedfatemi et al., 2007), and enhancement of time
management skills of nursing students, and counseling (Chen
& Hung, 2013). In one study, the authors suggested the
establishment of support systems to help equip nursing
students with positive coping strategies along with the
formulation of hospital policies which will support nursing
student learning (Al-Zayyat & Al-Gamal, 2014c). Another
study suggested the use of social support system such as the
family, friends, relatives and even co-workers is essential to
counteract the harmful effects of stress (Lo, 2002). Evans &
Kelly (2004) suggested implementing a teaching pedagogy,
which empowers nursing students to promote positive skills
such as interpersonal and intrapersonal skills. Both Chan
et al., (2009) and Pulido-Martos et al. (2012) suggested
providing nursing students with a supportive clinical learning
environment and teaching them effective coping strategies for
them to deal with stressors positively while enhancing their
learning.
It is also evident that the most preferred strategy used by
nursing students to cope with stress was the problem-solving
approach. This coping approach is considered the most
effective way of dealing with stress which involves behaviors
to address the main cause of the problem such as: setting up
objectives to resolve the problem, adopting various strategies
to solve problem, finding meaning of the stressful events, and
employing past experience to solve the problem (Folkman &
Lazarus, 1988). Conversely, few studies found student nurses
to use the emotion-focused approach. This approach, con-
sidered to be the least effective strategy in dealing with stress,
does not solve the cause of stress but rather manages feelings
related to stress. In one study, the frequent use of an emotion-
based coping strategy (transference) to deal with stressors
lead to negative results such as the nursing students’
perceiving higher levels of stress (Al-Zayyat & Al-Gamal,
2014a). Behaviors included sleeping, using self-distraction
activities, and watching TV or movies. Similarly, studies
suggested interventions aimed at enhancing nursing students
coping skills. One study proposed a counseling program for
first year nursing students which introduce effective coping
strategies (Seyedfatemi et al., 2007). Other studies highlighted
the role of self-efficacy in improving and enhancing nursing
students’ coping abilities. One study suggested clinical
simulation to enhance nursing student self-efficacy which is
necessary in order to moderate the effects of stress (Zhao
et al., 2014).
Implications for nursing
This review is the first to critically review and discuss stress
and coping among nursing students during nursing education.
Stress during nursing education has deleterious effects on the
nursing workforce as this may contribute to a shortage of
nurses entering into the nursing profession. With that being
said, nursing faculty are in a prime position in which to assist
nursing students in dealing with their stress and stressors (Al-
Zayyat & Al-Gamal, 2014a,b,c; Labrague, 2014; Yamashita
et al., 2012; Zhao et al., 2014). Findings of this review may
provide direction in nursing education as it will provide
relevant information to nurse educators in exploring and
implementing empirically tested interventions to lessen,
reduce and prevent stress in order to facilitate maximum
learning both in the theory and clinical setting. In addition,
these findings call for a greater challenge to nurse educators
in planning strategies to prevent recurrence of stress among
nursing students while keeping them driven to achieve
maximum knowledge.
Since clinical training is essential for the acquisition of
skills, nurse educators should further strengthen the nursing
students’ positive coping skills to deal with the different
stressors during educational experiences. Such interventions
may include a counseling program (Seyedfatemi et al., 2007)
while other studies highlighted the role of self-efficacy in
improving and enhancing nursing students’ coping (Zhao
et al., 2014). Both Chan et al. (2009) and Pulido-Martos et al.,
(2012) suggested providing nursing students with a supportive
clinical learning environment and teaching them effective
coping strategies to deal with stressors positively while
enhancing their actual learning (Seyedfatemi et al., 2007;
Yamashita, et al., 2012). Being able to assist the nursing
student with the appropriate interventions that may allow for
positive outcomes of stressful situations in addition to
promoting a process in which to utilize for future events not
only in all aspects of their nursing education and as a graduate
nurse, but in their future. Furthermore, further studies should
be conducted identifying specific coping strategy appropriate
to a certain stressor, thus covering in detail the complexities
of an issue.
Conclusion
Mounting evidence suggests that stress has a detrimental
effect not only on the physio-psycho-social health of the
nursing students but also with their well-being. This review is
considered as the pioneer in the field of nursing. The review is
valuable to nurse educators as this is the first to critically
discuss stress and coping mechanisms among nursing students
during the nursing education process. It demonstrates the need
for more research to link specific coping strategies to nursing
school stressors. Once that link is established, nursing
programs can provide better education and support for
nursing students. In general, students experience moderate
to high levels of stress from various stressors (caring of
patients, assignments and workloads, negative interactions
with staff and faculty, lack of clinical competence, and taking
8 L. J. Labrague et al. J Ment Health, Early Online: 1–10

10. of examinations) during nursing education. The most com-
monly used strategy to deal with and cope with stress was the
problem-solving approach, an approach considered the most
appropriate way of dealing with stress. However, although this
review provided recent empirical data on stress and coping in
nursing students, several methodological weaknesses were
identified such as research design, scale or instruments used,
sample size and sampling methods.
Acknowledgements
The authors would like to thank the support and expertise of
Dr. Dolores Arteche.
Declaration of interest
The authors declare no conflict of interest.
Funding
None.
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