In the healthcare delivery system, student nurses (SNs) are the next-liners in patient care. Therefore, they are obliged to experience scenarios that they will encounter when they become registered nurses (RNs) which are achieved through clinical placements. However, they often face a variety of stressors that may have consequential effects to their health and well-being. Stressors are hindrances in providing optimum quality of care that student nurses render to their respective patients. This essay will demonstrate critical analysis as to what are the stressors that contribute to a nursing students’ inability to cope in the clinical environment. Furthermore, the negative effect of stressors on emotional and psychological health of nursing students which manifest the inadequacy of patient care delivery. Finally, the nursing students’ highlight on how coping strategies can help them in dealing with stressors be managed and implemented by nursing institutions.

Stress is defined as an individuals’ reaction to any change that requires an adjustment and response, which can be physical, mental, or emotional (Townsend, 2012). Stress continues to pose a concern due to the negative consequences on students’ health and well-being (Jimenez et al., 2010). In fact, nursing student has been reported experiencing high levels of stress compared to other students in the healthcare field (Reeve et al., 2013). High levels of stress in nursing students can lead to emotional and psychological breakdown, thereby, can affect the quality of the patient care they provide (Shaban et al., 2012). Additionally, nursing students are often introduced to a highly specialized clinical environment integrated with the stress of completing unknown assignments and procedures which can lead to higher stress levels (Eswi et al., 2013).

A cross-sectional study conducted by Blomberg et al., (2014) in Sweden, reveals that nearly half of the nursing students (43%) experienced high level of stress during clinical practice. The participants are one hundred and eighty-four nursing students at three universities in central Sweden who completed their final year on the nursing course (Blomberg et al., 2014). The result of the study measured the absolute risk of stress which was 57% in nursing students with placements in hospital departments, as compared to 13% in nursing students with placements in other clinical settings (Blomberg et al., 2014). The study used numerical rating scale (NRS-10) for the assessment of experience of stress. The confidence interval of the study was 95% (0.67-0.89), p < 0.01 (Blomberg et al., 2014). This illustrates the need for a change in performance in the clinical environment over-crowded with patients (Burnard et al., 2008). Furthermore, Burnard et al., (2008) reported that the risk of stress is frequent in nursing students in the clinical environment, while Pulido-Martos et al., (2012) has identified the source of stress are usually described in respect of either the clinical or the academic part of the nursing education.

Clinical
Stressors has been perceived more intensely stressful than academic stressors by
nursing students at both experienced and novice level (Jimenez et al., 2010).
Common clinical stressors reported are witnessing dying patients, the
relationship between student and nursing preceptors, providing care, lack of
professional knowledge and skills, practical assignments and workload
(Pulido-Martos et al., 2012). In the clinical rotations, nursing students had
to carry a high level of responsibility and accountability while dealing with
patients. Sometimes, nursing students deal with seriously ill or dying
patients. Caring for paediatric patients in general causes an increase in
stress for nursing students and the death of a patient is also a stressful
event (Ab Latif & Mat Nor, 2016). Moreover, nursing students are supervised
by their respective nurse preceptor/educator during their clinical placements
(Sundler et al., 2014). The supervisory relationship and the students’ learning
also seemed to be influenced by the preceptors’ interest, attitude, and
approaches as being the most common reason for students’ dissatisfaction (Sundler
et al., 2014). Nursing students reported that implementing new procedures are stressful
as they are concerned about lack of experience and technical skills; and the
need for more time in the clinical ward (Ab Latif & Mat Nor, 2016). Nursing
students frequently identified preparing for clinical assignments as a
concerning part (Ab Latif & Mat Nor, 2016). The area of concern was the
writing of nursing care plans as they perceived it as burden while in clinical
practices. Additionally, nursing students also perceived heavy workload as one
of their clinical stressors (Ab Latif & Mat Nor, 2016).

Academic
stressors embody the whole area of learning and achieving, as well as adjusting
to a new environment (Seyedfatemi et al., 2007). Distinct features of the
nature of nursing that impact on academic stressors include assessments, examinations,
fear of failing academic course and advanced-level education focusing on
research based knowledge (Jimenez et al., 2010).  These features are at the essence of stress
and it leads directly to negative effects of emotional breakdown on the nursing
students’ performance in the clinical environment (Brown & Edelman, 2000).

Stress
has been recognized as the major factor resulting to negative and maladaptive
coping such as lowered self-esteem, lack of control, negative attitudes towards
self, work and colleagues which progresses to emotional storm (Brown &
Edelman, 2000). Emotional storm demonstrates the nursing students’ behaviour
such as being extra cautious, crying, avoidance, withdrawal,
overprotectiveness, and overcompensation (Brown & Edelman, 2000). In
addition, student nurses have recognized both difficulties of interaction with
patients and nurse preceptors throughout the clinical environment (Freeburn
& Sinclair, 2009). These difficulties can lead to another negative effect
of stressors in psychological health (Pryjmachuk & Richards, 2007).

Nursing
students’ success in clinical education is directly influenced by psychological
and emotional health (Pryjmachuk & Richards, 2007). Research has shown that
nursing student experiences psychological distress and difficulties in
adjustment as important issues facing nurse preceptors in clinical environment
(Warbah et al., 2007). Inadequately skilled faculty members and unpreparedness in
the clinical environment are some of the contributing factors to severe stress
in nursing students, followed by psychological effects such as anxiety and
depression (Pryjmachuk & Richards, 2007). Moreover, anxiety and depression coexist
with the students along the nursing education period which can affect their
health and educational performance (Edward et al., 2010). The combination of emotional
and psychological effects lead to inadequacy of patient care provision for
nursing students (Sheu et al., 2002).

Stress during undergraduate education influences the future working life of a nursing student, in the form of psychological impairment and emotional breakdown (Sheu et al., 2002). Thus, stress can affect the quality of care for their respective patients (Sheu et al., 2002). This was strengthened by a study conducted by Seyedfatemi et al., (2007) student nurses identified sense of inadequacy in associating with acutely ill patients and has difficulty establishing relationships with nursing preceptors. In addition, nursing students feared the possibility of harming themselves and their patients due to inadequacy of skills and knowledge that leads to neglection in patient care (Seyedfatemi et al., 2007).

Despite
the negative effects on emotional and psychological health of nursing students,
stressors also have its advantages. Stressors have been acknowledged to have potential
significant impact upon the educational process, including particularly
academic performance and well-being of students (Burnard et al., 2007). In the
contrary, stress can sometimes lead to increased motivation and achievement,
recent nursing research into the concept reflects growing concerns of prolonged
stress among the nursing profession (Burnard et al., 2008). This evidence was supported
by a study conducted by Gibbons (2010) research has shown that stress can be
beneficial to nursing students as it acts as a powerful motivator for learning.
 Nursing students cannot avoid the
stressors, however, their ability to adjust to demands and coping strategies
are important in achieving success in the clinical environment (Seyedfatemi et
al., 2007).

Coping
is the individual cognitive evaluation towards stress (Luo & Wang, 2008). Coping
has been considered as a stabilizing factor that can support individuals in
maintaining psychosocial adaptation during stressful events (Seyedfatemi et
al., 2007). Moreover, coping responses can be described as positive or negative
depending on the situation and the content of the response (Seyedfatemi et al.,
2007). In a recent study conducted by Labrague et al., (2017) deemed that strengthening
the student nurses with positive coping mechanisms may support them in dealing
with stressors and achieve maximum clinical learning. Positive coping does not
only reduce stress level but also moderates the effect of stress on their
physiological and psychological well-being (Klainin-Yobas et al., 2014). Thus,
helping the student nurses’ build coping skills that are essential to their
self-efficacy through simulation in the clinical environment (Zhao et al.,
2015). Furthermore, linking these coping strategies to nursing institutions are
helpful to better prepare nursing students manage stress effectively
(Klainin-Yobas et al., 2014). This knowledge has implications for nursing
students, nurse preceptors, lecturers, tutors, and nursing institutions,
highlighting the need for additional proactive approaches to the provision of
guidance on professional support for students and staff (Freeburn &
Sinclair, 2009).

The outcome of the essay clearly states the stressors of a nursing student in the clinical environment. Nursing students experience stress mainly from clinical and academic stressors. However, the degree of stress and coping strategies differ significantly according to the nursing students’ emotional and psychological well-being. Nursing students’ year of study influenced their overall stress experience and coping abilities respectively. Clinical environment is an important part of any undergraduate nursing curriculum. Implementing techniques to cope with stress can support the nursing students’ performance in the clinical environment. Therefore, it is important that nursing students manage the pressure because it will affect the level of achievement in their academic course. Thus, affecting the nursing students’ clinical skills in the clinical environment and the care of patients. Nursing students are the primary beneficiaries as the listed strategies can ease the stressful clinical environment of their nursing programme. Lastly, educational institutions and their affiliated partners are the secondary beneficiaries as they can support the students on the initial clinical exposure in the clinical environment.

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