EXPERIENCE BEFORE AND THROUGHOUT THE NURSING CAREER

A longitudinal study of perceived level of stress, coping and self-esteem

of undergraduate nursing students: an Australian case study

Ruth Lo PhD RN

Senior Lecturer, School of Nursing and Health Care Practices, Southern Cross University, Lismore, New South Wales, Australia

Submitted for publication 5 July 2001

Accepted for publication 9 April 2002

Introduction

Stress is a natural phenomenon that everyone experiences in

his or her lifetime. How people cope with difficult or

stressful circumstances has been the subject of a consider-

able amount of research over the past decade. It is well

known that for most students tertiary education, in general,

is highly stressful (Thyer & Bazeley 1993, Hamill 1995).

The high level of stress often leads to disruptions in

physiological and psychological health (Sarafino 1998). In

addition to affecting the well-being of nursing students,

stress can adversely affect the quality of nursing care

delivery (Beck & Srivastava 1991).

The unusually intense anxiety and stress associated with

nursing education are familiar topics in the literature (Quarry

1990, Courage & Godbey 1992, Kirkland 1998). Hamill

(1995) conducted a qualitative study involving 18 Project

2000 students to examine their perceptions of stress. He

found problems arising from adjusting to tertiary education,

as well as to the ward environment were the major sources of

stress for participants in his study. Clarke and Ruffin (1992)

found the main sources of stress were essentially the same for

� 2002 Blackwell Science Ltd 119

Correspondence:

Ruth Lo,

School of Nursing and Health Care Practices,

Southern Cross University,

PO Box 157,

Lismore,

NSW 2480,

Australia.

E-mail: rlo@scu.edu.au

LO R (2002)LO R. (2002) Journal of Advanced Nursing 39(2), 119–126

A longitudinal study of perceived level of stress, coping and self-esteem of under-

graduate nursing students: an Australian case study

Aim. The aim of this study was to investigate the perception and sources of stress,

coping mechanisms used, and self-esteem in nursing students during 3 years of their

undergraduate nursing programme.

Methods. The sample consisted of a cohort of nursing students going through

3 years of a nursing programme. The method was a descriptive corelational design.

The questionnaire consisted of demographic data, the General Health Questionnaire

(GHQ-12), Self-esteem Scale, and the modified Ways of Coping Scale. Data were

analysed using frequency distributions, content analysis, and measures of correla-

tion.

Results. Results indicated that students in year 1 experienced significantly less

transient stress as compared with year 2; students in year 3 had more positive self-

esteem than year 2 students. There were no significant differences with regard to

chronic stress, avoidance and proactive coping, and negative self-esteem. Chronic

and transient stress, as measured by GHQ, were significantly correlated (P < 0Æ01)

with avoidance coping behaviours, and negative self-esteem. Positive self-esteem

was significantly correlated (P < 0Æ01) with proactive coping behaviours. The four

main stressors in the last three years for this cohort of students, in descending order

are nursing studies, finance, family and health. They coped by using both problem-

focused and emotion-focused coping skills. There is a need to review the nursing

curriculum and evaluate what impacts on students’ stress levels, and also introduce

strategies to reduce the stress levels of nursing students.

Keywords: stress, coping, self-esteem, nursing students, longitudinal study

female and male student nurses. These concerns focused on

study-related issues, the emotional demands of nursing, the

use of technical equipment, interpersonal interaction, and

lack of time for family and personal pursuits.

Evidence exists that the major stresses among nursing

students are: attrition in nursing education during the first

12 months, followed by 13–14 months of training (Lees &

Ellis 1990); the traumatic experiences of being subjected to

cases of death and dying, as well as the responsibility entailed

in taking care of a sick person so early in the students’

educational careers.

People develop habitual ways of dealing with stress and

these habits or coping styles can influence their reactions

(Carver & Scheier 1994). There is diversity among studies

regarding the effects of active coping. There is evidence that

using an active coping approach to life in general promotes

well-being (Aspinwall & Taylor 1992). Conversely, several

studies have found that active coping has the opposite effect

when one is dealing with a focal stressor. Bolger (1990)

found that problem-focused coping during exam prepar-

ation led to higher anxiety just before the exam, whereas

Carver and Scheier (1994) found that problem-focused

coping after the exam led to higher anxiety after grades

were posted.

A study by Lees and Ellis (1990) showed that coping

strategies also depended on experience. Trained staff showed

more use of problem-focused ways of coping, whilst students

and leavers relied more on emotion-focused strategies to deal

with stressful situations. These differences were related to

personality characteristics of the stressful episode. On the

contrary, Adejumo and Brysiewicz (1998) found that stu-

dents tended to use a mixture of coping strategies that were

problem, as well as emotion, focused.

Self-esteem, a positive regard of oneself, is a universal need

for every human being and is a key component in restoring

and maintaining mental and physical health (Meisenhelder

1985). High self-esteem people tend to use denial defence

and to repress or ignore negative information about them-

selves, whereas those with low self-esteem are more flexible,

more able to admit weaknesses and shortcomings, less

dependent on personal facades and less authoritarian (Ootim

1998). According to Jenny (1990), self-esteem is important

to nurses because it is inextricably linked to the nurse’s

ability to communicate, and it enhances the potential for

success.

Theoretical framework

Stress, appraisal, coping and self-esteem were the guiding

concepts for this study, reflecting the view of Seyle (1974),

Lazarus and Folkman (1984), and Rosenberg (1965). Seyle

(1974) differentiated stress as, �the specific response of the

body to any demand upon it from the stress producing

factors, technically called stressors� (p. 27). Lazarus and

Folkman (1984) focused on psychological stress, defining it as

�a particular relationship between the person and the

environment that is appraised by the person as taxing or

exceeding his or her resources and endangering his or her

well-being� (p. 19).

Lazarus and Folkman (1984) defined coping as �constantly

changing cognitive and behavioural efforts to manage specific

external and/or internal demands that are appraised as taxing

or exceeding the resources of the person� (p. 141). Coping

efforts may be directed outward toward changing the

environment (problem-focused) or inward toward changing

the meaning of the event (emotion-focused or palliative).

Reappraisal then influences subsequent coping efforts

(Folkman & Lazarus 1988). The extent to which a person

feels threatened and the coping strategies employed to

mediate the threat are dependent on the appraisals of the

individual regarding the availability and effectiveness of

resources (Lazarus & Folkman 1984).

Self-esteem, according to Rosenberg (1965), means that

individuals respect themselves, consider themselves worthy,

recognize their limitations and expect over time to grow and

improve. It does not mean that individuals consider

themselves better than others, but they definitely do not

consider themselves to be worse than others.

There is a lack of longitudinal studies of the perceived

stress, coping and self-esteem of nursing students going

through their nursing programme. This study is an attempt to

identify the stresses experienced by nursing students, how

they cope with these stresses, and how their self-esteem is

affected during 3 years of nursing education.

The study

Research questions

This study examined the following questions:

• Are there any differences in the level of stress, coping and

self-esteem of nursing students during their 3 years of study?

• What stressors are encountered by students during their

nursing programme?

• How do they cope with their stresses?

• What support systems do they use while doing their nur-

sing programme?

• How do they successfully decrease their stress levels in

relation to their academic studies by the time they enter

their third year of training?

R. Lo

120 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 119–126

Design

The study used descriptive analyses to examine a range of

variables of a cohort of students undertaking their nursing

programme during their first year (Time 1), second year

(Time 2), and third year (Time 3).

Sample selection

The questionnaire, along with a cover letter, was delivered

to a target population of nursing students at a rural uni-

versity where the researcher works. The questionnaires

were distributed during the respective lectures of the cohort

of students during their 3 years in the nursing programme.

There was a total of (n ¼ 120) of first year students

(n ¼ 112) second year students, and (n ¼ 101) of third

year students.

Ethics

The research protocol was passed by the Ethics Committee of

the university. Students had a choice as to whether they

wanted to participate in the study. No names were used on

the questionnaires in order to preserve confidentiality.

Measures

The 12 item version of the General Health Questionnaire

(GHQ) (Goldberg 1978) was used to measure chronic and

transient stress (MacLean 1990, Lo 1999). Each of the items

can be scored for the presence or absence of stress (GHQ

method of scoring) with a score of 5 or more taken as indi-

cating significant emotional stress, or on a 4-point scale of

stress with scores summed to give a continuous measure of

stress. Reliability and validity studies with a range of popu-

lations are described by Goldberg (1978).

The Rosenberg (Rosenberg 1965, Rosenberg et al. 1995)

Self-esteem Inventory was used to measure positive (positive

items) and negative (negative items) self-esteem. Both the

GHQ and Rosenberg inventories are well-known, reliable

and valid measures. All instruments used in this study with

this sample were internally consistent with Cronbach a’s in

excess of a¼ 0Æ80 (see Table 3). It would be expected that

those with high positive self-esteem are more likely to

experience less psychological health than those with low

self-esteem. Similarly, whilst students may suffer from more

transient stress from time to time, it would be expected that

those with long-term more chronic stress are those experien-

cing difficulty with coping.

Lazarus and Folkman’s (1984) Ways of Coping instrument

consists of a 68-item checklist containing a wide range of

actions and thoughts that individuals use to deal with

stressful situations. It is a process measure designed to elicit

information about the strategies an individual uses to deal

with a specific stressful encounter. Factor analysis was used

where four scales were developed: Avoidance, Effort, Advice

and Growth. In this present study, two scales were generated,

an Avoidance scale (a ¼ 0Æ81) and the Proactive scale

(a ¼ 0Æ86), which is the combination of the three scales,

Effort, Advice and Growth.

Results

There were fewer students in third year (n ¼ 101), than in

second (n ¼ 112) or first (n ¼ 120) year. This was because of

attrition rates and also the absence of students from lectures

during the days when the questionnaires were distributed.

Scheffe test (0Æ05), which represents Scheffe’s test using a 5%

significance level was used to test for significant differences.

There was a significant difference in the economic status with

respect to year of students in the programme (F ¼ 6Æ90,

P < 0Æ001). The economic status was measured by students’

income between $5000 and 40 000 and above per annum.

Students in year 1 have significantly less income as compared

with their second, and third year of nursing education.

Biographical factors such as age, gender, marital status and

economical status had no statistical significance in any of the

following analyses.

Differences in the level of stress, coping and self-esteem

of nursing students during their 3 years of study?

Table 1 presents the study variables, means and SD. There

was a significant difference in �Transient stress� with respect

to what year students were in the programme (F ¼ 3Æ55,

P ¼ 0Æ02). Students in year 1 experienced significantly less

transient stress as compared with year 2 of nursing pro-

gramme. There was also a significant difference in �Positive

self-esteem� (F ¼ 2Æ88, P ¼ 0Æ05), students in year 3 had

more positive self-esteem than year 2 students. There were no

significant differences in regard to chronic stress, avoidance

and proactive coping, and negative self-esteem.

Table 2 presents the statistically significant Pearson’s

correlation coefficients among the variables. Chronic and

transient stress, as measured by GHQ, were significantly

correlated (P < 0Æ01) with avoidance coping behaviours,

and negative self-esteem. Positive self-esteem was signifi-

cantly correlated (P < 0Æ01) with proactive coping beha-

viours, where students put more effort into their studies,

and seek information and advice from their lecturers and

friends.

Table 3 shows the mean, standard deviation, minima,

maxima and Cronbach’s a of scales used in this study.

Experience before and throughout the nursing career Stress, coping and self-esteem of undergraduate nursing students

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 119–126 121

What stressors were encountered by students during their

nursing programme?

Table 4 presents the stressors and their ranks by students in

their final year of the nursing programme.

As indicated in Table 4, 81Æ2% students found the nursing

studies most stressful during their nursing programme. They

indicated that other stressors included broken relationships,

parenthood, work pressures and time management, illness,

and the long distance to travel to university.

How do they cope with their stresses?

The information obtained from the open-ended question

asking how students coped with identified stressful events

was grouped into four categories. Three of the categories

represent problem-focused coping (problem solving, recre-

ation and sport, and social support) and one characterized

emotion-focused coping (tension reduction). The content

validity of coping strategies was assessed by two nurse

academics with 92% agreement.

Table 1 Study variables, means and SD

Variable

Year 1 (n ¼ 120) Year 2 (n ¼ 112) Year 3 (n ¼ 101)

Mean SDSD Mean SDSD Mean SDSD

Transient stress 15Æ18 3Æ43 16Æ69 5Æ26 15Æ66 4Æ02

Chronic stress 9Æ81 3Æ20 10Æ68 3Æ32 10Æ31 3Æ33

Avoidance 13Æ71 2Æ89 14Æ21 2Æ80 13Æ32 3Æ69

Proactive 47Æ39 7Æ33 45Æ73 7Æ50 47Æ22 7Æ29

Positive self-esteem 19Æ23 3Æ67 18Æ90 3Æ53 20Æ08 3Æ62

Negative self-esteem 10Æ30 3Æ77 10Æ54 3Æ63 10Æ65 3Æ90

Scores range from 5 to 65, with higher scores indicating increased stress, self-esteem and coping skills employed.

Table 2 Table showing statistically significant Pearson Product Moment Correlations (P < 0Æ05) and probability levels among all variables

Chronic

stress

Transient

stress

Positive

self-esteem

Negative

self-esteem Avoidance Proactive

Chronic stress – 0Æ81 �0Æ54 0Æ49 0Æ46 �0Æ31

P ¼ 0Æ000 0Æ000 0Æ000 0Æ000 0Æ002

Transient stress – �0Æ48 0Æ41 0Æ44 �0Æ31

P ¼ 0Æ000 0Æ000 0Æ000 0Æ002

Positive self-esteem – �0Æ61 �0Æ39 0Æ41

P ¼ 0Æ000 0Æ000 0Æ000

Negative self-esteem – 0Æ56 �0Æ39

P ¼ 000 0Æ000

Avoidance – �0Æ35

P ¼ 0Æ000

Proactive –

P ¼

Variable Mean SDSD Min. Max.

Items

in scale a

Chronic stress 10Æ31 3Æ33 5 19 5 0Æ86

Transient stress 15Æ66 4Æ02 7 26 7 0Æ87

Avoidance 13Æ32 3Æ69 4 20 5 0Æ81

Proactive 47Æ22 7Æ29 25 65 13 0Æ86

Positive self-esteem 20Æ08 3Æ62 9 25 5 0Æ87

Negative self-esteem 10Æ65 3Æ90 4 20 4 0Æ81

Table 3 Means, standard deviations,

minima, maxima, Cronbach’s a of scales

R. Lo

122 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 119–126

Problem solving

There were a few examples given by students as to how they

problem solved. These included keeping things in perspective

such as instead of feeling guilty when insufficient time was

spent with the family, the students set a side a certain time or

day in the week to spend quality time with their families.

When an assignment was due, instead of procrastinating in

doing the assignment, the student makes an effort to do a

search in the library for the topic at hand or spoke to the

lecturer for guidance. Realistic goal setting was also seen as

important, such as making a daily timetable for study, which

could be accomplished for the day.

Recreation and sport

These included gardening, playing with pets, going to the

movies, exercising, laughing, joking, long walks on the beach,

listening to soothing music, and playing sports.

Seeking social support

These included social support from family, spouse/partners,

workmates, classmates, lecturers and tutors.

Tension reduction

These included smoking, drinking, crying, meditation, yoga

and contemplation.

What support systems do they use while doing their

nursing programme?

Table 5 indicates the social support used by the students

during their 3-year nursing programme. It does not correlate

with the number of students but rather with the frequencies.

Four students indicated that they had no social support while

studying at the university. Most students indicated their

family, spouse or partner as their main social support. Item 8

�Other� indicated lecturers, tutors, workmates and a dog. Not

many students used the minister, counsellor or doctor as their

social support.

How do they successfully decrease their stress levels

in relation to their academic studies by the time

they entered their 3 years of training?

Twenty-two (21Æ8%) out of the 101 third-year students

indicated that they have successfully decreased their stress

levels since entering the nursing programme. They were

under three main categories:

Studies

• capable of fulfilling the unit expectations;

• developed better research skills;

• knowledge of resources availability;

• increased knowledge and understanding of studies;

• passing units;

• better studying techniques;

• better time management;

• know that I can approach lecturers for help;

• greater knowledge of what is expected of me;

• more confidence in doing assignments.

Family

• gave up part-time work to allow more time for my family;

• prioritized my life – family is most important;

• allocated specific time to spend with family.

Personal

• better understanding of self and where I am in the world;

• re-examined my life;

• being comfortable in my new environment;

• got to know the people in the programme;

Table 4 Ranked frequency of stressors identified by third year stu-

dents during their nursing programme

Stressors

Number of students (n ¼ 101)

Frequency %

1. Nursing studies 82 81Æ22. Finance 62 61Æ43. Family 49 48Æ54. Health 37 36Æ65. Other 27 26Æ76. Relocation 24 23Æ87. Divorce/separation 20 19Æ88. Death in family 17 16Æ89. Marriage 9 8Æ9

Table 5 Ranked in descending order of frequency of social support

used as identified by third year students during their nursing pro-

gramme

Social support

Number of students (n ¼ 101)

Frequency %

1. None 4 4Æ02. Family 72 71Æ33. Spouse/partner 51 50Æ54. Friends 73 72Æ35. Minister 3 3Æ06. Counsellor 11 10Æ97. Doctor 8 7Æ98. Other 5 5Æ0

Students usually use more than one type of social support, hence the

frequency column does not equate to the number of students.

Experience before and throughout the nursing career Stress, coping and self-esteem of undergraduate nursing students

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 119–126 123

• not working full time, more time for me;

• learned to walked away from things when stressed;

• more peer support.

Discussion

This study examined the perceived stress, self-esteem, and

coping strategies of nursing students, who went through a

3-year nursing programme. The transient level of stress was

greater for nurses in their second year of nursing, than in their

first year. During the second year of nursing training, the

students were engaged much more in clinical practice in

health facilities, thus it might be a possibility that they

experienced transient stress more than in their first year of

nursing. A number of studies have indicated that nursing

students have identified the clinical component of nursing as

the most stressful one (Lindop 1990, Beck & Srivastava

1991, Mahat 1996, Mahat 2001).

As indicated by Gunnings (1982), all college students are

vulnerable to

The strains and tensions that accompany course examinations, the

difficulties of keeping up with academic stands of the institution,

financial difficulties, sexual adjustments, peer pressures, and the

difficulties involved in maintaining stable, supportive family relation-

ships back home. (p. 12)

Nursing students historically have had to deal with the

additional demands of preparation and performance in a

human laboratory, and assuming responsibility and liability

for the safety and well-being of patients (Kirkland 1998).

Sources of stress

The four major sources of stress for this cohort of students, as

ranked in descending order of frequency, were academic

(81Æ2%), financial (61Æ4%), family (48Æ5%), and health

(36Æ6%). The second major stress for students was financial

in nature. During the students’ first year of studies 44Æ2%

experienced stress, in the second year 28Æ4% felt stressed, and

in the third year 21Æ8% were stressed. Many students lived

around the poverty line. About 40% of them were mature-

aged students, and there was the problem of trying to strike a

balance between studies, work and family. Furthermore, as

this is a rural university, about 10% of students travelled

1–3 hours per day to the university from where they live. This

also adds more stress.

Kirkland (1998) study of female African American nurses

in their nursing programme prioritized stressors, as ranked in

descending order of frequency as academic studies (37Æ5%),

environmental (e.g. housing condition) (21Æ9%), financial

(17Æ2%), interpersonal (12Æ5%), and personal (10Æ9%).

Academic studies was still ranked the highest stressor in this

study. The implications of this study suggest that there are

multiple stressors, which are imposed on students while

during tertiary education, and more could be carried out in

regard to facilitate students in their courses.

Coping strategies

In this study, the students indicated that they coped by using

problem solving, recreation and sport, social support, and

tension reduction strategies. In Mahat’s (2001) study, the

perceived stressful experiences in clinical settings for students

were interpersonal relationships, ability to perform, heavy

workload, and feelings of helplessness. The students coped by

using problem solving, seeking social support, tension

reduction and avoidance. In Kirkland (1998) study, the

major stressors identified by African American baccalaureate

nursing students were academic in nature, environmental,

financial, interpersonal, and personal stressors. Coping strat-

egies used with the greatest regularity and success were active

coping, and seeking social support for instrumental and

emotional reasons. Behavioural disengagement, denial, and

alcohol-drug disengagement were reported to be unsuccessful

coping strategies in the majority of instances (Kirkland 1998).

Support systems

Results from this study indicated that most students have

their family, spouse or partner as their main support system.

Social support most commonly refers to functions performed

(e.g. supporting an individual emotionally, financially) for a

distressed individual by significant others such as family

members, friends, coworkers, relatives and neighbours.

Considerable research now indicates that social support

reduces, or buffers, the adverse psychological impacts of

exposure to stressful life events and ongoing life strains

(Cohen & Wills 1985, Thoits 1986). Relationships with

others, especially with intimates or confidants, can signifi-

cantly lower the risk of psychological disturbance in response

to stress exposure (Thoits 1986).

Four students indicated that they had no social support at the

university. As this is a rural university, a number of students

had to relocate to a new environment, and maybe these four

students did not find anybody they felt could give them support

during times of need. Although there are ministers, counsellors

and doctors on campus, they are not used much by students

during their stressful times. Jones (1978) found that 25% of his

sample of 50 nurse trainees said that they would not know who

to turn to when in need of counselling and guidance. For nurses

R. Lo

124 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 119–126

in this position, burnout becomes a real possibility, and this

lack of support underpins the success of group and individual

counselling programmes in reducing reported stress and staff

turnover (Gray-Toft & Anderson 1983).

Methods used by students to successfully decrease their

stress levels

Twenty-one students (21%) identified methods of decreasing

their stress levels. They developed better studying techniques

and skills in research, time management and greater know-

ledge in what was expected. These skills were developed over

time and as students improve, they felt more at ease with their

academic studies. Furthermore, in order to have a balance

between studies, work and family, they prioritized their life

so that what was important to them became the main focus.

Personally, they developed more confidence and a better

understanding of themselves.

Study limitations

Although the study has provided some useful and interesting

data, several limitations should be noted. The relatively small

sample size precludes generalization beyond the study pop-

ulation. As well, this study looked at only selected charac-

teristics of the individual and environment. Many of the

variables (self-efficacy, locus of control) could account for

differences in stress experience of students. Finally, no

comparison group was used in the study, therefore it is

difficult to ascertain how the stress scores of nursing students

are different from other populations in the university.

Conclusion

A number of implications for curriculum planning in nursing

education and finding ways to relieve stress emerge from the

results of this study. They are as follows:

• The examination of the impact of the curriculum structure

on students’ perceptions of stress and how stress affects

decisions to continue or withdraw from the nursing pro-

gramme. In regard to assessments/assignments, there

should be a collaborative effort among academic staff

members to make sure that assessments/assignments are

not all due in the same weeks during the semester; rather,

there should be a spread in when assessments/assignments

are due, as this will make it less stressful for the students.

• The aspects of stress induced by the academic element

of the training should be addressed at the foundations of

nurse education (Rhead 1995). During the first semester of

the nursing programme, students need to be instructed on

how to write academic assignments, how to conduct a

proper search for a topic in the library, and where to go

for help when they encounter difficulties in writing aca-

demic assignments.

• Students need a comprehensive orientation programme

to inform and thoroughly acquaint them with the cur-

riculum requirements, available services, how to access

them, and when they should be accessed. During the

orientation programme, ministers, counsellors and doc-

tors working on campus should be introduced to the first

year students and inform students where they are located

in the university campus. This face-to-face encounter will

assist students in identifying the relevant support per-

sons.

• Stress management training should also be introduced in

the curriculum for students in order to equip them with

methods of reducing their stress levels. In this university,

this is an elective unit, and students who have taken this

unit found that it had been of great benefit to them not

only in their academic but their personal lives.

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