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Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Low interest in clinical practicum placement is associated with increased

stress in nursing students in Taiwan: A cross-sectional survey study
Shoa-Jen Pernga,b, Huei-Chuan Sunga,b,⁎, Chen-Jung Chenc, Tzu-Ying Leeb, Malcolm Kooa,d,⁎
a
Graduate Institute of Long-term Care, Tzu Chi University of Science and Technology, Hualien City, Hualien, Taiwan
b
Department of Nursing, Tzu Chi University of Science and Technology, Hualien City, Hualien, Taiwan
c
Department of Nursing, Mackay Medical College, New Taipei City, Taiwan
d
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

ARTICLEINFO ABSTRACT

Keywords: Background: Nursing students often find themselves in a highly competitive environment, and stress is a com-
Nursing student monly acknowledged experience in nursing students.
Nurse Objectives: The aim of this study was to explore factors, particularly an interest in nursing and in clinical
Stress practicum placement, associated with stress in Taiwanese nursing students.
Clinical practicum Design: Cross-sectional survey study.
Settings: A nursing college in central Taiwan and a university in eastern Taiwan.
Participants: 814 nursing students.
Methods: Level of stress of the participants was measured using the 43-items Stressors in Nursing Students (SINS)
scale, which was translated into a traditional Chinese version (TC-SINS). Simple and multiple linear regression
analyses were used to evaluate factors significantly associated with stress.
Results: A total of 814 nursing students completed the questionnaire with a return rate of 83.6%. The mean age
of the participants was 18.9 years and 94.8% was female. Regarding the students' interest in nursing, 2.6%
expressed that they strongly or somewhat disagree. In addition, regarding the students' interest in clinical
practicum placement, 7.2% indicated that they strongly or somewhat disagree. Results from multiple regression
analysis showed that students who expressed somewhat or strong disagreement to interest in clinical practicum
placement were significantly associated with a higher level of stress. Of the various strategies for stress relief,
listen to music (75.2%) was the most popular choice, followed by talk to a friend (72.3%), and catch up on sleep
(61.3%). A third of the participants used three strategies for stress relief.
Conclusions: Low interest in clinical practicum placement was associated with increased stress levels in nursing
students in Taiwan. Future studies should explore the underlying reasons for stress induced by clinical practicum
placement, and possible solutions for stress reduction in nursing students.

1. Introduction The nursing student experience is known to be an inherently

Stress can act as a positive motivation for a student, but excess le-
vels of stress could lead to unhealthy behaviours and psychological is-
sues (Hudd et al., 2000; Compton et al., 2008). A cross-sectional study
on 357 nursing diploma students found that higher perceived stress,
female sex, and an introverted personality trait were significant in-
dependent factors of physio-psycho-social symptoms during their clin-
ical practicum (Chen and Hung, 2014). Another survey study on 625
Taiwanese nursing students also showed that stress, anxiety, and sleep
quality were the three major predictors of depressive symptoms (Chen
et al., 2015).
stressful one (Jones and Johnston, 2000). The prevalence of symptoms
of stress has been reported to be 20.0% among baccalaureate nursing
students in Hong Kong (Cheung et al., 2016) and 20.2% among voca-
tional college nursing students in China (Zeng et al., 2019). Research
suggested that there are three major sources of stress among nursing
students, namely academia, clinical practice, and personal or social
environment (Labrague et al., 2017). A cross-sectional study on 357
nursing diploma program at a Spanish nursing college reported that
clinical stressors were perceived more intensely compared with aca-
demic and external stressors (Jimenez et al., 2010). Unmanaged stress
could affect not only the physical and emotional state of the nursing

⁎
Corresponding authors at: Graduate Institute of Long-term Care, Tzu Chi University of Science and Technology, Hualien City, Hualien 97005, Taiwan.
E-mail addresses: sung@ems.tcust.edu.tw (H.-C. Sung), m.koo@utoronto.ca (M. Koo).

https://doi.org/10.1016/j.nedt.2019.104241
Received 17 March 2019; Received in revised form 2 September 2019; Accepted 8 October 2019
02 60-6 917/© 2 0
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S.-J. Perng, et al.
students (Huang et al., 2011; Ni et al., 2010), but might also influence
their ability to deliver quality care (Gibbons et al., 2011; Labrague
et al., 2017).
With a global shortage of nursing workforce, greater efforts should
be made to prevent the attrition of nursing students from training
programs. Reduction of stress may be one way to deal with this issue
(Taylor and Reyes, 2012). A study on 9698 nurses from 181 hospitals in
China found that high levels of burnout were associated with an in-
tention to leave (Zhang et al., 2014). In addition, a survey study on 231
fourth-year nursing students revealed that the degree of stress during
clinical practice was one of the significant factors associated with their
career decision (Lai et al., 2006). Therefore, it is important to better
understand the stress experience of nursing students, as this could in-
fluence their future career choice and impact on nurse turnover rate.
Another potential problem related to nursing students is that they
are not adept at recognizing stressors. Suffering from stress could be
perceived as a weakness, and students might be reluctant to seek
counselling or other forms of support (Dixon and Robinson Kurpuis,
2008). Furthermore, most nursing students in Taiwan are young female
adolescents who start nurse training directly after finishing high school
education. A retrospective cohort study on 1259 nursing students at a
large English university found that students who were younger on entry
were less likely to complete preregistration nursing programs
(Pryjmachuk et al., 2009).
There is considerable need for appropriate measurement scales to
measure the stress levels in nursing students. However, determination
of the overall impact of stress in student nursing and its bearing on
psychological well-being is problematic, mainly due to diverse ap-
proaches to stress measurement in studies conducted (Glossop, 2001).
Several measurement scales and methods have been used to measure
this construct (Pulido-Martos et al., 2012). The Stressors in Nursing
Students (SINS) scale is a 43-item self-administered questionnaire spe-
cifically developed for use with nursing students in United Kingdom
(Deary et al., 2003; Watson et al., 2010). Likert scaling is used for each
item with responses ranging from 1 = ‘not stressful’ to 5 = ‘extremely
stressful’. Previous SINS studies have identified a four-factor structure
of stress in nursing students; clinical, confidence, education, and fi-
nance (Watson et al., 2009). The original SINS scale has been translated
and back translated into simplified Chinese (Stressors in Nursing Stu-
dents Scale-Chinese (SINS-CN)), and tested in China. A four-factor
structure, which was largely similar to that of the original ques-
tionnaire, albeits with a slightly different confi
ofgiutreamtisolnoading
on each of the factors (Watson et al., 2013). The aim of this study was to
explore factors, particularly an interest in nursing and in clinical
practicum placement, associated with stress in Taiwanese nursing stu-
dents, based on a traditional Chinese version of the SINS scale.
2. Methods
2.1. Design and participants
This study was a cross-sectional survey using a self-administered
questionnaire. Convenience sampling was used to recruit senior nursing
students enrolling in two nursing departments: a college in central
Taiwan and a university in eastern Taiwan. Both were private schools
with similar curricula and with over 2000 nursing students in each
school. While universities could award students with an associate's
degree or a bachelor's degree, colleges could only award an associate's
degree. Students who were undertaking their clinical placement in
medical or surgical units in the two study hospitals were eligible to
participate. Students from the college were undertaking their clinical
placement in a regional hospital in central Taiwan while those from the
university were undertaking their clinical placement in a medical
center in eastern Taiwan. All these students had already completed
their first clinical practicum of basic nursing skills. The total sample size
was estimated to be > 301 according to a sample size calculation based
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on the ratio of respondents to instrument items. However, we exceeded
this sample size and invited all eligible students from both colleges to
participate in the study. A total of 975 senior nursing students were
invited to complete the survey.
2.2. Translation of the Stressors in Nursing Students Scale
For the present study, the SINS was translated from English into
traditional Chinese (TC-SINS) by a bilingual native Chinese speaker
(HS). Back translation was carried out by another bilingual native
Chinese speaker who is an expert in nursing education with previous
translation experiences (SP). SP explained in English, the meaning of
the traditional-Chinese translation to HS. Cross-checking of the SINS
was conducted. This process allowed the researchers to confirm that the
translation did not result in any loss or alteration of the original
meaning among translated scale items, and to ensure that the forward
translation was accurate (Sung et al., 2013). The TC-SINS consists of 43
items and a total score was obtained by summing all the items, with a
higher score indicates a higher stress level.
2.3. Procedure
The study protocol was approved by the human research ethics
committee of the National Dong Hua University, Taiwan (No. 200802).
To evaluate the face validity, a pre-test was conducted on ten college
nursing students to ensure that the TC-SINS was easy to understand.
The questionnaire required approximately 15 min to complete.
Six lead mentors of the junior nursing program in the college in
central Taiwan and five lead mentors from the junior nursing program
of the university in eastern Taiwan were approached by the researchers
for permission to access their students. Information flyers explaining
the study and invitation letters were distributed to potential students by
the research assistants in classrooms during class break. All participants
were informed that participation was voluntary, and only those who
provided informed consent participated in the study. The research as-
sistants then distributed paper-based questionnaires to nursing students
who agreed to participate in the study. Participants were given three
days to complete the questionnaire. Drop boxes located in the mentors'
office were provided for the students to return their questionnaires.
2.4. Data analysis
Data were analyzed using IBM SPSS Statistics for Windows, Version
24.0 (Armonk, NY: IBM Corp.). Descriptive statistics were computed
using frequency and percentage or mean and standard deviation, as
appropriate. Simple linear regression analyses and multiple linear re-
gression analyses based on a stepwise procedure were used to evaluate
factors associated with stress levels.
3. Results
A total of 814 nursing students completed the questionnaire with a
return rate of 83.6%. The mean age of the participants was 18.9 years
and 94.8% was female. Around 28% of the students indicated they had
sleep problems or < 7 to 8 h of sleep per night. Regarding the students'
interest in nursing, 2.6% expressed that they strongly or somewhat
disagree. In addition, regarding the students' interest in clinical prac-
ticum, 7.2% indicated that they strongly or somewhat disagree. The
mean TC-SINS score was 118.0 (standard deviation = 28.6) (Table 1).
The score for each of the 43 items of the TC-SINS was shown in Table 2.
Seven items showed a score of 3 or higher, indicating a stress level of
above neutral. The items, in descending order of magnitude were: (1)
item 9 – Fear of making a mistake in clinical placements (score = 3.49);
(2) item 33 – Fear of failing in the course (score = 3.44); (3) item 1 –
The amount of classwork material to be learned (score = 3.26); (4) item
7 – Examinations and placement gradings (score = 3.22); (5) item 4 –
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Table 1 Table 2
Basic characteristics of participants (N = 814). Results of the traditional Chinese version of Stressors in Nursing Students score.

Variable N (%) or mean (standard No. Descriptive of item Mean (standard

deviation) deviation)

Age, year 18.9 (1.4) 1 The amount of classwork material to be learned 3.26 (0.91)
Sex 2 Relationships with family members 2.05 (1.05)
Male 42 (5.2) 3 Having too much clinical responsibility 3.08 (1.09)
Female 772 (94.8) 4 The difficulty of the classwork material to be learned 3.13 (0.85)
School 5 Personal problems other than health 2.51 (0.96)
University T 193 (23.7) 6 Not getting enough feedback about performance 2.72 (0.99)
College L 621 (76.3) 7 Examinations and placement gradings 3.22 (1.07)
Sleep status 8 Patients' attitudes towards me 2.55 (1.07)
Normal 583 (71.6) 9 Fear of making a mistake in clinical placements 3.49 (1.14)
Had sleep problems or sleep < 7–8 h/night 231 (28.4) 10 Competition from fellow students 2.73 (1.04)
Interest in nursing 11 Relations with staff in the clinical area 2.79 (1.03)
Strongly agree 62 (7.6) 12 Caring for the emotional needs of patients 2.64 (0.98)
Somewhat agree 398 (48.9) 13 The attitudes and expectations of other professionals 2.76 (0.98)
Neutral 333 (40.9) (doctors, administrators, social workers, etc.) towards
Somewhat disagree 17 (2.1) nursing
Strongly disagree 4 (0.5) 14 Being interrupted on clinical duties 2.57 (0.97)
Interest in clinical practicum 15 Not having enough staff or equipment to meet 2.69 (1.00)
Strongly agree 89 (10.9) patients' needs
Somewhat agree 348 (42.8) 16 Fear of poor job prospects 2.75 (1.08)
Neutral 318 (39.1) 17 Conflicts with peers 2.66 (1.09)
Somewhat disagree 44 (5.4) 18 Having too much to learn 3.10 (1.04)
Strongly disagree 15 (1.8) 19 The atmosphere created by teaching staff 2.67 (1.05)
TC-SINS score 118.0 (28.6) 20 Dealing with uncooperative, anxious, abusive or 2.76 (1.04)
otherwise difficult patients or relatives
TC-SINS: traditional Chinese version of Stressors in Nursing Students. College L 21 Conflicts with staff in placements 2.54 (1.03)
and university T were located in central and eastern Taiwan, respectively. 22 The lack of free time 2.94 (1.05)
23 Not being sure what is expected in the course 2.73 (1.01)
24 Criticism from peers or senior staff 2.89 (1.14)
The difficulty of the classwork material to be learned (score = 3.13); 25 Not having enough time for friends and family 2.66 (1.12)
(6) item 18 – Having too much to learn (score = 3.10); and (7) item 3 – 26 The college response to students needs 2.68 (1.04)
Having too much clinical responsibility (score = 3.08). 27 Conflicts with administrators or managers 2.45 (1.04)
Results from the simple linear regression analyses indicated age, 28 Not having enough money for entertainments 2.61 (1.09)
29 Meeting deadlines for coursework 3.01 (1.10)
school, sleep status, students' interest in nursing, and students' interest 30 Relations with other professionals 2.60 (1.00)
in clinical practicum were significantly associated with the TC-SINS 31 Not having anyone to talk to about the course 2.62 (1.01)
score. Multiple regression analysis further showed that students who 32 Patients attitudes towards nursing 2.60 (1.00)
expressed neutral (β = 7.31, p = .021), somewhat disagreement 33 Fear of failing in the course 3.44 (1.20)
34 Not being sure what is expected on placements 2.72 (1.09)
(β = 28.49, p < .001) or strong disagreement (β = 35.08, p < .001)
35 Having no time for entertainment 2.67 (1.09)
to interest in clinical practicum placement, compared with those ex- 36 Conflicts with college staff 2.37 (1.03)
pressed strong agreement, were significantly and independently asso- 37 Surviving on a low income 2.52 (1.12)
ciated with a higher level of stress, adjusting for school and sleep status 38 Personal health problems 2.41 (1.09)
(Table 3). 39 Feeling responsible for what happens to patients 2.82 (1.08)
40 Speaking to patients' relatives 2.62 (0.99)
Of the various strategies for stress relief, listen to music (75.2%) was
41 Making less money than friends who are not nurse 2.38 (1.08)
the most popular choice, followed by talk to a friend (72.3%), and catch 42 Physical health of family members 2.77 (1.14)
up on sleep (61.3%). A third of the participants used three strategies for 43 Coping with suffering or death of patients 2.86 (1.08)
stress relief (Table 4).
The score for each item was obtained using a 5-point Likert scale from 1 (not at
all stressful) to 5 (extremely stressful).
4. Discussion
nursing students also revealed that caring of patients, assignments and
The main finding of this survey study on Taiwanese nursing students workloads, and negative interactions with staff and faculty were the
was that their expressed interest on clinical practicum placement was main stressors (Labrague et al., 2017). Another systematic review of 23
significantly associated with increased stress levels, even after adjusting quantitative studies also indicated that academics and clinical work
for potential confounding factors. A clear trend of higher stress levels were common sources of stress in nursing students. Lack of knowledge
was evidenced from the increasing magnitude of regression coefficients and professional skills, high workload, fear of making mistakes, and
from students who responded neutral (β = 7.3) to somewhat dis- harming the patient were main types of stress expressed by nursing
agreement (β = 28.5) to strong disagreement (β = 35.1) compared to students during their clinical practice (Pulido-Martos et al., 2012).
those responded strong agreement. In other words, clinical practicum Moreover, a study in Japan on 28 third-year nursing students com-
placement represent a significant source of stress to college nursing paring the stress level before and during clinical practicum found that
students. an increase in stress along with a decrease in estrogen secretion
The clinical setting is an invaluable learning environment for nur- (Chikamura et al., 2008). Based on an Urdu-translated version of the
sing students. However, the learning process that occurs in this en- SINS, a cross-sectional study on 762 nursing students from 11 schools in
vironment may also cause students to experience stress and anxiety. A Pakistan was conducted to explore the effect of a range of demographic
longitudinal study of 65 Jordanian students registered in psychiatric/ variables on the perception of stressors. Results showed that male stu-
mental health nursing clinical courses showed that the highest reported dents, senior years of study, and students in private schools of nursing
types of stressors included taking care of patients, stress related to had a signifihicgahnetrlystress level ( Watson et al., 2017). Further-
teachers and nursing staff, and from assignments and workloads (Al- more, a cross-sectional survey on 625 nursing students from a junior
Zayyat and Al-Gamal, 2014). A recent literature review on stress in college in Taiwan found that depressive symptoms were significantly

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Table 3
Simple and multiple linear regression analyses of the traditional Chinese version of Stressors in Nursing Students (TC-SINS) score.
Variable Simple linear regression analysis Multiple linear regression analysis

Unstandardized regression Standardized regression P value Unstandardized regression Standardized regression P value
coefficient coefficient coefficient coefficient

Age, year 2.92 0.140 < 0.001 – – –

Sex (reference: female) 3.27 0.025 0.470 – – –
School (reference: college L) 17.62 0.263 < 0.001 13.3 0.198 < 0.001
Sleep status (reference: normal) 12.06 0.191 < 0.001 7.3 0.115 0.001
Interest in nursing (reference:
strongly agree)
Somewhat agree 3.74 0.066 0.328 – – –
Neutral 13.58 0.234 < 0.001 – – –
Somewhat disagree 22.08 0.111 0.004 – – –
Strongly disagree 33.72 0.083 0.020 – – –
Interest in clinical practicum
(reference: strongly agree)
Somewhat agree 0.31 0.005 0.923 0.93 0.016 0.767
Neutral 8.60 0.147 0.008 7.31 0.125 0.021
Somewhat disagree 33.20 0.263 < 0.001 28.49 0.226 < 0.001
Strongly disagree 39.64 0.187 < 0.001 35.08 0.165 < 0.001

Table 4 capture the changes of students' perception of their interest of nursing

Strategies for stress relief used by the participants. and clinical practicum placement over the full course of their nursing
Variable n (%)
program.

Strategy for stress relief 5. Conclusion

Listen to music 612 (75.2)
Talk to a friend 589 (72.3)
Catch up on sleep 500 (61.3)
Findings from our cross-sectional survey study suggested that a low
Go shopping 355 (43.6) interest in clinical practicum placement was associated with increased
Take time to eat well 263 (32.3) stress levels in nursing students in Taiwan. Future studies should in-
Talk to a teacher 80 (9.8) vestigate the underlying reasons for stress induced by clinical practicum
Number of strategies used for stress relief
1 strategy 64 (7.9)
placement, and explore possible remedies.
2 strategies 241 (29.6)
3 strategies 271 (33.3) Funding source
4 strategies 159 (19.5)
5 strategies 70 (8.6)
None.
6 strategies 9 (1.1)

Percentages for the strategy for stress relief added to > 100 due to multiple
responses.
associated with interest in nursing, interest in clinical placement, and
grade point average (Chen et al., 2015).
Six strategies were reported to be used by our study participants.
Listen to music represents the most commonly used strategy, followed
by talk to a friend and catch up on sleep. About a third of the students
employed three strategies at the same time to relief their stress, with the
most common combination also being listen to music, talk to a friend,
and catch up on sleep. These three strategies could be broadly classified
as seeking diversions, ventilating feelings, and relaxing, respectively. In
a cross-sectional study on 180 nursing students in India also showed
that seeking diversions, particularly listen to music, and let off stream
by complaining to friends were the most common strategies to cope
with stress (Kumar, 2011). While these strategies were commonly used
by nursing students, their effectiveness in stress management is not
clear. Additional studies using a longitudinal design or interventional
design will be needed before any concrete suggestions could be pro-
vided to the students.
Furthermore, since a sense of belonging has been shown to be in-
versely associated with perceived stress among nursing students during
their clinical placement (Grobecker, 2016), further research on how to
improve a sense of belonging in nursing students is merited.
Several limitations of our study should be mentioned. First, con-
venience sampling was used in the recruitment of nursing students,
which could limit the generalizability of our findings. Second, a cross-
sectional study design was used and therefore, our results could not
Ethical approval
The study protocol was approved by the human research ethics
committee of the National Dong Hua University, Taiwan (No. 200802).
Declaration of competing interest
None declared.
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