significance of the study in nursing research

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Research benefits from nursing insight.

The Johns Hopkins Clinical Research Network’s nursing collaboration brings clinical nurses into the research realm.

How can novice nurses best learn about the difficulties that older LGBTQ adults face in dealing with the health care system?

Suzanne Dutton, a geriatric advanced practice nurse at Sibley Memorial Hospital, decided to screen Gen Silent , a 2010 documentary that follows six LGBTQ seniors who are trying to decide whether to be open about their sexuality while navigating options in long-term care.

Afterward, according to a 2021 study she published in Nurse Education Today , Dutton found a statistically significant increase in knowledge and inclusive attitudes among the 379 nurses who watched the film.

“If we’re not showing these things — that LGBTQ people had to be closeted and that homosexuality was classified as a pathological disease until 1974 — nurses won’t fully understand their health care challenges and emotional hardships,” Dutton says.

Her study was one of several conducted within the Johns Hopkins Clinical Research Network (JHCRN) nursing research collaboration. The network, founded in 2009, connects physician-scientists and staff members from Johns Hopkins Medicine with community health care systems for multisite clinical research. The nursing portion, started in 2014, engages nurses in research that addresses ways to improve working conditions for nurses as well as outcomes for patients.

“Nursing research is looking at ways to overcome barriers in health care, refine education, promote cultural sensitivity and achieve resilience in nursing,” says Melissa Gerstenhaber, the JHCRN research nurse navigator who started the nursing collaboration. “There are plenty of reasons to study nurses themselves because they’re the ones who are really out there in the grind.”

Along with Johns Hopkins hospitals, partners in the network include Luminis Health, TidalHealth, Reading Hospital, George Mason University and WellSpan. The network offers a triple win: The research benefits from a diverse pool of subjects, the partner hospitals benefit by gaining access to cutting-edge treatments and ideas, and patients benefit by receiving those new treatments at their local hospitals.

In addition to engaging in multisite studies, the research collaboration helps nurses stay abreast of emerging nursing and interdisciplinary research; provides peer review on grant proposals, abstracts and publications; serves as a think tank for future research ideas through sharing possible resources, funding options, journals and conferences; and helps mentor clinical nurses and share best practices to engage them in research. So far, about two dozen nurses have taken part in research throughout the network.

Topics of other published studies from the nursing collaboration include how to engage nurses in research, and burnout and resilience in health care workers (see sidebar).

Dutton’s LGBTQ study won the systemwide award for outstanding research project at the 2021 SHINE Conference (the Johns Hopkins Health System Showcase for Hopkins Inquiry and Nursing Excellence).

Gerstenhaber mentions an upcoming study by Rebecca Wright, an assistant professor and director for diversity, equity and inclusion in the school of nursing, who has received a $10,000 grant from the Dorothy Evans Lyne Fund to study how health care professionals can partner with Puerto Rican and Korean American communities to facilitate culturally sensitive decision-making at the end of life. Additionally, a follow-up looking at the role of mid-level managers in research — led by principal investigator Mary Jo Lombardo, clinical education program manager at Howard County General Hospital — should be published soon.

Adrian Dobs , director of the JHCRN and a professor of medicine at the Johns Hopkins University School of Medicine, says the nursing collaboration is an important part of the network. She notes that because nurses are highly involved in caring for patients, they often have more interactions with them than doctors do.

“Nurses see things and hear things that doctors don’t, which affects conditions and diseases,” Dobs says. “Nursing care needs to be studied. We’re excited that we have this opportunity of working with groups of nurses at many medical institutions.”

Nurses interested in learning more can contact Melissa Gerstenhaber at [email protected] .

Related Reading

Alliance expands research potential.

The Johns Hopkins Clinical Research Network connects investigators to patients in other hospitals.

Making Their Voices Heard

Revised nursing governance structure helps bedside nurses at The Johns Hopkins Hospital brainstorm about problems and possible solutions.

The importance of nursing research

Affiliation.

• 1 Medical College of Georgia, Georgia Prevention Institute, HS-1755, Augusta, GA 30912, USA. [email protected]
• PMID: 19297969
• PMCID: PMC3677814
• DOI: 10.3928/01484834-20090301-10

Nursing research has a tremendous influence on current and future professional nursing practice, thus rendering it an essential component of the educational process. This article chronicles the learning experiences of two undergraduate nursing students who were provided with the opportunity to become team members in a study funded by the National Institute of Nursing Research. The application process, the various learning opportunities and responsibilities performed by the students, and the benefits and outcomes of the experience are described. The authors hope that by sharing their learning experiences, more students will be given similar opportunities using the strategies presented in this article. Nursing research is critical to the nursing profession and is necessary for continuing advancements that promote optimal nursing care.

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• Education, Nursing, Baccalaureate / organization & administration*
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‘Let’s hear it for the midwives and everything they do’

STEVE FORD, EDITOR

• You are here: Hospital nurses

How research can improve patient care and nurse wellbeing

07 September, 2020

Research evidence can inform the delivery of nursing practice in ways that not only improve patient care but also protect nurses’ wellbeing. This article, the first in a four-part series, discusses four studies evaluating interventions to support the delivery of compassionate care in acute settings recommended by the findings of the Francis Inquiry report

This article, the first in a four-part series about using research evidence to inform the delivery of nursing care, discusses four studies that were funded following the two Francis inquiries into care failings at Mid Staffordshire NHS Foundation Trust. Each study evaluated an intervention method in an acute hospital setting that aimed to improve patient care and protect the wellbeing of nursing staff; these included a team-based practice development programme, a relational care training intervention for healthcare assistants, a regular bedside ward round (intentional rounding), and monthly group meetings during which staff discussed the emotional challenges of care. The remaining articles in this series will explore the results of the studies and how they can be applied to nursing care during, and after, the coronavirus pandemic.

Citation: Bridges J et al (2020) Research that supports nursing teams 1: how research can improve patient care and nurse wellbeing. Nursing Times [online]; 116: 10, 23-25.

Authors: Jackie Bridges is professor of older people’s care, University of Southampton; Ruth Harris is professor of health care for older adults, King’s College London; Jill Maben is professor of health services research and nursing, University of Surrey; Antony Arthur is professor of nursing science, University of East Anglia.

• This article is open access and can be freely distributed
• Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
• Click here to see other articles in this series

Introduction

When asked what would make their working life easier or how they could be better supported to deliver the care to which they aspire, nurses most often say “better staffing”, according to a body of research evidence linking nurse staffing with staff wellbeing, care quality and patient outcomes (Bridges et al, 2019; Aiken et al, 2012). What is not always given much attention by nursing teams and managers is the ‘taken-for-granted’ context in which individual nurses work – the way nursing care is organised, the learning opportunities available to the team and the attention paid to staff wellbeing. It may be possible to change these to support nurses and the care on which they lead and deliver, but opportunities may be missed to think differently about them. The evidence base is growing in this area but does not always reach those nurses who are managing and delivering care.

This is the first in a series of four articles highlighting nursing research findings that can directly inform the management and delivery of nursing care in acute hospital settings. The articles highlight four studies that were funded after publication of Francis’ (2013; 2010) reports on the independent and public inquiries into care failings at Mid Staffordshire NHS Foundation Trust. However, as this series will argue, the inquiries’ findings have relevance for nursing practice during, and beyond, the coronavirus pandemic, as nursing teams regroup and reset what they do in response to a rapidly changing care environment.

Using research evidence to improve patient care

Change in the complex, adaptive system of healthcare is usually incremental, rather than transformative, and it is unusual for events to lead to a ‘phase transition’, in which radical and transformative change occurs (Braithwaite et al, 2017). Arguably the coronavirus pandemic has stimulated a phase transition in healthcare (and in wider society), disrupting certainties about healthcare and how it should, and can, be delivered. As we move through this system shock, there are opportunities to think about new ways of working; however, it is also important to retain the valuable knowledge gained from other events that have affected the healthcare system.

The lessons learned from the care failings at Mid Staffordshire NHS Foundation Trust during the late 2000s and the inquiries that followed had an important impact on hospital nursing and the wider system, stimulating reflection, innovation and research to improve nursing care quality. The evidence generated as a result, some of which is explained below, is a reminder of aspects of care that are at risk of being overlooked during the current pandemic. These include the:

• Complexities of caring for older people;
• Importance of nurses’ relational work;
• Importance of nursing care, especially when there is no surgical/medical ‘cure’.

In the absence of a cure for Covid-19, nursing is at the forefront of the supportive care needed by people with the most severe symptoms. As such, it is important to draw on evidence that supports good nursing care and how best to support nurses’ wellbeing, which can be negatively affected by their caring work.

Research studies investigating intervention

The research world responded to the Francis inquiries: the National Institute for Health Research (NIHR) funded several studies to inform policy and practice improvements in this area. The research delivered through four such studies (Box 1) – each of which was led by an author of this article – is summarised below.

Box 1. The four studies

Creating Learning Environments for Compassionate Care (CLECC)

This study trialled a pilot intervention focusing on team building and understanding patient experiences. Participants felt it improved their capacity to be compassionate.

Chief investigator: Jackie Bridges

Full study report available here

Older People’s Shoes

This study trialled an interactive programme to help healthcare assistants (HCAs) get to know older people and understand the challenges they face. The programme was well received by participants, especially as HCAs’ training needs are often overlooked.

Chief investigator: Antony Arthur

Intentional Rounding

This study aimed to evaluate how intentional rounding works in diverse ward and hospital settings. Participants expressed concern that rounding oversimplifies nursing, and favoured a transactional and prescriptive approach over relational nursing care.

Chief investigator: Ruth Harris Full study report available here

Schwartz Center Rounds

This study aimed to understand the unique features of Schwartz Rounds, comparing them with 11 similar interventions. Attending rounds increased staff members’ empathy and compassion for colleagues and patients, and improved their psychological health.

Chief investigator: Jill Maben

Study 1: Creating Learning Environments for Compassionate Care

Bridges et al (2018) investigated the feasibility of implementing a team-based practice development programme into acute care hospital settings. Under the Creating Learning Environments for Compassionate Care (CLECC) programme, all registered nurses and healthcare assistants (HCAs) from participating teams attended a study day, with a focus on team building and understanding patient experiences. A senior nurse educator supported the teams to try new ways of working on the ward, including holding regular, supportive discussions on improving care. Each ward manager attended learning groups to develop their compassionate care leadership role, and two team members received additional training in carrying out observations of care and feeding back to colleagues.

The programme was piloted on four wards in two English hospitals, with two control wards continuing with business as usual. Researchers interviewed staff and observed activities related to the project to understand whether these could be easily put into practice and whether changes were needed. They also tested evaluation methods, including ways to measure compassion and ensuring enough older patients could be recruited to a future study.

The study found that the CLECC programme can be made to work with nursing teams on NHS hospital wards and that staff felt it improved their capacity to be compassionate. Researchers also learned they could improve the programme to help staff continue using it, for example, by helping senior nurses to understand their role in supporting staff with this.

Study 2: Older People’s Shoes

Arthur et al (2017) studied the feasibility of a relational care training intervention for HCAs to improve the relational care of older people in acute hospitals. They initially conducted a telephone survey of acute NHS hospitals in England to understand what training HCAs received. They undertook group interviews with older people and individual interviews with HCAs and staff working with them to establish what participants thought should be included in HCA training. Training was highly variable and focused on new, not existing, staff; relational care was not a high priority.

In response to their findings, the study team designed and produced an innovative interactive training programme called Older People’s Shoes, which aimed to encourage HCAs to consider how to get to know older people and understand the challenges they face. A train-the-trainer model was used to allow the intervention to be viable beyond the testing sites. To see whether they could formally test this new training, the team conducted a pilot cluster-randomised trial in 12 wards from three acute hospitals; it concluded that a larger study to examine whether changes in patient outcomes could be observed would be challenging, but possible.

Older People’s Shoes was well received by participants. This was particularly so for the HCAs, whose training needs were often overlooked or restricted to mandatory requirements, where the focus is almost exclusively on safety.

Study 3: Intentional Rounding

Originating in the US, intentional rounding is a timed, planned intervention that aims to address fundamental elements of nursing care through a regular bedside ward round. Harris et al’s (2019) study aimed to explain which aspects of intentional rounding work, for whom and under what circumstances. It aimed to do this by exploring how intentional rounding works when used with different types of patient, by different nurses, in diverse ward and hospital settings, and whether and how these differences influence outcomes. The study methods included:

• An evidence review to create a theory of why intentional rounding may work;
• A national survey of how intentional rounding had been implemented;
• A case study evaluation exploring the perspectives of senior managers, health professionals, patients and carers;
• Observations of intentional rounding being undertaken;
• An analysis of costs.

The national survey found that 97% of NHS trusts had implemented intentional rounding, although with considerable variation: fidelity to the intentional rounding protocol was observed to be low. All nursing staff thought intentional rounding should be tailored to individual patient need and not delivered in a standardised way. Few felt intentional rounding improved either the quality or frequency of their interactions with patients; they perceived the main benefit of intentional rounding to be the documented evidence of care delivery, despite concerns that documentation was not always reliable. Patients and carers valued the relational aspects of communication with staff, but this was rarely linked to intentional rounding. It is suggested these results should feed into a wider conversation and review of intentional rounding.

Study 4: Schwartz Center Rounds

These were developed in the US to support healthcare staff to deliver compassionate care by helping them to reflect on their work. Schwartz Rounds are monthly group meetings, in which staff discuss the emotional, social and ethical challenges of care in a safe environment. The number of organisations hosting Schwartz Rounds has increased markedly over recent years.

Maben et al (2018) conducted a study to evaluate Schwartz Rounds and understand how the system works. The study used mixed methods, including:

• An evidence review to understand the unique features of Schwartz Rounds;
• A comparison with 11 other similar interventions, such as action learning sets;
• A national survey of 48 staff running Schwartz Rounds in 46 organisations, using telephone interviews to discuss how these had been implemented;
• A survey of 500 staff in 10 organisations to examine how Schwartz Rounds affect work engagement and wellbeing;
• A case study evaluation investigating the perspectives of people who shared their stories at Schwartz Rounds (panellists), audience members who listened and contributed, facilitators, and people who did not attend.

The researchers also observed preparation meetings, actual Schwartz Rounds and steering group meetings to determine how the rounds worked, and under which circumstances they worked optimally.

Their survey found psychological health improved in those attending Schwartz Rounds but not in those who did not attend. Participants described Schwartz Rounds as interesting, engaging and supportive. How they were run varied, creating different levels of trust and safety, and who attended varied – frontline staff found attendance difficult.

It was concluded that Schwartz Rounds are a ‘slow intervention’ that increases its impact over time and creates a safe, reflective space for staff to talk together confidentially. In the staff observed, attending Schwartz Rounds increased their empathy and compassion for colleagues and patients, supported them in their work and helped them make changes in practice.

Applying research findings

The findings from the above studies not only tell us about the impact of each of these four interventions, but also highlight the changes required to better support nursing teams to deliver high-quality care. Written by nursing professors, who were the chief investigators on each of these studies, this series will bring together the findings from the four studies to:

• Highlight the impact of care organisation and related learning opportunities on nurses and on care delivery, as well as the need for staff wellbeing interventions to support nurses;
• Signpost to practical, evidence-based ways in which individuals and teams can improve support for nurses and nursing care;
• Pose questions that individuals and teams can ask in the context of the coronavirus pandemic to optimise support for nurses and care.

The series is part of a collaboration funded by the NIHR to bring the findings of the individual studies to a wider audience; more details about the collaboration and the individual projects can be found at go.soton.ac.uk/cn4. This work will culminate in an event, due to be held in spring 2021, to engage a range of stakeholders in considering how nursing policy and practice should respond to the findings. Readers interested in finding out more can register their interest at Bit.ly/NursingTeams.

The series aims to provide evidence to support nursing teams as they work to recover from the coronavirus pandemic, review ways of working to retain the better areas of nursing care that existed before it took hold and, also, to embrace any lessons learned through their experiences during the pandemic.

• Care failings at Mid Staffordshire NHS Foundation Trust generated the need for evidence about how to improve patient care
• In response to this, four studies have each investigated a different intervention method in acute hospital settings
• The studies’ findings highlight changes that can help nursing teams to deliver high-quality care and protect nurses’ wellbeing

Also in this series

• Learning opportunities that help staff to deliver better care
• Research that supports nursing teams, part 3 of 4
• Nursing interventions that promote team members’ psychological wellbeing
• The four featured studies were funded by NIHR Health Services and Delivery Research programme. The views and opinions expressed are those of the authors and do not necessarily reflect those of the Health Services and Delivery Research programme, NIHR, NHS or the Department of Health and Social Care.

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Interpreting statistical significance in nursing research

Don’t let p values distract you from scientific reasoning..

• P values are useful to report the results of inferential statistics, but they aren’t a substitute for scientific reasoning.
• After a statistical analysis of data, the null hypothesis is either accepted or rejected based on the P value.
• Reading statistical results includes summary statistics (descriptive statistics), test statistics, and P value with other considerations such as one-tailed or two-tailed test, and sample size.

Improper interpretation of statistical analysis can lead to abuse or misuse of results. We draw valid interpretations when data meet fundamental assumptions and when we evaluate the probability of errors. Statistical analysis requires knowledge for proper interpretation, which relies on considering the null hypothesis, two-tailed or one-tailed tests, study power, type I and type II errors, and statistical vs. clinical significance. In many domains, including nursing, statistical significance ( P value) serves as an important threshold for interpretation, whether the result is statistically significant or not. However, statistical significance frequently is misunderstood and misused.

Statistical test components

In empirical research, all statistical tests begin with the null hypothesis and end with a test statistic and the associated statistical significance. A test of statistical significance determines the likelihood of a result assuming a null hypothesis to be true. Depending on the selected statistical analysis, researchers will use Z scores, t tests, or F tests. Although three methods exist for testing hypotheses (confidence intervals [CIs], P values, and critical values), essentially the P value serves as the significance level. Many researchers consider P values the most important summary of an inferential statistical analysis.

Null hypothesis

Before conducting a study, researchers propose a null hypothesis, which begins with an initial idea they want to demonstrate. It guides the statistical analysis and predicts the direction and nature of study results. Traditionally, a null hypothesis proposes no difference between two variables being studied or the characteristics of a population. An alternative hypothesis states a result that’s either not equal to, greater than, or less than the null hypothesis.

Two-tailed test vs. one-tailed test

Researchers commonly check a null hypothesis or statistical significance using a two-tailed test, which postulates that the sample mean is equal or unequal to the population. A one-tailed test postulates that the sample mean is higher or lower than the population mean. Nursing researchers rarely use a one-tailed test because of the consequences of missing an effect. (See Different distribution results .)

Study power and type I/type II errors

The possibility of error exists when testing a hypothesis. Type I errors (false alarms) occur when we reject a null hypothesis that’s true. Type II errors (misses) occur when we accept a null hypothesis that’s false. Sample size can influence the power of the study. For example, even small treatment effects can appear statistically significant in a large sample.

The alpha (α)—the probability of a type I error—refers to the likelihood that the truth lies outside the confidence interval (CI). The smaller the α, the smaller the area where we would reject the null hypothesis, which reduces the chance that will occur. The most widely acceptable α cutoff in nursing research is 0.05. Keep in mind that the confidence level and α are analogous. If the α=0.05, the confidence level is 95%. If α=0.01, the confidence level is 99%.

Confidence interval

A CI provides an idea of the range within which a value might occur by chance. It indicates the strength of the estimate by providing a range of uncertainty. Frequently, researchers use CIs without a dichotomous result of the P value. Consider the following example: On a scale between 0 and 10, patients with an advanced illness reported an average pain score of between 4.1 and 6.3 (95% CI: 4.1 to 6.3). With a 95% CI, researchers risk being wrong 5 out of 100 times.

Statistical vs. clinical significance

Statistical significance indicates the study results’ confidence in probability, while the clinical significance reflects its impact on clinical practice. Measures of statistical significance quantify the probability that a study result is due to chance rather than a real treatment effect. On the other hand, clinical significance indicates the magnitude of the actual treatment effect or impact in nursing practice.

Consider this example: Researchers compare two groups (exercise group and diet group). The mean body weight of subjects after treatment with exercise is 1 pound lower than after treatment with diet. The difference between these groups could be statistically significant, with a P value of <0.05. However, the clinical implications of a 1 pound weight loss wouldn’t be clinically significant. In this example, the mean weight—172 pounds (exercise group) vs. 173 pounds (diet group), P =0.04—is statistically significant . The 0.04 P value means only a 4% chance exists that this observed weight difference occurred randomly. However, the clinical significance of a 1 pound difference between the groups would be considered small and not clinically significant.

The results section of a quantitative research study report includes names of statistical tests, the value of the calculated statistics, and the statistical significance ( P value). After a statistical analysis of data, the null hypothesis is either accepted or rejected based on the P value. For example, if a report indicates a significant finding at the 0.05 probability level (α=0.05), the findings might have an error 5% of the time (only 5 out of 100) and a 95% confidence that the results aren’t erroneous after repeated testing. (See P value examples.)

Study example: Reading results and tables

Use the mean to understand the center of the data. Most statistical analyses use the mean and/or median for a central tendency. Also, use the standard deviation (SD) to understand how widely spread the data are from the mean. As shown in Table 2, the mean of pre-intervention pain is 7.2, while the mean of post-intervention pain is 4.6. The SD in pre-intervention pain is 1.4, and the SD in post-intervention pain is 1.8. A higher SD value indicates a greater spread in the data.

Table 2—The mean and SD of pre- and post-intervention pain for 30 patients

Table 3 shows a mean difference between pre- and post-intervention pain of 2.5667. Based on the t-test results, the t score is 7.92. The confidence interval (CI) is 95% for the mean difference, with pre- and post-intervention pain scores ranging from 1.41 to 2.39.

Table 3—Paired samples t-test of change score

95% CI of the difference

Next, find the associated P values

• If P <α (0.05), reject the H 0 and accept the H α .
• If P >α (0.05), accept the H 0 .

In this example, P <0.001, which means the Ho can be rejected. We accept the H α that the mean post-intervention pain score is significantly different from the mean pre-intervention pain score.

Interpreting statistical results

Reading and interpreting statistical results includes summary statistics (descriptive statistics), test statistics, and P value with other considerations such as one-tailed or two-tailed test, sample size, and multiple comparisons. We must not only understand the decision to accept or reject a hypothesis based on a test used, but also understand the descriptive statistics and other considerations such as normality and equal variance. For complex statistics, tables provide the most effective way to view the results.

Rely on scientific reasoning

Quantitative nursing research uses a testing hypothesis in decision making. P values are useful for reporting the results of inferential statistics, but we must be aware of their limitations. The P value isn’t the probability that the null hypothesis is true but the probability of the test statistics against a null hypothesis. It measures the compatibility of data with the null hypothesis but can’t reveal whether an alternative hypothesis is true. Also keep in mind that the 0.05 significance level is merely a convention. Researchers commonly use it as a threshold whether it’s statistically significant or not.

P values were never intended as a substitute for scientific reasoning. All results should be interpreted in the context of the research design (sample size, measurement validity or reliability, and study design rigor).

Joohyun Chung is a biostatistician and assistant professor at the University of Massachusetts Elaine Marieb College of Nursing in Amherst.

American Nurse Journal. 2023; 18(2). Doi: 10.51256/ANJ022345;

Key words: P value,  statistical significance, significance level

Andrade C. The P value and statistical significance: Misunderstandings, explanations, challenges, and alternatives. Indian J Psychol Med. 2019;41(3):210-5. doi:10.4103/IJPSYM.IJPSYM_193_19

Cook C. Five per cent of the time it works 100 per cent of the time: The erroneousness of the P value. J Man Manip Ther. 2010;18(3):123-5. doi:10.1179/106698110X12640740712257

Heavey E. Statistics for Nursing: A Practical Approach. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2018.

Houser J. Nursing Research: Reading, Using, and Creating Evidence . 4th ed. Burlington, MA: Jones & Bartlett Learning; 2018.

Ioannidis JPA. The importance of predefined rules and prespecified statistical analyses: Do not abandon significance. JAMA . 2019;321(21):2067-8. doi:10.1001/JAMA.2019.4582

Polit DF, Beck CT. Essentials of Nursing Research: Appraising Evidence for Nursing Practice . 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2021.

Ranganathan P, Pramesh CS, Buyse M. Common pitfalls in statistical analysis: Clinical versus statistical significance. Perspect Clin Res . 2015;6(3):169-70. doi:10.4103/2229-3485.159943

Wasserstein RL, Lazar NA. The ASA statement on p -values: Context, process, and purpose. Am Stat . 2016;70(2):129-33. doi:10.1080/00031305.2016.1154108

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Nursing research: A marriage of theoretical influences

Kari toverud jensen.

1 Oslo Metropolitan University, Oslo, Norway

Associated Data

The aim is to examine PhD theses in nursing science, their purpose or aim and the theoretical approaches and methods employed. The study seeks to examine how such theses may be categorized, what they study, what theoretical approaches they employ and, in particular, to what degree nursing theory is employed as a current theoretical approach.

This study has a descriptive qualitative design.

This study complied with the Standard for Reporting Qualitative Research (SRQR). Data were collected from 61 PhD theses in nursing science published from 1994–2015, at University of Edinburgh.

Twenty of the PhD theses used theoretical approaches with a sociological perspective and 12 used a psychological perspective. Eighteen of the PhD theses were based on theoretical approaches from philosophy, ethics, pedagogy, medicine or biology as a primary perspective. Nursing theories, in their conventional definition, have a limited presence in the theses examined.

1. INTRODUCTION

Nursing as a profession is changing as other health professions work with and alongside nurses in practice, and patients' knowledge levels have improved. The number of nursing scientists has increased, and research knowledge and skills have improved. Nursing research happens in an increasingly diverse research community with colleagues from other disciplines, often in an international context. In an interdisciplinary environment, the theoretical basis of nursing, as opposed to other disciplines, may be obscured. Nursing research plays a role in developing the theoretical basis of nursing, but this may not be explicit in the way nursing research is conducted.

2. BACKGROUND

As described by Alligood ( 2013 ), a result of the recognition of nursing as an academic field of study is that nursing theories have become more important in nursing science. However, what is the prevalence of nursing theories in nursing science? A literature study by Bond et al. ( 2011 ), looking at articles from seven leading nursing journals, found that 21% of the articles used nursing theory. In her review of US doctoral dissertation abstracts in nursing (2000–2004), Spear ( 2007 ) found that less than one‐third referred to nursing theories or theory development in their abstracts. About 45% referred to non‐nursing theory, with psychosocial theories the most prevalent. Lundgren, Valmari, and Skott ( 2009 ) found that dissertations in Nordic countries completed in 2003 were more likely to have nursing practice as their core, while “nursing concepts and theories” (p. 413) received less attention.

However, beyond the studies mentioned, few have been preoccupied with the theoretical approaches in nursing science. Heyman ( 1995 ) has conducted a study of Swedish nursing and caring research across 65 doctoral theses written by nurses from 1974–1991. She found that the researchers had been inspired by different sciences, belonging to at least one of the two divergent traditions, either biomedical research or the social sciences. The study indicates heterogeneity in theoretical conditions, methodologies, rationales and structures across the PhD theses studied. Yarcheski, Mahon, and Yarcheski ( 2012 ) concluded, in a study of research published in scientific nursing journals, that there was a trend towards less theoretically oriented research and that “the study of psychological variables has dominated the last 20 years (1990–2010) of nursing research” (p. 1,120). In addition, Yarcheski and Mahon ( 2013 ) concluded, in a study of characteristics of quantitative nursing research between 1990–2010, that while quantitative nursing research in general could be defined as multidisciplinary, the discipline of psychology dominated throughout the research literature. Larsen and Adamsen ( 2009 ) studied the emergence of Nordic nursing research. They found three distinct positions operating in nursing research: a clinical and applied position closely connected to clinical contexts or practices, a profession and knowledge position focused on frameworks of knowledge and its dissemination and a theoretical and concept position. The theoretical and conceptual positions were used to describe, explain and interpret practice.

After the 1980s, the number of PhD graduates in nursing has increased worldwide. Doctoral theses are an important source in the interpretation of the development in most sciences. Accordingly, the production of PhD dissertations is crucial for nursing science, as well as the building of a body of knowledge important for education, clinical practice and patient outcomes. In this study of nursing science, I have selected data from doctoral theses in nursing from the University of Edinburgh because this university is of special interest for European nursing as it was one of Europe's first universities to introduce nursing science as an academic discipline in their academic body. The university has a long history and decades of influence on nursing research both in the UK and in Europe. It has been educating doctoral candidates in nursing science since 1959 and established, in 1972, the first professorship in nursing studies in Europe (Anderson, Lynch, & Phillipson, 2003 ). Nursing studies at the University of Edinburgh are, as of 2002, located in the School of Health in Social Science; until 2002, the studies were located in the Faculty of Social Sciences (ibid), which may account for the close relationship with the social sciences. An interesting distinction in theoretical approaches is the one between the social sciences and the biomedical sciences (Heyman, 1995 ) and how the different PhD theses shape the field of nursing, through nursing research and theoretical approaches.

In order to understand the implementation of a scientific approach to nursing, PhD theses have in small‐scale been studied and we lack this type of empirical study also from the UK. The aim of this paper is to examine PhD theses in nursing science, their purpose or aim and the theoretical approaches and methods employed. The study seeks to examine how such theses may be categorized, what they study, what theoretical approaches they employ and, in particular, to what degree nursing theory is employed as a current theoretical approach. Nursing theory has been a contested concept. Meleis ( 2012 ) emphasizes that the “multiple use of concepts to describe the same set of relationships has resulted in more confusion” (p. 29). To meet this challenge, the present study will examine the use of the concept “nursing theory” as what the PhD researchers define as content.

This study has a descriptive qualitative design, with PhD theses in nursing science as data sources. The data underwent analysis, inspired by Braun and Clarke ( 2006 ), Hsieh and Shannon ( 2005 ) and Heyman ( 1995 ).

3.1. Method

Data were collected from 61 PhD theses in nursing science published from 1994–2015. The number of PhD theses represents the total number completed during the period in nursing studies at University of Edinburgh. A total of 101 doctoral theses have been submitted from 1959–2015. The decision to include PhD theses from 1994–2015 resulted in a convenience sample reflecting the field of nursing research following the British “Project 2000: a new preparation for practice” (Fawcett, Waugh, & Smith, 2016 ). This study complied with the Standard for Reporting Qualitative Research (SRQR; O'Brien, Harris, Beckman, Reed, & Cook, 2014 ; File S1 ).

3.2. Data analysis

The coding of texts is inspired by Braun and Clarke's ( 2006 ) thematic analysis involving identifying, analysing and reporting patterns in data. While such an analysis may be inductive or deductive, in this study the analysis is deductive in nature. In the first phase, the PhD theses' abstracts were read, followed by a reading of sections of the thesis, such as summary, background and the theory chapter. In the second phase, the PhD theses were systematically analysed by applying three categories to the collected data: the field of study, the aim/purpose of the study and the research methodology. The summative content analysis, inspired by Hsieh and Shannon ( 2005 ), was used to identify and quantify the concept “nursing theory(ies)”.

The third phase involved the coding, inspired by Heyman's ( 1995 ) characteristics of the affiliation to different disciplines' perspectives, in the theoretical approaches or the field of study of the theses. Heyman identified how nursing researchers have studied the human being from many perspectives, including biological and medical, psychological, sociological, organizational and ethical (as a cultural perspective), in addition to pedagogical perspectives. To identify the theoretical perspective or field of study, information from PhD theses, such as use of concepts, models, theories and references to theorists, was collated in a data matrix and structured. The matrix also recorded author, year, title, aims, research questions, findings and type of PhD thesis (monograph or articles). The data, related to theory, models and concepts, as well as references to theorists, were compiled and classified. In the fourth phase, the collected data were reviewed multiple times in order to define the theoretical approaches of the dissertations. Most of the theses' theoretical approaches were obvious and some used multiple approaches. As an example, McGrath's ( 2006 ) PhD thesis, using both sociological theories of identity and psychology, is described in Table ​ Table1, 1 , whereas the main approach is identified as sociological in accordance with the phases described above. Data collection took place through the Centre of Research Collection, University of Edinburgh, from October 2015–April 2016.

PhD theses: aim, theoretical approach, method and use of nursing theory

Use of NT (how many times the concept nursing theory is used in the PhD text not included reference lists), — refer to “not access” on internet databases.

3.3. Ethical approval

Investigating one's peers' research work is important and requires curiosity, interest and respect for other perspectives. I have not changed the candidates' names but have presented them as official literature sources. All readers may therefore check the PhD theses used in this study to assess how they have been treated, analysed and interpreted. This study is approved by the Norwegian Centre for Research Data, project number 51425.

All 61 PhD theses examined were written as monographs, which is an atypical form compared with the Nordic countries (Larsen & Adamsen, 2009 ), where article‐based PhD theses make up the vast majority. Twenty of the PhD theses used theoretical approaches with a sociological perspective and 12 used a psychological perspective. Eighteen of the PhD theses were based on theoretical approaches from philosophy, ethics, pedagogy, medicine or biology as a primary perspective. Two PhD theses used a theoretical approach with a cultural or linguistic perspective, and the organizational perspective was used by seven PhD theses. An “other” category was created to accommodate the theses that did not fit into any established category. “Others” represented just two PhD theses, one using nursing theories of spiritual care and another exploring historical sources. The PhD theses thematically described, investigated, explored, uncovered, examined, compared, identified, determined, provided, created, developed, generated, extended, measured or contributed to advanced understanding of the challenges faced by patients, the changes associated with illness as disease, sickness and experience and how nurses can help, intervene and alleviate; what nurses and nurse students do when they are nursing and preparing for nursing; and the interaction between patients and nurses.

The Internet and the search function were helpful in examining the use of the concept «nursing theory» in the PhD theses. Of the 61 PhD theses examined, 54 were available on the Internet and were included in this concept search (7 March 2018; https://www.era.lib.ed.ac.uk/ ). In the 54 accessible PhD theses, the concept “nursing theory/theories” was referred to by 13 authors. Five theses referred to the concept more than once. In addition, one thesis used “theory of caring” as one of the theoretical approaches and mentioned it 11 times (Frei, 2005 ). Most of the theses used theoretical approaches based on non‐nursing disciplines (Table ​ (Table1). 1 ). Post‐2005, nursing theory is referred to in only two of 26 theses accessible online (Table ​ (Table2 2 ).

Summarizing through the years; field of study, methods and references to nursing theory

Qualitative research methods were the most commonly used methodologies (43 of 61 PhD theses used qualitative methods; Table ​ Table2). 2 ). Prior to 2000, the dissertations were inspired more by organizational and psychological theoretical approaches and showed more diversity in the use of methods compared with after 2000, when the use of sociological and philosophical approaches increased, as did the extensive use of qualitative methods. The 5‐year period preceding 2015 shows a trend of a greater use of mixed methods.

5. DISCUSSION

This study reveals that different scientific disciplines, traditions and abstraction levels informed the PhD theses we examined. Only a few of the PhD theses referred to nursing theory and even fewer used it as their theoretical approach, or as part of the theoretical approach (Table ​ (Table1; 1 ; Everingham, 2012 ; Frei, 2005 ; Grosvenor, 2005 ; Hogg, 2002 ; Rukholm, 1999 ). Most authors used theories based in disciplines other than nursing as theoretical approaches for studying their topic. Risjord ( 2011 ) claims that “it is a mistake to suppose that a theory is either a nursing theory or a non‐theory; disciplines do not own theories” (p. 517). McEven and Wills ( 2014 ) discuss the use of shared or borrowed theories used by nurse researchers and tried to identify what the application of different theories means for nursing. They argue that use of theory offers structure and organization to nursing knowledge and promotes rational and systematic practice and make nursing practice more purposeful, coordinated and less fragmented. Meleis ( 2012 ) brings in another point of view when she states that “all theories used in nursing to understand, explain, predict, or change nursing phenomena are nursing theories” (p. 35), wherever they may have originated.

This study confirms the limited references to nursing theories and shows that after 2005, such references are only rarely present. Why is this? Most nursing theories were developed in the USA, with roots tracing back to the 1980s and earlier. The nursing education systems in the USA differ from those in the UK and Europe in general, and these differences might also have affected the type of theoretical approaches used. Another reason might be that methods and theories from related sciences frame some nursing research questions better. The limited use of, or references to, nursing theories might also reflect a perception that using such theories does not aid the study of nursing practice or the nursing context. As explained by Risjord ( 2010 ), this might historically relate to the relevance gap between the professional nurses' need of knowledge and the nursing theorists' knowledge production. Critical voices have also claimed that nursing theories have no relevance as tools in nursing practice and that clinically based nurses find nursing theory to be of no practical value, useful only as an academic abstraction separating theory from everyday practice (Doane & Varcoe, 2005 ). According to Alligood ( 2014 ), these assumptions undermine a rationale for developing nursing theories as a means of facing challenges in nursing practice and patient care more confidently. These perspectives will have consequences for education and leadership in nursing.

The use of sociological theories represents 20 of the theses. This is perhaps not surprising, considering that nursing studies at the University of Edinburgh are affiliated with the social sciences. More importantly though, the sociological approach emphasizes the interaction between human society and individuals, which is valuable for the subject of nursing and its impact on individuals, families, groups and societal health and well‐being. According to Laiho ( 2010 ), nursing science is clearly a social discipline, motivated to develop itself through the influence of social interests and goals. Nursing research with a sociological approach is crucial in order to consider social factors and issues that prevent, constrain and promote societal health behaviours (Laiho, 2010 ). An example is Muangman ( 2014 ), who studied the nature of “emotion work” in the context of care among adult stroke survivors aged 18–59 and their carers, situated in Thailand. This helped advance knowledge and understanding of the interaction between stroke survivors and their carers, the sociology of family, helping nurses to better facilitate and optimize their nursing and family care.

The use of psychological theory represents 12 of the studied doctoral theses. This is not surprising. Psychology or behavioural science theories are often used by nurse researchers, especially the theories surrounding stress and/or coping. An example here is Kilbride's ( 2006 ) PhD thesis. This study explored changes in neurological function and the emotional challenges experienced by patients with malignant glioma and their families, during the time period between surgery and radiotherapy. In addition to measuring changes in neurological functional status, the researcher used a coping framework to examine practical and emotional issues. This is relevant knowledge for nursing practice to anticipate and predict the physical and emotional responses of patients and their carers and to contribute to optimal quality of life for both patients and relatives.

Philosophical/ethical theory defined nine theses, with most of them leaning more towards the philosophical. Philosophy is defined by Teichman and Evans ( 1999 ) as “… a study of problems that are ultimate, abstract and general. These problems are concerned with the nature of existence, knowledge, morality, reason and human purpose” (p. 1). Adamson's ( 2015 ) study explored the shared experiences of one woman's experience with ovarian cancer from diagnosis to death, using philosophical theories. Adamson used the insights from German idealism (18th century) as a framework for understanding the aesthetics of how to live and die. In this context, philosophy brings to light knowledge on how to identify what is valuable and essential for this woman and her partner. Nurses need such knowledge to better understand, be prepared for and better care for both patients and their families during the disease trajectory.

Organizational theories were employed by seven PhD theses that looked at different applications of management and administration. One example is Miller ( 2004 ), who studied the processes of Trust managers and how they handle incidents involving qualified nurses, as well as how the outcomes of these processes are used to inform the organization and to develop new models of management. Leading an organization, which many nurses do, requires knowledge of, for instance, theories of error as employed by Miller ( 2004 ). Such theories allow nurses to be better prepared and develop strategies to improve leadership, change, decision‐making and motivation in the repertoire of practice among advanced nursing practitioners (McEven & Wills, 2014 ).

Fields of study in culture and linguistics were represented by two PhD theses. One of them, Quickfall ( 2009 ), studied cross‐cultural promotion of health, investigating issues underlying culturally competent nursing for asylum seekers. Knowledge from such theses has implications for all healthcare professions, including nurses, in providing culturally sensitive and evidence‐based nursing, regardless of geographic location (McEven & Wills, 2014 ).

Important aspects of nursing, including promoting health, advising patients and clients how to live with their illness and teaching nurse students, were addressed by four PhD theses. In the investigation of such phenomena, pedagogy and learning theories contribute to a scientific understanding of nurses in their teaching endeavours. Examples of the use of learning theory include the thesis by Msiska ( 2012 ), who explored the clinical learning experiences of undergraduate student nurses in Malawi and Nugent ( 2014 ), who studied the interactive effects of the construction of a special learning theory in relation to predicting health behaviour when supporting patients with type 2 diabetes mellitus in Scotland.

The last field of study is medicine and biology, used by five PhD theses. An example is Bailey ( 1998 ), who developed a description of the acute exacerbation event of Chronic Obstructive Pulmonary Disease to assist nurses in their work with the patient and their families. Bailey used a theoretical model of managing a medical crisis. The development of knowledge in this field has implications for clinical practice. Nurses need deep knowledge about how to manage crises to ensure the best care for patients and their families in acute situations.

As indicated, the nursing programme at the University of Edinburgh is affiliated with the social sciences, owing to its inclusion in the School of Health in Social Science. This affiliation may have influenced the choice of theoretical approaches in the examined PhD theses' nursing research. This might represent a distinctiveness associated with the location of the PhD programmes in nursing science, either in independent faculties or as a part of other disciplines' PhD programmes. In this study, most of the PhD theses were included in the collective term social sciences and only a few in medicine or biology. With regard to this, the findings in this study diverge from the results of Heyman ( 1995 ), who found that the theoretical approaches fell within either biomedical research or the social sciences.

According to Silverman ( 2011 ), “the facts that we find in ‘the field' never speak for themselves but are impregnated by our own assumptions” (p. 38). The facts remain the challenges faced by patients, the changes associated with illness as disease, sickness and experience and how nurses can help, in their research focus, which the present study has shown.

Complex tasks often require a heterogeneous knowledge base. They require that a professional practitioner in the actual action situation is able to coordinate and merge various forms of disciplinary and practice‐based knowledge. Professional occupation can therefore not be reduced to a question of the relationship between “theory” and “practice”. It is actually not just about applying theoretical knowledge in practical situations. Describing theories used exclusively in nursing research as nursing theory (Meleis, 2012 ) is not seen as a fruitful way to discuss the theoretical challenges in nursing science. The use of different theoretical approaches in nursing research, as the results of this study show, reveals the different theoretical approaches' importance for the development of advanced nursing knowledge as a support for nursing practice. Nursing science originates in a heterogeneous and fragmented body of knowledge, which this study of PhD theses also reflects. According to Risjord ( 2010 ), nursing knowledge will be strengthened when theory is shared with other disciplines, not weakened.

Nursing research is an amalgamation, inspired by a broad range of theories and methodological approaches. This status is what brought nursing to its present academic level: scientific nursing journals, PhD programmes, professors, nursing institutes and faculties. Risjord ( 2011 ) asks “does nursing science need a distinct kind of theory?” (p. 489). It is interesting that nursing research does not seem to rest on one distinct kind of theory. Most of the theses in this study do not refer to or use nursing theory as a theoretical approach. There is quite simply a gradual reduction in direct reference to nursing theory over time.

Professions, such as nursing, are characterized by heterogeneous and fragmented bodies of knowledge and there is no one theory used, but nursing is rather enacted in the application of multiple theories (Grimen, 2008 ). In general, PhD theses represent the scientification of nursing, understood as a scientific contribution to the improvement of nursing knowledge and nursing practice, through an increase in research‐based knowledge. A seemingly natural extension is that increased research activities, given their importance to nursing practice, will boost the nursing reputation and its position in the health research landscape.

6. CONCLUSION

This study concludes that most PhD theses have aims and research questions connected to nursing contexts and practices and are thus nursing related. All the theses studied can be seen as appropriate contributions to improving a general body of knowledge, driven by nursing research.

A relevant question generating from this study is whether the failure to relate research to nursing theory has meant that the traditional nursing theories are obsolete and outdated? It might look that way. However, we need more research to investigate this very question, both empirically and theoretically. The present study investigated all PhD theses on nursing‐related issues, all most likely increasing the knowledge base in nursing practice. Nursing research and nursing science offer a different perspective on health through examining nursing phenomena and posing research questions from a nursing perspective. The PhD theses examined in this study applied a wide variety of theories from other disciplines. The core principle of developing the theoretical basis for nursing and nursing knowledge remains, however, to advance and support nursing practice.

7. LIMITATIONS

The strength of this study is the access to all of the PhD theses from the University of Edinburgh and the Centre of Research Collection. The systematic descriptions in Table ​ Table1 1 strengthen the transparency of this study. The weakness of this study lies, however, also in this interpretive table, as some of the PhD theses combined different fields of study, such as Robertson ( 2007 ), who used both sociological and psychological theories. I chose to include Robertson's study in the field of sociology based on its thematic issues, a subjective decision that is open for discussion.

The selection of only one university for examination may also be considered a weakness. However, the University of Edinburgh has contributed pioneering work in building nursing science in Europe. It therefore represents an important and interesting institution for the investigation of nursing studies. Further research is, however, required to present a more complete picture of nursing researchers' use of theoretical approaches in their research.

CONFLICT OF INTEREST

There were no conflicts of interest associated with this study.

Supporting information

Acknowledgement.

I want to thank Professor Tonks Fawcett, University of Edinburgh, and Professor Kristian Larsen, Aalborg University, for their important comments and inspiration.

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This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

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• Open access
• Published: 11 May 2024

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

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

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

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

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

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

Conclusions

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

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

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

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

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

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

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

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

Setting and participants

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

Research instrument

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

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

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

What factors hindered your clinical training?

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

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

Data collection

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

Data analysis

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

Ethical considerations

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

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

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

Theme 1: managing expectations

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

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

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

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

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

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

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

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

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

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

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

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

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

Theme 2: theory-practice gap

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

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

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

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

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

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

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

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

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

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

One student made the following comment:

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

Theme 3: learning to cope

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

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

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

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

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

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

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

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

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

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

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

Other participants used physical activity to manage their stress.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Implications of the study

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

Clinical level

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

Educational level

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

Organizational level

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

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

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

Data availability

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

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

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

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

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