Nurse Education Today (2008) 28, 134–145

Nurse
Education
Today
intl.elsevierhealth.com/journals/nedt

A comparative, longitudinal study of stress in

student nurses in five countries: Albania, Brunei,
the Czech Republic, Malta and Wales
Philip Burnard a,*, Deborah Edwards a, Kim Bennett a, Hjh Thaibah b,
Valerie Tothova c, Donia Baldacchino d, Petrit Bara e, Jetona Mytevelli e

a
Cardiff University, Cardiff School of Nursing and Midwifery Studies, Wales, United Kingdom
b
Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah College of Nursing, Brunei
c
University of Southern Bohemia, Faculty of Health and Social Sciences, Czech Republic
d
University of Malta, Institute of Health Care Nursing and Midwifery Studies, Malta
e
Tirana Higher School for Nursing and Midwifery, University of Korçe, Nursing and Midwifery Branch,
Albania

Accepted 11 April 2007

KEYWORDS Summary
Stress; Background and aims: Stress amongst nursing students is a global issue. There is an
Nursing students absence of published international comparative studies which investigate this and so
this paper sets out to explore the sources of stress among nursing students through-
out their course of study and to determine whether they were more stressed by aca-
demic or clinical factors across five different countries (Albania, Brunei, the Czech
Republic, Malta and Wales). Although each country, within this study, has a unique
culture, a cross-cultural comparison can be made in an attempt to better under-
stand stress in the student nursing population.
Methods: The study was undertaking using a descriptive quantitative design using
the Stress in Nurse Education Questionnaire with 1707 nursing students across the
five countries.
Results: The mean score for the total sample for all the items on the stress scale
was 52.3 (SD 17.1). The sample from Wales had the lowest mean score and those
in Brunei had the highest. Students in Brunei and Malta were more stressed by the
academic elements of the course than by the clinical elements. Whereas for those
students in the Czech Republic For students in Wales and in Albania – Korçe there
were no differences in stress experienced between the academic and clinical ele-
ments of the course. The results indicated that there were no significant differences

* Corresponding author.
E-mail address: burnard@cardiff.ac.uk (P. Burnard).


0260-6917/$ - see front matter c 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2007.04.002
A comparative, longitudinal study of stress in student nurses in five countries 135

in total stress scores by year of study for students in Albania – Tirana, Albania –
Korçe, Malta and Wales. In Brunei however, ANOVA revealed that there were signif-
icant differences in total stress scores by year of study. Further analysis revealed
that students in year 3 scored higher on the overall scale than students in year 1.
The individual item on the stress scale with highest mean in the Albania – Korçe
and the Albania – Tirana sample was ‘‘The death of a patient’’ whilst the Bruneian
sample, Maltese sample and Welsh sample opted for ‘‘Revising for and sitting exam-
inations’’ and the Czech sample chose: ‘‘Continuous pressure to meet deadlines for
assessments’’.
Conclusions: This study has succeeded as the first of its kind to compare and con-
trast levels and sources of stress amongst an international sample. The findings indi-
cate that student nurses worldwide do share much in common while still retaining
individual cultural features relating to stress throughout their course of study.
c 2007 Elsevier Ltd. All rights reserved.

Introduction identified students’ stress experiences during their

It is well recognised that nursing is a stressful occu-
pation (Bennett et al., 2001; Jones and Johnston,
2000; McVicar, 2003). The majority of studies con-
ducted within the field of nursing have referred to
the work of Lazarus to place their work around
stress within a theoretical context who have de-
fined stress:
‘‘a particular relationship between the person and
the environment that is appraised by the person as
taxing or exceeding his or her own resources and
endangering his or her well being.’’ p. 19 (Lazarus
and Folkman, 1984).
It has been suggested by Rhead (1995) however,
that the problem of stress does not begin when the
nurse starts working on the wards, but is evident
during nurse training. Stress has been identified
as an important psychosocial factor in the educa-
tional process because it may influence academic
performance and student well being (Sawatzky,
1998).
Literature review
Since the early eighties researchers have investi-
gated the issues that cause stress for nursing stu-
dents whilst they undertake the practical aspects
of nurse training (see for example Jack, 1992; Klee-
hammer et al., 1990; Oermann and Standfest,
1997; Parkes, 1980a,b, 1982, 1984, 1985; Saxena,
2001; Shipton, 2002). A number of studies have fo-
cused on the stressors associated with the initial
clinical experience (Admi, 1997; Mahat, 1996,
1998; Chesser-Smyth, 2005; Pagana, 1988, 1990;
Sheu et al., 2002), whereas Abu Tariah and al-Sha-
raya (1997) looked at the clinical experiences of
second year nursing students. Other studies have
formal education (see for example Lindop, 1987,
1989, 1991).
A number of investigators have addressed very
specific issues associated with the academic expe-
rience which include a comparison of full time day
and part time evening baccalaureate nursing stu-
dents (O’Connor and Bevil, 1996), course-related
family and financial problems for mature nursing
students (Cuthbertson et al., 2004), a comparison
of levels of stress and academic performance in
nursing students studying a traditional generic
nursing degree and a baccalaureate nursing degree
program (Gwele and Uys, 1998) and stress amongst
male nursing working in Malawi (Simukonda and
Rappsilber, 1989). Other investigators have looked
at specific ethnic groups which include an investi-
gation of stress and academic achievement for His-
panic student nurses (Maville and Huerta, 1997)
and an investigation of stressors among female
African American baccalaureate nursing students
in three universities in south Carolina, USA (Kirk-
land, 1998).
A further literature search was conducted to
identify those studies which measured both aca-
demic and clinical stressors for nurses undergoing
a programme of study at either diploma or degree
level. A total of 14 papers were identified (see
Table 1). These papers have identified a wide vari-
ety of stressors associated with their course of
study and clinical experiences.
Clinical Stressors that were most commonly
reported
 handling emergencies in the clinical area (Basson
and van der Merwe, 1994; Clarke and Ruffin,
1992),
 death of a patient (Clarke and Ruffin, 1992;
Rhead, 1995; Thyer and Bazeley, 1993; Timmins
and Kaliszer, 2002b),
136 P. Burnard et al.

Table 1 Study measuring academic and clinical stress studies

Author/s n Stage of training Study design Stress measurement details
Basson and van der 82 Second and Third pdt 60 items
Merwe (1994), year
South Africa
(4 year course) 7-point Likert scale (levels of stress)
Beck and Srivastava 94 Second years and Modified the work Part 1 asked the students to
(1991), USA above of Firth (1986) and describe a real event other than
Frances and Naftel examinations that has occurred in
(1983) became the past month was stressful.
known as the BBSI Part 2 consisted of 44 items with a
5-point Likert scale
(Levels of stress)
Brown and Edelmann Phase 1
(2000), UK
55 0 month pdt Open ended questions which related
to potential stressors, resources and
support
Phase 2
18 18 months pdt Structured questionnaire to identify
stressors the students have felt to
have actually experienced in the
previous 6 months
15 6 months into
first post
Clarke and Ruffin 306 First year pdt 28 items
(1992), Australia
Second week 5-point Likert scale (levels of stress)
189 First year
Final week
Evans and Kelly 52 All years pdt 109 items
(2004), Ireland
4-point Likert scale (levels of
agreement)
Hamill (1995), UK 35 Third year pdt Open ended questions to discover
perceived stress
10 Third year In depth interviews
Jones and Johnston 109 First year BBSI 43 items
(1997), UK
Wk 40 Post- 5-point Likert scale (levels of stress)
placement
111 First year
Wk 24 Pre-
placement
Lindop (1999), UK 146 All years pdt 144 items
Project 2000 4-point Likert scale (levels of
agreement).
146 All years
Pre-project 2000

Lo (2002), Australia 120 All years GHQ-12 Measures chronic and transient
stress
112
101
A comparative, longitudinal study of stress in student nurses in five countries 137

Table 1 (continued)
Author/s n Stage of training Study design Stress measurement details
Rhead (1995), UK 55 All years Adapted NSS 32 items
RGN students 4-point Likert scale (levels of
stress)
51 29.75 months
All years
Dip HE students
20.5 months

Thyer and Bazeley 79 First year Modified SWSS 33 items

(1993), Australia (second semester)
5-point Likert scale (levels of
anxiety)

Timmins and 110 Third year pdt 12 items 4-point Likert scale
Kaliszer (2002), (levels of stress)
Ireland
Tully (2004), 20 First year SNSI 22 items
Ireland
15 Second year 5-point Likert scale (levels of
stress)

Wang (1991), USA 94 All years Critical incident Content analysis of 245
analysis critical incidents
pdt: purpose designed tool, BBSI: Beck and Srivastava Stress Inventory (Beck and Srivastava, 1991); GHQ-12: General Health
Questionnaire, NSS – Nurse Stress Scale (Gray Toft and Anderson, 1981), SNSI – Student Nurse Stress Index (Jones and Johnston,
1999), SWSS – Students’ Work-place Stressors Schedule (Silins and Cooper, 1989).

 lack of practical skills, negative attitudes of
ward staff and misunderstanding of supernumer-
ary status (Hamill, 1995),
 relationships with clinical staff (Evans and Kelly,
2004; Hamill, 1995; Lo, 2002; Thyer and Bazeley,
1993; Timmins and Kaliszer, 2002b).
Academic stressors that were most commonly
reported
 pressure of grades or fear of failing (Jones and
Johnston, 1997; Tully, 2004),
 intense amount of work (Basson and van der
Merwe, 1994; Beck and Srivastava, 1991; Clarke
and Ruffin, 1992; Evans and Kelly, 2004; Tully,
2004),
 study associated with the programme (Clarke
and Ruffin, 1992; Evans and Kelly, 2004;
Jones and Johnston, 1997; Thyer and Bazeley,
1993),
 lack of free time (Basson and van der Merwe,
1994; Beck and Srivastava, 1991; Jones and
Johnston, 1997),
 finding academic work difficult including exam-
inations (Beck and Srivastava, 1991; Clarke and
Ruffin, 1992; Evans and Kelly, 2004),
 long hours of study long hours of study (Beck and
Srivastava, 1991; Jones and Johnston, 1997),
 relationships with academic staff (Evans and
Kelly, 2004; Hamill, 1995; Lo, 2002; Thyer
and Bazeley, 1993; Timmins and Kaliszer,
2002b),
 finances (Beck and Srivastava, 1991; Brown and
Edelmann, 2000; Clarke and Ruffin, 1992; Thyer
and Bazeley, 1993; Timmins and Kaliszer, 2002b),
 female students experienced higher levels of
stress than male students (Tully, 2004),
 not being treated as an adult learner, confusing
assignment guidelines and the amount of self
directed learning (Hamill, 1995),
 examinations (Beck and Srivastava, 1991;
Hamill, 1995; Lindop, 1999; Timmins and Kalis-
zer, 2002b; Tully, 2004),
 scheduling of courses (Wang, 1991).
Other areas of stress include
 interpersonal relationships of both clinical
(Evans and Kelly, 2004; Hamill, 1995; Thyer and
Bazeley, 1993; Timmins and Kaliszer, 2002b)
and academic staff (Thyer and Bazeley, 1993;
Timmins and Kaliszer, 2002b),
138
 financial stressors (Beck and Srivastava, 1991;
Brown and Edelmann, 2000; Clarke and Ruffin,
1992; Lo, 2002; Thyer and Bazeley, 1993; Tim-
mins and Kaliszer, 2002b).
The research instruments used to measure stress
vary widely across these 14 studies.
Seven of the studies developed their own stress
scales and three studies modified existing question-
naires. When authors develop their own question-
naires then sufficient detail should be provided
with regards to the development process with re-
gard to piloting the questionnaire and demonstrat-
ing validity and reliability (Rattray and Jones,
2007). Of the 10 studies that developed or modified
questionnaires only four undertook pilot studies
(Evans and Kelly, 2004; Rhead, 1995; Timmins and
Kaliszer, 2002b) and a further study referred the
authors to a PhD thesis for information on the scale
that had been developed (Lindop, 1999). Reliability
issues were discussed in six studies (Basson and van
der Merwe, 1994; Brown and Edelmann, 2000;
Clarke and Ruffin, 1992; Evans and Kelly, 2004; Lin-
dop, 1999; Timmins and Kaliszer, 2002b) and valid-
ity in two studies (Beck and Srivastava, 1991;
Timmins and Kaliszer, 2002b). A further tool for
developing questionnaires is exploratory factor
analysis and this was undertaken in three studies
(Clarke and Ruffin, 1992; Rhead, 1995; Timmins
and Kaliszer, 2002b). The study by Evans and Kelly
(2004) stated that they used the Likert scale used
by Lindop (1999) who used a 144 item question-
naire and assumed validity and reliability to be
adequate but went on to use a 109 item scale in
their own study. The number of items on each
questionnaire is also an issue for a number of other
studies as some questionnaires had 12 items
whereas others had as many as 144 items. There
is a need for consistency in this area so that find-
ings from studies can be compared more easily.
Jones and Johnston (1999) suggest that there is a
lack of psychometrically adequate measures of
sources of stress for student nurses because of all
the factors listed above.
Further care should be taken when comparing
across studies as to which years of the nursing pro-
gramme was the sample taken from as research has
shown that stress varies across years of study (Lin-
dop, 1999; Rhead, 1995). Only five have examined
specific academic and/or clinical stressors through-
out the entire programme of study (Evans and
Kelly, 2004; Lindop, 1999; Lo, 2002; Rhead, 1995;
Wang, 1991). Some authors chose to look at the
first year of study or the final year whilst others
looked at students across several different years
(see Table 1).
P. Burnard et al.
This literature search has identified that there is a
need for further research across the entire course of
study. Hence the first aim of the study was to explore
the sources of stress among nursing students
throughout their course of study. It has also been
established from previous research the nature of
both academic and clinical stressors but there is lit-
tle information as to which area i.e. clinical or aca-
demic causes the students the most stress. The
second aim of this study was therefore to determine
whether nursing students are more stressed by aca-
demic or clinical sources during their course of study.
As can be seen from the literature review stress
amongst nursing students is a global issue. There is
an absence of published international comparative
studies in these areas and so this paper sets out to
compare clinical and academic stress from five dif-
ferent countries. An international sample was cho-
sen in order to further understand stress in nursing
students and how this is likely to differ across cul-
tures. Although each country, within this study, has
a unique culture, a cross-cultural comparison can
be made in an n attempt to better understand stress
in the student nursing population. A descriptive
quantitative design was chosen so that a reliable
and valid questionnaire could be used as this method
is a convenient, cost and time effective means of
gathering such data. The current research team has
well established links with a number of overseas
nursing establishments who had expressed in inter-
est in comparing the stress levels of their students
with those students in the UK. It was therefore
decided to utilise these links to address the issue of
stress in nursing students on an international basis.
Sample details
The research population in this study were one
group of students from
 A university in Albania undertaking a full time 3
year Diploma in Nursing.
 A Higher School for Nursing and Midwifery in
Albania undertaking a full time 3 year Diploma
in Nursing.
The Diploma is divided into 12 months common
foundation programme (CFP) branching out for
the remaining two and a half years to qualify
either in Adult General Nursing or Midwifery.
The CFP consists mostly of theory with three
weeks (75 h) clinical practice in the second
semester. Following completion of the CFP, stu-
dents continue to have four weeks of clinical
practice each year, 50 h per semester. Only
adult general nursing students were included in
the study.
A comparative, longitudinal study of stress in student nurses in five countries
 A College of Nursing in Brunei undertaking a full
time 3 year Diploma in Nursing.
The course is a generic nursing programme of
three years and six months’ duration reflecting
the inclusion in the programme of subjects addi-
tional to nursing, namely English language stud-
ies, Government structure and concepts (MIB)
and Islamic religious studies. The course has an
overall balance of theory and practice of 50:50.
 A university in the Czech Republic undertaking a
full time 3 year Degree in Nursing.
In the Czech Republic students are required to
pass admission exams. The program consists of
4600 h of training of which 2300 h are practical
training.
 A university in Malta undertaking a full time 4
year Diploma in Nursing.
The four year Diploma is divided into two aca-
demic years the CFP branching followed by a fur-
ther two years to qualify in Adult General
Nursing, Psychiatric nursing and Midwifery. The
CFP has an overall balance of theory and practice
of 50:50. Only adult general nursing and psychi-
atric nursing students were included in the study.
 A university in Wales undertaking a full time 3
year Diploma in Nursing course.
Students enter the programme to qualify as
either Adult Nurses, Child nurses, Mental Health
Nurses or Learning Disability Nurses (branch pro-
gramme). The first 18 months is a CFP and this
followed by the branch programme. The overall
balance of theory and practice for the duration
of the course is 60% clinical work and 40% aca-
demic work. All nursing students participated
in the study.
Method
The study was undertaking using a cross sectional
survey approach with the use of the Stress in
Nurse Education Questionnaire (SINE). The ques-
tionnaire is English and translations were not used
in this study. Additional demographic data was
also obtained which included data on gender,
age, marital status, and any academic study
undertaken prior to entry on the course. The SINE
questionnaire has developed by Rhead (1995) and
is a modified version of the Nurse Stress Scale
(Gray-Toft and Anderson, 1981a) to incorporate
academic stressors and was designed specifically
for use within Nurse Education. During the devel-
opment of the questionnaire a full pilot study con-
ducted. The questionnaire was developed further
by undertaking principle component analysis. The
questionnaire had previously been used with a co-
139
hort of nursing students within one of the univer-
sity departments with nursing students and was
found to be a valid and reliable measure (Bennett,
2002).
The questionnaire consists of 32 items that de-
scribe stressful situations. Sixteen items describe
clinical situations and another 16 items describe
academic situations. A 4-point Likert scale was
used for each item to measure the intensity
of stress. Subjects were asked to respond on a
0–3 scale signifying not stressful to extremely
stressful.
A total stress score could then be obtained for
each student by summing their responses to the
32 items with a possible range of scores from 0 to
96. As well as a total stress score the 16 items that
described the clinical stressors could be summed to
achieve a clinical stress score and likewise for the
academic items.
The questionnaire was administered and com-
pleted in the presence of the one of the
researchers. Prior to administering the question-
naire a full explanation was given to the respon-
dents regarding the status of the researcher and
the purpose of the study. Respondents were gi-
ven the opportunity to withdraw from the study,
and assured that all data given would be treated
as confidential. Individual students could not be
identified and, following normal procedure, data
will be stored for five years. The questionnaire
was administered along with an information sheet
about the study and a consent form to nursing
students in all the participating countries and
who were at the end of each year of their period
of training. The data was collected between 2001
and 2003. It took longer to gain access and go
through ethics committees in certain countries.
Approval through the appropriate channels was
obtained in each nursing establishment and ethi-
cal issues fully considered. The size of the sam-
ple was determined on the basis of those
students who attended lectures on the day of
the study and who had consented to take part
(Table 2).
Data analysis
The data obtained were summarised and descrip-
tive statistics applied. The study utilised frequency
tables, means and standard deviations. The com-
parisons between two means that independent
t tests were utilised and more comparison of means
between more than two groups then analysis of
variance was utilised. Data were entered and pro-
cessed using SPSS 10 for Windows.
140 P. Burnard et al.

Results

(67)
(62)
(99)
(74)
(85)
(97)
(%)
Demographic characteristics

Returned
In total 1707 questionnaires were analysed. The

190
271
265

282
285
69
n
Total sample
majority of respondents were female, 71% were
single. A third of the students from the UK had chil-
Sample
dren living with whereas for students in Albania –
Korçe, Albania – Tirana, Brunei and Malta this fig-

94
282
438
269

330
294
ure was 10% and none of the students from the
Czech Republic had children living with them (see

(66)
Table 3).
(%)
Returned

43 Stress scores
n
Fourth year

The mean score for the total sample for all the
Sample

items on the stress scale was 52.3 (SD 17.1). The

sample from Wales had the lowest mean score
65

and those in Brunei had the highest (see Table 4).

ANOVA revealed a significant difference between
(58)
(70)
(98)
(68)
(93)
(96)
(%)

the means (df = 5, F = 310.5, P < 0.001) and a

Returned

post-hoc Tukey test revealed differences between

Wales and all other centres. The mean score for
44
81
63
15
71
77
n

the sample from Brunei was found to be signifi-

cantly different to all but Czech Republic
Third year

(p < 0.0001). The samples from Albania – Korçe

Sample

and Albania – Tirana and Malta had very similar

77

64
22
76
80
115

mean scores and were all found to be significantly

different from the samples from Wales, Brunei
and the Czech Republic (p < 0.0001). The mean
(86)
(51)
(99)
(87)
(97)
(96)
(%)
Returned

score for the sample from the Czech Republic was

found to e significantly different to all but those
from Brunei (p < 0.0001).
74
69
83
38
67
85
n
Second year

Students in Brunei (t = 8.33, 95% CI 2.06–3.33,

Sample size by end of each year of academic study

p = 0.00) and Malta (t = 4.14, 95% CI 0.78–2.18,

Sample

p = 000) were more stressed by the academic ele-

135
86

84
33
69
89

ments of the course than by the clinical elements.

Whereas for those students in the Czech Republic
(t = 4.09, 95% CI = 2.30 to 0.81) and Albania
(61)
(64)
(98)
(41)
(84)
(98)
(%)

Tirana (t = = 3.60, 05% CI to 0.65, p = 0.00) it

Returned

was the clinical elements that caused them the

most stress. For students in Wales and in Albania
121
119

101
123
72

16

– Korçe there were no differences in stress experi-

n

enced between the academic and clinical elements

First year

of the course.
Sample

The results indicated that there were no signifi-

39
119
188
121

120
125

cant differences in total stress scores by year of

study for students in Albania – Tirana, Albania –
Korçe, Malta and Wales (Table 5). There were
Albania – Tirana
Albania – Korçe

insufficient numbers for any analysis to be under-

Czech Republic

taken for students in the Czech Republic. In Brunei

however, ANOVA revealed that there were signifi-
Table 2
Country

cant differences in total stress scores by year of

Brunei

Wales
Malta

study (f = 3.995, p = 0.020). Further analysis re-

vealed that students in year 3 scored higher on
A comparative, longitudinal study of stress in student nurses in five countries 141

Table 3 Selected demographic features

Country Female Single Children at home Age
n (%) N (%) n (%) Mean Range
Albania – Korçe 146 (77) 169 (89) 29 (15) 21 18–46
Albania – Tirana 191 (71) 256 (95) 43 (16) 21 18–37
Brunei 203 (77) 259 (98) 28 (10) 21 18–35
Czech Republica 65 (96) 67 (97) 0 (0) 20 19–27
Malta 206 (73) 273 (97) 29 (15) 20 19–44
Wales 255 (90) 188 (66) 96 (33) 27 18–48
a
Data missing for n = 1.

Table 4 Distribution of total and subscales stress for all countries

Score Academic stress score Clinical stress score Total stress score
Mean (SD) Mean (SD) Mean (SD)
a
Albania – Korçe 31.2 (6.3) 31.4 (6.5) 62.6 (11.7)
Albania – Tiranaa 29.9 (6.7) 31.3 (6.5) 61.2 (11.5)
Brunei 34.0 (6.3) 31.4 (7.4) 65.4 (12.8)
Czech Republic 28.7 (6.9) 30.4 (6.7) 59.4 (12.1)
Maltaa 31.5 (6.8) 30.0 (7.0) 61.5 (12.4)
Wales 27.6 (7.6) 27.3 (7.7) 55.0 (14.1)
a
Data missing/incomplete for n = 1.

the overall scale than students in year 1 (t = 0.29,
p = 0.003, 95% CI 9.2 to 1.9).
The results indicated that there were no signif-
icant differences in academic or clinical stress
scores by year of study for students in the Wales,
Malta and Albania – Korçe. Thus, student nurses
at the end of their third year of the course are
no greater stressed with the academic element
of the course than those at the first or second
year of their course. However, in both academic
and clinical stress scores by year of study (aca-
demic: f = 4.1, p = 0.02; clinical: f = 4.5, p =
0.01) for Bruneian students. Further analysis re-
vealed that students in year 3 scored higher on
the academic stress subscale than students in
year 1 (t = 2.6, p = 0.010, 95% CI: 4.17 to
0.58) and year 2 (t = 2.57, p = 0.011, 95% CI:
4.96 to 0.65). Students in year 1 scored lower
on the clinical stress subscale than students in
year 3 (t = 2.87, p = 0.05, 95% CI: 5.37 to
0.99) and year 2 (t = 2.01, p = 0.046, 95% CI:
4.37 to 0.40). In Albania – Tirana ANOVA re-
vealed that there was a significant difference in
clinical stress scores by year of study (f = 3.34,
p = 0.04). Further analysis revealed that students
in year 1 scored higher on the clinical stress sub-
scale than students in year 2 (t = 2.45, p = 0.02,
95% CI 0.48–4.43).
The five highest individual item mean scores
across the five countries were examined (see Table
6). The highest mean in the Albania – Korçe (2.54)
and the Albania – Tirana (2.47) sample was ‘‘The
death of a patient’’ whilst the Bruneian sample
(2.58), Maltese sample (2.62) and Welsh sample
(2.74) opted for ‘‘Revising for and sitting examina-
tions’’ and the Czech sample chose: ‘‘Continuous
pressure to meet deadlines for assessments’’
(2.55).

Table 5 Total scores overall by year of study

First year Second year Third year Fourth year
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Albania – Korçe 61.5 12.1 62.4 11.9 64.9 10.7
Albania – Tirana 62.6 11.7 59.4 11.6 60.8 11.0
Brunei 63.5 12.3 65.3 14.2 69.1 10.9
Czech Republic 55.2 10.7 61.5 13.9 56.9 6.9
Malta 61.0 9.3 62.4 12.3 62.2 11.9 60.7 14.0
Wales 55.2 13.1 54.9 16.2 54.6 13.2
142 P. Burnard et al.

Table 6 Rank order of stressors (top five)

Country Stressor Score
Albania – Korçe The death of a patient 2.54
Amount of academic work involved in your training 2.47
Watching a patient suffer 2.42
Feedback from tutors that emphasises negative aspects of your work 2.41
Listening or talking to a patient about his/her approaching death 2.41
Albania – Tirana The death of a patient 2.47
Feedback from tutors that emphasises negative aspects of your work 2.47
Amount of academic work involved in your training 2.42
Watching a patient suffer 2.40
Having to study after a days work 2.34
Brunei Revising for and sitting examinations 2.58
Continuous pressure to meet deadlines for assessments 2.50
Not enough time to complete all your nursing tasks 2.40
Fear of making a mistake in caring for a patient 2.37
Difficulty in finding literature in the library relevant to a subject 2.34
Czech Republic Continuous pressure to meet deadlines for assessments 2.55
Revising for and sitting examinations 2.49
The death of a patient 2.36
Having to pass assessments before moving to the next stage of the course 2.35
Not enough time to complete all your nursing tasks 2.29
Malta Revising for and sitting examinations 2.62
Having to study after a days work 2.50
Watching a patient suffer 2.36
Listening or talking to a patient about his/her approaching death 2.35
Having to pass assessments before moving to the next stage of the course 2.34
Wales Revising for and sitting examinations 2.74
Watching a patient suffer 2.30
Having to study after a days work 2.29
Fear of making a mistake in caring for a patient 2.20
Continuous pressure to meet deadlines for assessments 2.05

Discussion therefore to determine whether nursing students

This study set out to compare and contrast the re-
sponses of a large international sample of student
nurses with regard to levels and sources of stress
throughout their course of study. The samples were
mainly women who were single and in four of the
countries studied a third had children living at
home who they were responsible for. In the sample
from Wales students tended to be older and were
more likely to be married with children. When
investigating levels of stress Welsh nursing students
had the lowest mean score and those in Brunei had
the highest. Whereas the samples from Albania –
Korçe and Albania – Tirana and Malta had very sim-
ilar mean scores.
It has also been established from previous re-
search the nature of both academic and clinical
stressors but there is little information as to which
area i.e. clinical or academic causes the students
the most stress. The second aim of this study was
are more stressed by academic or clinical sources
during their course of study. The findings from this
study showed that students in Brunei and Malta
found the academic elements of the course are
more stressful. Whereas, it is the clinical elements
that are more stressful for nursing students in Czech
Republic and Albania Tirana. For students in Albania
– Korçe and Wales there were no differences in
stress levels between the academic and clinical ele-
ments. These findings obviously require further
investigation in explore whether cultural or curric-
ula differences have influenced these findings.
In terms of the intensity of stress across nursing
programmes, analysis of the findings suggested
that intensity of stress remained constant through-
out the three year course for students from Albania
– Tirana, Albania – Korçe, Malta and Wales. In Bru-
nei however, the intensity of stress varied through-
out the course. Students in year 3 had higher levels
of stress related to the academic element of the
A comparative, longitudinal study of stress in student nurses in five countries
course than students in year 1. Rhead (1995) sug-
gested that by the third year students should be
more experienced at coping with academic assess-
ments thus possibly reducing the stress associated
with the academic part of the course. Lindop
(1999) argues however, that third year students
experience greater stress than students from for-
mer years of training and suggests three possible
explanation for this. Firstly that there are greater
professional stressors placed on third year students
and that they are perceived by peers to be more
knowledgeable and skilful and therefore may be gi-
ven greater responsibility. Secondly that students
may expect more from themselves as they see
themselves on the verge of qualification. Lastly
that they may have greater insight and empathy
into patients situation due to their expanded role.
A number of studies have reported a great deal
of stress and anxiety associated with the initial
clinical experience of first year nursing students
(Admi, 1997; Beck and Srivastava, 1991; Mahat,
1996, 1998; Pagana, 1988, 1990; Sheu et al.,
2002). The main concerns for students during this
period have been identified as fear of doing harm
to patients through lack of knowledge (Neary,
1997), worrying about not giving the right informa-
tion, fear of failure and making mistakes during
procedures (Sharif and Masoumi, 2005). However
Bruneian students in their first year scored lower
for clinical element of the stress scale than stu-
dents in their second and third years. In a previous
qualitative study students from Brunei expressed
their views about clinical stressors (Burnard
et al., in press). The authors found that the stu-
dents status in the nursing hierarchy was a theme
for many of the respondents, perceiving a sense
of tension at being a student in a clinical setting.
Having to wear a pink uniform which denoted the
grade of student nurse was a source of stress. Uni-
form colour appeared to inform other staff of how
students should be treated and viewed. Brunei is a
hierarchical society and, within the nursing profes-
sion, it would appear that those who wear pink may
occupy the lower rungs of that hierarchy.
Regardless of where in the world students are
undertaking their nurse training this study has iden-
tified a number of common stressors. The most
commonly reported academic stressor appears to
be revising and sitting for examinations. This is
confirmed by previous work undertaken by Beck
and Srivastava (1991), Hamill (1995), Lindop
(1999), Timmins and Kaliszer (2002). Also having
continuous pressure to meet deadlines for assess-
ments and/or having to pass assessments before
moving to the next stage of the course were ranked
amongst the top five stressors for students in four
143
of the countries studied. This result suggests that
no matter what kind of assessment strategy is used
that is, continuous assessment or written examina-
tions, students perceive any type of assessment as
being stressful, especially as failure could lead to
discontinuation of the course. When examining
these results, the timing of the administration of
the questionnaires has to be borne in mind has
questionnaires were distributed at the end of the
academic year when students had recently taken
or were about to take their written examinations.
This might have influenced their responses at the
time the questionnaires were completed.
The most commonly reported clinical stressors
include watching a patient suffer, death of a patient
or listening or talking to a patient about his/her
approaching death. In both Albania – Tirana and
Albania – Korçe the death of a patient was ranked
as the most stressful factor during their nurse train-
ing. Timmins and Kaliszer (2002) found that witness-
ing death and suffering among patients to have an
emotional impact on learners. They suggested that
supportive relationships with staff on the ward need
to be developed in order to lessen the impact of
such events and so that the students can be
equipped to deal with them. In a cross cultural com-
parison of workplace stressors is was found that the
emotional issues surrounding death/dying to be pri-
mary work place stressors for nurses across all the
countries studied (Lambert et al., 2004).
Carson and Kuipers (1998) suggest that if that an
individual has insufficient resources (coping strate-
gies) to manage stress that this can lead to nega-
tive stress outcomes. There is substantial
evidence that stress can lead to various negative
consequences for individuals, including somatic
diseases, mental health disorders or feeling of
exhaustion. The impact on educational establish-
ments is reflected in the increased attrition rates
(stress Deary et al., 2003; Lindop, 1989; Lees and
Ellis, 1990; Last and Fulbrook (2003) and increased
sickness absence Timmins and Kaliszer, 2002a,c).
Shipton (2002) found that the emotions gener-
ated by stress in the clinical experience had been
reported to lead to nervousness, depression, anxi-
ety, fear, frustration, anger, hopelessness, loneli-
ness and inferiority (Shipton, 2002). Nursing
students in the study by Evans and Kelly (2004) re-
ported being exhausted, under pressure, upset,
worrying about what might happen, rundown, frus-
trated and worried. This is in keeping with the work
of Deary et al., 2003 who demonstrated that stu-
dents who experienced increasing levels of stress
and who used more negative coping mechanisms
as the programme progressed were more likely to
report psychological symptoms.
144
When compared to students from other health
related disciplines baccalaureate nursing students
regardless of year of program or university of
attendance, experienced higher levels of stress
and more physical and psychological symptoms
than students in other health related disciplines
(Beck et al., 1997).
Conclusions
This large sample has contributed useful data for
future research and comparison across and within
cultures using a validated scale. This study has suc-
ceeded as the first of its kind to compare and con-
trast levels and sources of stress amongst an
international sample. The findings indicate that stu-
dent nurses worldwide do share much in common
while still retaining individual cultural features
relating to stress throughout their course of study.
Limitations
When considering the findings from this study, var-
ious factors need to be kept in mind. First, there
are likely to be cultural differences between these
student groups that cannot be accounted for in a
study of this sort. Those cultural differences may
include issues such as the teacher/student rela-
tionship, attitudes towards teaching and learning
and views of how patients and co-workers should
be treated. All of these factors – and others –
are likely to have an effect on stress levels. Or,
from another perspective, it is possible that they
do not have a stressing effect as cultural issues
may well be ‘taken for granted’ by those living
within particular cultures.
Second, differences are likely to exist in the cur-
ricula offered to the various student groups. This is
likely to include factors such as the breadth, depth
and type of content offered, examination and
assessment processes and evaluation methods.
Again, these factors may or may not effect stress
levels – although the ‘breadth and depth’ issues
seems likely to have potential as a stressor.
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