Demographic characteristics
A total of 790 questionnaires were distributed to eligible respondents in the associate nursing degree program and 724 completed questionnaires were returned with an overall response rate of 91.6%. The demographic characteristics of the participants are presented in Table 1. The majority of participants were females (96.7%). Their average age was 19.13 (SD ± 0.42) years and a great majority (79.4%) were in the final year of the degree programme. While more than half of the students (57.6%) reported their sleeping hours as 6–8 hours, 39.8% of the students slept for less than 5 hours per day. The practice areas included Medical Surgical Nursing, Obstetrics Nursing, Paediatrics Nursing, Psychiatric Nursing and Community Nursing.
Table 1
Demography data (N = 724 )
Variable
|
Numbers
|
%
|
Gender
|
|
|
Male
|
24
|
3.3
|
Female
|
700
|
96.7
|
Practice grade
Fourth grade
|
149
|
20.6
|
Fifth grade
|
575
|
79.4
|
Quality sleep (hours)
|
|
|
9–10
|
11
|
1.5
|
6–8
|
417
|
57.6
|
4–5
|
288
|
39.8
|
1–3
|
8
|
1.1
|
Nursing students’ health status
The health status scores among the participants varied from 28 to 139, with higher score indicating worse health status. The average score was 68.40 (SD = 25.75). The worst health status was reported on domains of anxiety and insomnia (Mean: 24.97; SD: ±4.35) and social dysfunction (Mean: 24.31; SD: ±3.26). (Table 2). Based on the overall scores, the health status was deemed to be ‘good’ (scores 28–55) in 35.5% (n = 257) of the participants, moderate (scores 56–83) in 24.6% (n = 178) participants, and poor (Scores ≧ 84) in 39.9% (n = 289) participants. The most common areas reported indicating poor health status were: “Been satisfied with the way you have carried out your tasks” (Mean 2.89; SD ± 1.14) “Been feeling capable of making decisions about things,” (Mean 2.86; SD ± 1.14) “Been managing to keep yourself busy and occupied,” (Mean 2.41; SD ± 1.09) “Been feeling everything is getting on top of you.” (Mean2.77; SD ± 1.21) (Table 3).
Table 2
Students’ health status scores on individual domains
Domain
|
Good
(Scores 28–55)
(35.5%, n = 257)
|
Moderate
(Scores 56–83)
(24.6%, n = 178)
|
Poor
(Scores ≧ 84)
(39.9%, n = 289)
|
Overall
(n = 724)
|
|
M ± SD
|
Range
|
M ± SD
|
Range
|
M ± SD
|
Range
|
M ± SD
|
Range
|
Somatic symptoms
|
10.11 ± 3.36
|
7–22
|
18.33 ± 4.32
|
7–34
|
23.57 ± 3.86
|
16–67
|
17.45 ± 6.74
|
7–35
|
Anxiety and insomnia
|
9.69 ± 3.42
|
7–23
|
19.8 ± 4.42
|
7–30
|
24.97 ± 4.35
|
19–68
|
18.24 ± 7.60
|
7–35
|
Social dysfunction
|
11.05 ± 4.13
|
7–23
|
19.76 ± 4.23
|
9–45
|
24.31 ± 3.26
|
15–35
|
18.47 ± 6.87
|
7–35
|
Severe depression
|
7.77 ± 2.24
|
7–21
|
12.44 ± 5.16
|
7–25
|
20.93 ± 4.35
|
8–35
|
14.17 ± 7.03
|
7–35
|
Table 3
Students’ health status scores on individual items
Health status factor/item
|
M
|
SD
|
Range
|
Item ranking
|
Factor ranking
|
I. Somatic symptoms
|
|
|
|
|
3
|
1. Been feeling perfectly well and in good health?
|
2.71
|
1.09
|
1–5
|
7
|
|
2. Been feeling in need of a good tonic?
|
2.35
|
1.19
|
1–5
|
19
|
|
3. Been feeling run down and out of sorts?
|
2.49
|
1.16
|
1–5
|
12
|
|
4. Been feeling that you are ill?
|
2.71
|
1.15
|
1–5
|
6
|
|
5. Been getting any pains in your head?
|
2.46
|
1.17
|
1–5
|
16
|
|
6. Been getting a feeling of tightness or pressure in your head?
|
2.60
|
1.22
|
1–5
|
11
|
|
7. Been having hot or cold spells?
|
2.14
|
1.08
|
1–5
|
22
|
|
II. Anxiety and insomnia
|
|
|
|
|
2
|
8.Been losing much sleep over worry?
|
2.48
|
1.21
|
1–5
|
14
|
|
9.Been having difficulty in staying asleep once you fall asleep?
|
2.48
|
1.22
|
1–5
|
13
|
|
10.Been feeling constantly under strain?
|
2.74
|
1.24
|
1–5
|
5
|
|
11.Been getting edgy or bad tempered?
|
2.65
|
1.21
|
1–5
|
10
|
|
12.Been getting scared or panicky for no reason?
|
2.41
|
1.19
|
1–5
|
17
|
|
13.Been feeling everything is getting on top of you?
|
2.77
|
1.21
|
1–5
|
4
|
|
14.Been feeling nervous and strung-out all the time?
|
2.69
|
1.25
|
1–5
|
8
|
|
III. Social dysfunction
|
|
|
|
|
1
|
15.Been managing to keep yourself busy and occupied?
|
2.85
|
1.19
|
1–5
|
3
|
|
16.Been taking longer over the things you do?
|
2.69
|
1.19
|
1–5
|
9
|
|
17.Been satisfied with the way you have carried out your tasks?
|
2.89
|
1.14
|
1–5
|
1
|
|
18. Been feeling capable of making decisions about things?
|
2.86
|
1.14
|
1–5
|
2
|
|
19.Been able to enjoy your normal day-to-day activities?
|
2.48
|
1.10
|
1–5
|
15
|
|
20.Been managing to keep yourself busy and occupied?
|
2.41
|
1.09
|
1–5
|
18
|
|
21.Been taking longer over the things you do?
|
2.29
|
1.12
|
1–5
|
20
|
|
IV. Severe depression
|
|
|
|
|
4
|
22.Been thinking of yourself as a worthless person?
|
2.11
|
1.11
|
1–5
|
23
|
|
23.Been feeling that life is entirely hopeless?
|
2.10
|
1.12
|
1–5
|
24
|
|
24.Been feeling that life is not worth living?
|
2.06
|
1.11
|
1–5
|
25
|
|
25.Been thinking of the possibility that you may do away with yourself?
|
1.94
|
1.06
|
1–5
|
26
|
|
26.Been feeling at times that you could not do anything because your nerves were too bad?
|
2.24
|
1.18
|
1–5
|
21
|
|
27.Been finding yourself wishing you were dead and away from it all?
|
1.87
|
1.05
|
1–5
|
27
|
|
28.Been finding that the idea of taking your own life keeps coming into your mind?
|
1.85
|
1.03
|
1–5
|
28
|
|
Overall
|
68.4
|
25.75
|
28–139
|
-
|
-
|
The perceived stress of clinical practice among nursing students
The perceived stress of clinical practice scores ranged from 0–95 points with an average score of 36.65 (SD ± 15.95). Stress was mild (average single-item score, 1 point) in 26.7% (n = 193) of students, moderate (average single-item score, 1.5 points) in 64.5% (n = 467) of students, and moderate to severe (average single-item score > 1.5 points) in 8.8% (n = 64) of students (Table 4). On average, highest scores were reported on domains of stress of ‘taking care of patients’ (Mean:12.83; SD: ±5.14) and the ‘stress from assignments and workload’ (Mean:7.62; SD: ±3.91) ‘teachers and nursing personnel’(Mean:5.90; SD: ±3.47) (Table 4).
Table 4
Areas of stress perceived by students – findings from ANOVA
|
Mild
(Scores 0–29, n = 193)
|
Moderate
(Scores 30–43, n = 467)
|
Moderate to Severe (Scores ≧ 44, n = 64)
|
Overall
(n = 724)
|
p
|
|
M ± SD
|
Range
|
M ± SD
|
Range
|
M ± SD
|
Range
|
M ± SD
|
Range
|
|
Taking care of patients
|
7.51 ± 3.82
|
0–17
|
14.02 ± 3.50
|
5–23
|
20.83 ± 4.91
|
13–48
|
12.83 ± 5.14
|
0–29
|
.00
|
Teachers and nursing personnel
|
2.38 ± 1.84
|
0–8
|
6.54 ± 2.35
|
0–17
|
11.89 ± 3.03
|
5–19
|
5.90 ± 3.47
|
0–19
|
.00
|
Assignments and workload
|
3.47 ± 2.37
|
0–11
|
8.44 ± 2.64
|
3–19
|
14.11 ± 2.44
|
9–20
|
7.62 ± 3.91
|
0–20
|
.00
|
Peers and daily life
|
1.17 ± 1.29
|
0–6
|
3.51 ± 1.84
|
0–9
|
6.72 ± 2.75
|
0–14
|
3.17 ± 2.36
|
0–14
|
.00
|
Lack of professional knowledge and skills
|
2.19 ± 1.52
|
0–6
|
4.70 ± 1.56
|
0–15
|
7 ± 1.38
|
3–10
|
4.22 ± 2.03
|
0–10
|
.00
|
The clinical environment
|
.88 ± 1.14
|
0–4
|
3.24 ± 1.45
|
0–8
|
6.23 ± 1.89
|
2–10
|
2.88 ± 2.04
|
0–10
|
.00
|
Situations that were perceived as most stressful for students were in the area of providing care to patients especially the ‘lack of experience and ability in providing nursing care and in making judgments’, (Mean1.94; SD ± 0.89) ‘inability to reach one’s expectations dealing with challenges arising from the gap between clinical performance and self-expectation’ (Mean1.87; SD ± 0.92,) ‘inability to provide appropriate responses to doctors’, teachers’, and patients’ question’ (Mean1.77; SD ± 0.81,). Worry about grades was also an area of relatively more perceived stress for students (Mean1.76; SD ± 1.08). The domains that were perceived to cause the least stress were the stress from the environment and stress from peers and daily life (Table 5).
Table 5
Sources of stress perceived by nursing students
Stress factor/item
|
M
|
SD
|
Range
|
Item ranking
|
Factor ranking
|
I. Stress from taking care of patients
|
|
|
|
|
1
|
Lack of experience and ability in providing nursing care and in making judgments (Q2)
|
1.94
|
0.89
|
0–4
|
1
|
|
Lack of knowledge about how to help patients with physio-psycho-social problems(Q3)
|
1.74
|
0.89
|
0–4
|
5
|
|
Do not know how to communicate with patients(Q4)
|
1.41
|
0.86
|
0–4
|
13
|
|
Worry about not being trusted or accepted by patients or patients’ family(Q8)
|
1.47
|
0.91
|
0–4
|
11
|
|
Experience difficulties in changing from the role of a student to that of a nurse(Q9)
|
1.12
|
0.85
|
0–4
|
17
|
|
Inability to provide appropriate responses to doctors’, teachers’, and patients’ question(Q10)
|
1.77
|
0.81
|
0–4
|
3
|
|
Inability to reach one’s expectations dealing with challenges arising from the gap between clinical performance and self-expectation (Q11)
|
1.87
|
0.92
|
0–4
|
2
|
|
Unable to provide patients with good nursing care(Q12)
|
1.50
|
0.76
|
0–4
|
9
|
|
II. Stress from teachers and nursing staff
|
|
|
|
|
4
|
Experience discrepancy between theory and practice (Q1)
|
1.62
|
0.89
|
0–4
|
7
|
|
Feel that teachers do not give fair evaluation on students (Q14)
|
0.73
|
0.78
|
0–4
|
26
|
|
Medical personnel lack empathy and are not willing to help(Q17)
|
0.72
|
0.73
|
0–4
|
27
|
|
Do not know how to discuss patients’ illness with teachers, and medical and nursing personnel(Q18)
|
1.12
|
0.85
|
0–4
|
18
|
|
Feel stressed that teacher’s instruction is different from one’s expectations(Q20)
|
1.04
|
0.81
|
0–4
|
19
|
|
Lack of care and guidance from teachers(Q25)
|
0.68
|
0.73
|
0–4
|
28
|
|
Table 5
III. Stress from assignments and workload
|
|
|
|
|
2
|
Worry about bad grades(Q13)
|
1.76
|
1.08
|
0–4
|
4
|
|
Feel that the requirements of clinical practice exceed one’s physical and emotional endurance (Q15)
|
1.34
|
0.88
|
0–4
|
14
|
|
Experience pressure from the nature and quality of clinical practice (Q16)
|
1.70
|
1.09
|
0–4
|
6
|
|
Feel that dull and inflexible clinical practice affects one’s family and social life (Q19)
|
1.49
|
1.05
|
0–4
|
10
|
|
Feel that one’s performance does not meet teachers’ expectations (Q22)
|
1.31
|
0.88
|
0–4
|
15
|
|
V. Stress from peers and daily life
|
|
|
|
|
6
|
Feel that clinical practice affects one’s involvement in extracurricular activities (Q5)
|
0.84
|
1.00
|
0–4
|
24
|
|
Feel pressure from teachers who evaluate students’ performance by comparison (Q21)
|
0.76
|
0.79
|
0–4
|
25
|
|
Cannot get along with other peers in the group(Q23)
|
0.67
|
0.73
|
0–4
|
29
|
|
Experience competition from peers in school and clinical practice(Q24)
|
0.89
|
0.81
|
0–4
|
23
|
|
IV. Stress from lack of professional knowledge and skills
|
|
|
|
|
3
|
Unfamiliar with patients’ diagnoses and treatments(Q6)
|
1.42
|
0.76
|
0–4
|
12
|
|
Unfamiliar with medical history and terms(Q7)
|
1.51
|
0.82
|
0–4
|
8
|
|
Unfamiliar with professional nursing skills(Q26)
|
1.29
|
0.83
|
0–4
|
16
|
|
V. Stress from the environment
|
|
|
|
|
5
|
Feel stressed from the rapid change in patient’s condition(Q27)
|
0.93
|
0.72
|
0–4
|
22
|
|
Unfamiliar with the ward facilities(Q28)
|
0.95
|
0.79
|
0–4
|
21
|
|
Feel stressed in the hospital environment where clinical practice takes place(Q29)
|
1.00
|
0.90
|
0–4
|
20
|
|
Overall
|
36.65
|
15.95
|
0–95
|
---
|
---
|
Correlation between nursing students’ health status and the level of stress
In the unadjusted analysis of liner correlation between health status and perceived stress, health status was highly positively correlated with the level of stress (r = .665, p < .01); the more severe the health problems were, the greater the perceived stress was (Table 6).
Table 6
Adjusted analysis of the correlation of health status with internship stress (N = 724)
|
Average
|
Standard deviation
|
R
|
Health status
|
68.40
|
25.75
|
.665*
|
Internship stress
|
36.65
|
15.95
|
* p < .01. |
A number of factors including health status, practice subject, practice grade, gender, and sleeping hours were adjusted in the multivariate regression analysis. The variables that showed statistically significant associations were general health status, practice subject, practice grade, gender, sleeping hours in particular order. Among all the variables, health status had the most significant correlation to perceived stress (p < .000). Among various practice areas, the areas with significant correlation were Medical Surgical Nursing (p = .002) and Obstetrics and Paediatric Nursing (p = .007). Practice grade (p < .000), gender (p = .013) and sleeping hours (p = .046) also showed significant correlation. In the adjusted analysis, the association between health status remained significant (p < .001; R2 = .50) (Table 7).
Table 7
Multivariate regression analysis of association between individual factors and perceived stress (N = 724)
Independent variable
|
β
|
SE
|
t
|
p
|
Health status
|
.61
|
.018
|
21.25
|
.000
|
Practice subject
|
|
|
|
|
Medical Surgical nursing Practicum
|
.10
|
1.43
|
3.12
|
.002
|
Obstetrics, Pediatricnursing Practicum
|
.08
|
1.01
|
2.71
|
.007
|
Psychiatric, Communitynursing Practicum
|
NS
|
NS
|
NS
|
NS
|
Long-Term care Practicum
|
.004
|
1.36
|
.14
|
.893
|
Practice Grade
|
.15
|
1.12
|
5.36
|
.000
|
Gender
|
.07
|
2.37
|
2.50
|
.013
|
Sleeping hours
|
.06
|
.85
|
2.00
|
.046
|
R2
|
.50
|
|
|
|
Adj R2
|
.49
|
|
|
|
*p < .05. **p < .01. ***p < .001. |
Stress |
|
|
≦ 65.5 > 65.5 |
≦34.5 >34.5 ≦93.5 >93.5 |
≦ 84.5 > 84.5 |
A model for predicting perceived stress of clinical practice among nursing students: findings from the CART analysis
The CART analysis produced a tree model with three branches and five terminal nodes with values predicting perceived stress. The results of the CART analysis are shown in Fig. 1. The most appropriate tree for predicting perceived stress of clinical practice consisted of eight nodes and five terminal nodes. On the basis of the minimum Gini improvement measure of perceived stress, we found that general health status was the best predictor in the first layer. The general health status score, predicted score for perceived stress, and population size respectively were < 34.5, 17.06, and 104 at node 3; <34.5, 31.63, 210 at node 4; ≦84.5, 38.02, and 170 at node 7; >84.5, 44.19, and 130 at node 8; and > 93.5, 53.75, and 110 at node 6. Those who were in excellent (GHQ-28 score ≤ 34.5) or good (GHQ-28 score > 34.5–<84.5) health status, reported mild or moderate stress with a health status score of 84.5 as the point of transition to severe stress. When health status score was greater than 84.5, perceived stress was at a severe or extremely severe level, indicating that health status was the most predictive factor (Fig. 1).