Nurse Education Today

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1 Nurse Education Today 30 (2010) Contents lists available at ScienceDirect Nurse Education Today journal homepage: A longitudinal study of stress and self-esteem in student nurses Deborah Edwards *, Philip Burnard, Kim Bennett, Una Hebden Cardiff University, Nursing, Health and Social Care Research Centre, Cardiff School of Nursing and Midwifery Studies, 4th Floor, Eastgate House, Newport Road, Cardiff CF24 0AB, United Kingdom article info summary Article history: Accepted 15 June 2009 Keywords: Students Nursing Stress Self concept Introduction: It is well recognised that nurse education/training can be a stressful experience and that self-esteem is an important predictor of stress. Background/literature: While there are a significant number of studies showing levels and contributors to stress among students. There is little evidence of how these levels change over time. The aim of the study was to investigate nursing students experiences of stress and levels of self-esteem during three years of their undergraduate nursing programme. Methods: Participants completed the stress in nurse education questionnaire and the culture free selfesteem inventory at various time points in the study, and a demographic questionnaire at baseline. The students who took part in the study commenced their nurse training in September Data/results: This study has demonstrated that levels of self reported stress and general self-esteem are significantly different at different stages the nurse training process. Self reported stress were at the highest at the beginning of the third year and these were significantly higher when compared to stress reported at any other time point. Self-esteem levels were lowest at the end of training. Conclusions: Trying to obtain data only at single time point during nurse education/training is inadequate as this research has shown that there is indeed variation in student psychological well being across the academic year. Ó 2009 Elsevier Ltd. All rights reserved. Introduction Stress and self-esteem are the guiding concepts of this study, reflecting the view of Lazarus and Folkman (1984), and Rosenberg (1965). Lazarus and Folkman (1984) define stress as 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). Selfesteem broadly defined, refers to the extent to which individuals value themselves (Reber and Reber, 2001), and has long been identified as an important predictor of adjustment to stress (Lazarus and Folkman, 1984). Rosenberg (1965) suggests that individuals respect themselves, consider themselves worthy, recognise their limitations and expect over time to grow and improve. It is inversely related to psychological indicators of stress and strain (Kivimäki and Kalimo, 1996). It is well recognised that nursing is a stressful occupation (Bennett et al., 2001, Bennett, 2002; Jones and Johnston, 2000; McVicar, 2003). However, the problem of stress does not begin when the nurse qualifies, but is evident during nurse education/training (Rhead, 1995) and may affect academic performance and student * Corresponding author. Tel.: address: edwardsdj@cardiff.ac.uk (D. Edwards). well being. In the UK, a number of studies have investigated the stressors relating to the practical aspects of nursing for students prior to Project 2000 (see for example Jack, 1992; Parkes, 1980a,b, 1982, 1984, 1985). Other studies have identified students stress experiences during their formal education (see for example Lindop, 1989, 1991) and report that stress increases as training progresses. Background/literature More recently, studies among Project 2000 students (Brown and Edelmann, 2000; Evans and Kelly, 2004; Hamill, 1995; Jones and Johnston, 1997, 1999; Timmins and Kaliszer, 2002a; Tully, 2004) have identified specific academic and clinical stressors throughout the programme of study. Jones and Johnston (1997) reported a number of academic stressors for first year students which included lack of free time, long hours of study, college response to student need and fear of failing. Several studies have reported academic stressors for students in their final year and these include not being treated as an adult learner, confusing assignment guidelines and the amount of self directed learning (Hamill, 1995), financial concerns and relationships with teaching related staff (Timmins and Kaliszer, 2002a). Where studies have investigated academic stress throughout the entire /$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi: /j.nedt

2 D. Edwards et al. / Nurse Education Today 30 (2010) programme of study the issues that caused them stress included examinations (Evans and Kelly, 2004; Lindop, 1999), the intense amount of work (Evans and Kelly, 2004; Tully, 2004), finding the academic work difficult, being faced with study (Evans and Kelly, 2004) and financial concerns (Brown and Edelmann, 2000). The clinical stressors identified by research studies for students in their first year of study were lack of practical skills, negative attitudes of ward staff and misunderstanding of supernumerary status (Hamill, 1995), whereas for final year students the stressors were identified as death of a patient and relationships with clinical related staff (Timmins and Kaliszer, 2002a). Where studies have investigated clinical stress throughout the entire programme of study the issues that cause them concern have been identified as the theory to practice gap, atmosphere among clinical staff, being reprimanded in front of staff and patients (Evans and Kelly, 2004) and the death of a patient (Rhead, 1995). The most recent study conducted by Pryjmachuk and Richards (2007) found that stress in nursing students arises from a combination of personal and extracurricular factors rather than from the educational programme itself. While there are a significant number of studies showing levels and contributors to stress among students, there is little evidence of how these levels change over time. The one longitudinal study to examine this issue (Deary et al., 2003) found increasing levels of stress and use of emotion-oriented, avoidance and distraction coping strategies, as the programme progressed. Stress was measured at baseline and at the end of the first year whereas all other variables were measured again during the second and third year. Burnard et al. (2008) reported data from a series of cross-sectional surveys in student nurses in each year of training, and found no evidence of changes in the intensity of stress during the course of training. Accordingly, there is need of a longitudinal study of student stress over time. Self-esteem has long been identified as an important predictor of adjustment to stress (Lazarus and Folkman, 1984). Now considered a multidimensional construct that can change over time in response to a variety of external and internal influences (Greenier et al., 1995), high levels of self-esteem are considered important in terms of both managing the demands placed on nurses during their training and for developing a strong and therapeutic relationship with a patient (Ohlen and Segesten, 1998). Although a number of studies have shown how self-esteem varies over the course of the training period, there is little consensus within the data (Begley and Glacken, 2004; Lees and Ellis, 1990; Randle, 2003; Sasat et al., 2002). Different aspects of self-esteem (social, personal and general) in nursing students were investigated across three years of nurse training programmes in two countries and no relationship was found between self-esteem and year of study (Sasat et al., 2002). The three longitudinal studies conducted in the UK provided conflicting evidence. Randle (2003) found that although the majority of students commenced their nurse training with average levels of self-esteem as classified by the Tennessee Self Concept Scale, by the time they finished their education their self-esteem had fallen to the point that 95% of the students perceived themselves as anxious, depressed and unhappy. By contrast, Begley and Glacken (2004) found that students self-esteem rose as they neared the end of their education programme, although their overall self-esteem levels at their highest were only average. Lees and Ellis (1990) revealed that self confidence and self-esteem was higher at the beginning of the nursing program and decreased with each subsequent year. In view of these contradictory or preliminary findings, there is a clear need for more data concerning the longitudinal course of both stress and self-esteem in student nurses. This study provides such data. The aim of the study was to investigate nursing students experiences of stress and levels of self-esteem during three years of their undergraduate nursing programme and whether changes occur over this time. The is the first study of its kind which has explored stress and self-esteem. The study was longitudinal and prospective, and followed an entire year-of-entry cohort at one University (including nurses from adult, child and mental health training pathways). Method Questionnaires Participants completed two questionnaires at each time point in the study, and a demographic questionnaire at baseline. The Stress in Nurse Education questionnaire (Rhead, 1995) isa modified version of the Nurse Stress Scale (Gray-Toft and Anderson, 1981) which incorporates academic stressors and was designed specifically for use within nurse education. The questionnaire comprises 32 items that describe stressful situations. Sixteen items describe clinical situations and another sixteen items describe academic situations. A 4-point Likert scale (0 3; not stressful to extremely stressful) is to measure the intensity of stress associated with each item. A total stress score is obtained by summing responses to the 32 items, with a possible range of scores form Clinical and academic stress sub-scale scores can be obtained by summing the relevant item scores. Cronbach s alpha for the overall scale for this study was The Culture Free Self-esteem Inventory 2 (CFESI-2; Battle, 1981) comprises 40 items measuring four self-esteem subscales: general self-esteem (16 items); social self-esteem (eight items); personal self-esteem (eight items); and lie subtest (eight items that indicate defensiveness). The items in the instrument are divided into two groups: those that indicate high self-esteem and those that indicate low self-esteem. The responses are of forced choice variety; the individual checks each item either yes or no. General self-esteem is the aspect of self-esteem that refers to individuals overall perceptions of their worth, social self-esteem is the aspect of self-esteem that refers to individuals perceptions of the quality of their relationships with peers and personal self-esteem is the aspect of self-esteem that refers to individuals most intimate perceptions of self worth. Cronbach s alpha for the overall scale for this study was The demographic questionnaire recorded age, gender, previous academic qualifications, marital status and information on children living at home. Questionnaires were administered on the following occasions: Time one (T1) Time two (T2) Time three (T3) Time four (T4) Time five (T5) The beginning of the 3rd module after two clinical placements (approx 8 months) At the beginning of the 2nd year At the beginning of the 6th module after five clinical placements (approx 20 months) At the beginning of the 3rd year at the end of the 3rd year on the last day of term when exam results would already have been known The Ethics Committee of the relevant School of Nursing and Midwifery Studies passed the research proposal. The questionnaire was administered along with an information sheet about the study and a consent form and was administered and completed in the presence of the one of the researchers. Prior to administering the questionnaire a full explanation was given to the respondents regarding the status of the researcher and the purpose of the study.

3 80 D. Edwards et al. / Nurse Education Today 30 (2010) Table 1 Sample size. Year Cohort Size (n) Returned (n) Response rate (%) Time Time Time Time Time Respondents were given 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. Sample The students who took part in the study commenced their nurse training in September 2002; the intake for this course was 169. The number of participants at each time was determined by the number of students attending lectures on the day of the study (see Table 1). All students within each cohort were required to attend these lectures on all occasions. Data analysis The means of the stress and self-esteem scale at each time point was compared using ANOVA for Time 1 (T1) Time 5 (T5) and further analysis undertaken using pair wise comparisons (Bonferroni adjustment). Potential correlations between the self-esteem and stress scores were measured using Pearson s correlation. Data was entered and processed using SPSS 12 for Windows. Results The demographic data are presented in Table 2. Not all students answered all questions at each time point. Ninety (80%) had completed some form of academic study prior to entry, of these 38 (33.9%) had completed A Levels and 38 (33.9%) had completed an access course. Just over a third of students were mature students being older than 26 years at point of entry into the course. The average age at point of entry was 24. Three years of age with the youngest student being 18 and the oldest being 46 years of age. At the final time point students were asked if their marital status had changed since they had started their programme of study. Marital status had changed for seven students, five had married and two been divorced or separated. A quarter of the students had children living at home with them whilst they were studying throughout the period of training. Only a small number of males (10%) undertook nurse training. Table 3 Mean self-esteem scores. Self-esteem The mean scores for self-esteem are displayed in Table 3 and the categorisation of the scores into very low, low, intermediate, high and very high self-esteem are displayed in Table 4. A significant difference in the average scores across time was demonstrated for general self-esteem (F = 7.1, df = 4, p = 0.001) but not for social (F = 1.4, df =4, p = 0.2) or personal self-esteem (F = 1.2, df =4, p = 0.2). Table 5 shows the subsequent pair wise comparisons (Bonferroni adjustment) for general self-esteem across time which revealed a number of significant differences (T2 > T4/T5 (95% CI: / ), T3 > T5 (95% CI: ). The individual items on the CFSEI for general self-esteem that appeared to be of concern were finding it hard to meet new people, lacking in self confidence and wanting to change things about themselves if they were able. The correlation between overall stress scores and the overall self-esteem scores was explored using Pearson s correlations and revealed that as stress increased then self-esteem decreased at time 1, time 3 and time 4 (see Table 6). Stress Overall mean General mean Social mean Personal mean Norms 23.1 (6.7) 11.8 (3.7) 6.6 (1.5) 4.7 (2.4) T (5.9) 11.5 (3.3) 6.8 (1.3) 4.2 (2.4) T (5.3) 12.3 (2.8) 7.0 (2.3) 4.6 (1.5) T (6.2) 11.6 (3.2) 7.0 (1.3) 4.4 (2.4) T (5.3) 10.7 (2.6) 7.1 (1.1) 4.7 (2.6) T (4.9) 10.2 (2.3) 7.1 (1.1) 4.9 (2.3) Table 4 Categorization of overall scores. Levels of selfesteem Very low Low Intermediate High Very high n (%) n (%) n (%) n (%) n (%) T T T T T Very high (30+), high (27 9), intermediate (20 28), low (15 19), very low (<13). The mean overall scores for stress are displayed in Table 7. A significant difference in the overall scores over time was Table 2 Demographic information. Demographics Time 1 Time 2 Time 3 Time 4 Time 5 n (%) n (%) n (%) n (%) n (%) Males 11 (9.8) 11 (12.4) 6 (7.9) 8 (9.1) 10 (10.8) Females 101 (90.2) 78 (87.6) 70 (92.1) 80 (90.9) 83 (89.2) 25 and below at entry 74 (66.1) 26 and above at entry 38 (33.9) Children living at home 28 (25) 25 (28.15) 22 (28.2) 24 (22.6) 30 (29.4) Married 21 (18.8) 19 (21.3) 14 (18.4) 18 (20.2) 25 (26.9) Single 86 (76.8) 67 (75.3) 57 (75) 65 (73) 61 (65.6) Divorced/separated 5 (4.4) 3 (3.4) 5 (6.6) 6 (6.8) 7 (6.6) Mean age 24.3 years 25.4 years 25.6 years 26.1 years 27.7 years (Range) (18 46) (19 47) (19 47) (20 48) (20 52)

4 D. Edwards et al. / Nurse Education Today 30 (2010) Table 5 Pair-wise comparisons (Bonferroni adjustment) for general total self-esteem scores T1 T5. (I) Time (J) Time Mean difference (I J) S.E Sig 95% Confidence interval Lower T1 T T T T T2 T T T4 4.1 a T5 5.7 a T3 T T T T5 3.7 b Upper T4 T T2 4.1 a T T T5 T T2 5.7 a T3 3.7 b T Bonferroni adjustment made for multiple comparisons. a T2 > T4/T5 (95% CI: / ). b T3 > T5 (95% CI: ). demonstrated (F = 2.79, df =4, p = 0.03). Table 8 shows the subsequent pair wise comparisons (Bonferroni adjustment) for stress across time which revealed significant differences between T1 and T4 (T4 > T1 (95% CI to 0.49)). The individual items on the stress in nurse education questionnaire and their corresponding mean and standard deviations are presented in Table 9 in rank order. Across all the years the items that appeared to be of concern included revising for and sitting examinations, continuous pressure to meet deadlines for assessments, having to study after a days work, fear of making a mistake in caring for a patient and watching a patient suffer. Table 6 Correlation (r) between stress and self-esteem. Overall self-esteem scores T1 T2 T3 T4 T5 T1 Overall stress score 0.16 * Academic stress score 0.14 * Clinical stress score 0.14 * T2 Overall stress score 0.19 Academic stress score 0.17 Clinical stress score 0.16 T3 Overall stress score 0.27 * Academic stress score 0.25 * Clinical stress score 0.26 * T4 Overall stress score 0.27 * Academic stress score 0.24 * Clinical stress score 0.21 * T5 Overall stress score 0.12 Academic stress score 0.10 Clinical stress score 0.12 * Correlation significant at p<0.05. Table 7 Mean stress scores. Discussion Overall mean Academic mean Clinical mean T (13.56) (7.40) (7.64) T (14.33) (8.14) (8.05) T (14.68) (7.84) (8.35) T (12.80) 29.6 (7.13) (7.32) T (14.28) (7.74) (8.09) Table 8 Pair-wise comparisons (Bonferroni adjustment) for total stress scores T1 T5. (I) Time (J) Time Mean difference (I J) S.E Sig 95% Confidence interval Lower Upper T1 T T T4 6.1 a T T2 T T T T T3 T T T T T4 T1 6.1 a T T T T5 T T T T Bonferroni adjustment made for multiple comparisons. a T4 > T1 (95% CI to 0.49). This study has demonstrated that levels of self reported stress and general self-esteem are significantly different at different stages the nurse training process. General self-esteem is the aspect of self-esteem that refers to individuals overall perceptions of their worth. Students at the end of their training have lower levels of general self-esteem compared to when they were 8 months into nurse training. Epstein describes worth as being central to one s personality and that it is a made up of perception, experience and motivation. In simple terms it can be described as feeling good about oneself. According to Epstein two experiences in adult life have the potential to affect self-esteem most directly: experiences involving success failure and acceptance rejection (Epstein, 1980, 1985). Epstein also reported that when self-esteem was lowered then the feelings of unhappiness, anger, feelings of threat, weariness, withdrawal, nervousness, disorganisation, conflict, feelings of restraint, and self consciousness are high (Epstein, 1979). Bearing this in mind, in the current study the stage in nurse training when self-esteem is at its lowest is just after the students have discovered whether they have passed or failed their training linking in with the success failure experience and when they will be applying for jobs linking in with the acceptance rejection experience. Arthur (1992) in reviewing the literature from the 1970s onwards, suggests that low self-esteem is a problem for student nurses, that and self-esteem decreases as nursing courses progress,

5 82 D. Edwards et al. / Nurse Education Today 30 (2010) and that new graduates lack self-esteem (Olsen et al., 1984). Begley and Glacken (2004) studied nursing students perceived levels of self-esteem and their fear of negative evaluation prior to, and close to the completion of their 3 year degree programme and found increased self-esteem of students who were about to end the program although at its highest self-esteem at its highest level was only average. In contrast, Lees and Ellis (1990) revealed that self confidence and self-esteem levels were higher at the beginning of the nursing program and decreased with each subsequent year. Similarly, in the study by Randle (2003) at the end of the nursing program students self-esteem levels had decreased dramatically. Our study has shown that students had lower general self-esteem at the end of their training. The students with low general self-esteem in the current study find it hard to meet new people, lack self confidence and would like to change things about themselves if they were able. Self-esteem represents the extent to which we believe ourselves to be capable, significant, successful and worthy. Hence it has been suggested that nurses achievements and job satisfaction are closely associated with self-esteem (Jenny, 1990) and that self-esteem can provide a positive focus for therapeutic work with clients (Carson et al., 2001). Burgess suggests that the quality of care given by an individual will be consistent with the kind of person that the individual has become (Burgess, 1980). Self-esteem has been linked to the ability to communicate (Carson et al., 2001) and communication with patients is a vital part of effective therapy (Leddy and Pepper, 1989). If self-esteem is low then it is unlikely that nurses will be able to fulfil the demands resulting from many policies and structures currently affecting healthcare and patient care may suffer (Randle, 2001). Healthy self-esteem may therefore influence patient care in a positive direction (Arthur, 1992). It has been suggested that self-esteem acts as a buffer against stress. When encountering stress, those with higher self-esteem have a higher sense of personal worth, which acts as a shield against the negative impact of stress (Mruk, 1999). Those with lower self-esteem do not have this protective shield. In this study it can be seen that those with lower self-esteem do indeed have higher stress levels. This study demonstrated that levels of self reported stress were at the highest at the beginning of the 3rd year and these were significantly higher when compared to stress reported at any other time point. By the time that the students have finished their nurse training, completed their examinations and were in the process of applying for jobs, their stress levels went down. It has been suggested that Table 9 Stress items: mean score and item ranking. Item Time 1 Time 2 Time 3 Time 4 Time 5 Mean S.D. Rank Mean S.D. Rank Mean S.D. Rank Mean S.D. Rank Mean S.D. Rank Revising for and sitting examinations Not knowing how deep to study a subject Continuous pressure to meet deadlines for assessments Fear of making a mistake in caring for a patient Watching a patient suffer Having to pass assessments before proceeding to the next stage of the course Having to study after a days work Difficulty in finding literature in the library relevant to a subject Little direction as to what is expected of you Amount of academic work involved in your training Not enough time to complete all your nursing tasks Feeling that nothing is done when students constructively criticise aspects of the course Classroom environment is not conducive to learning Feeling inadequately prepared to help with the emotional needs of a patient Feeling inadequately prepared to help with the emotional needs of a patients family Not knowing what a patient or patient s family ought to know abut a patients medical condition Not enough time to provide emotional support to a patient Feedback from tutors that emphasises negative aspects of your work Inadequate support from tutors Unsure of the structure of the course Uncertainty regarding the operation and functioning of specialised equipment Listening or talking to a patient about his/her approaching death The death of a patient Home environment makes studying difficult Difficulty in working with a particular nurse or nurses on clinical placement Lack of an opportunity to talk openly with staff about problems on a clinical placement Conflict with supervisor on clinical placement Criticism by a supervisor on a clinical placement Difficulty in relating theory to the care of patients Disagreement concerning the treatment of a patient Feeling there is a label attached to your course Lack of an opportunity to share experiences and feelings with staff on a clinical placement

6 D. Edwards et al. / Nurse Education Today 30 (2010) third year students experience greater stress than students from former years of training as there are greater professional stressors placed on them and that they may expect more from themselves as they see themselves on the verge of qualification (Lindop, 1999). Pryjmachuk and Richards (2007) research suggests that it is the status of being a student that is stressful rather than being a student nurse and that balancing the role of student with the hassles of everyday living is responsible for student stress. When compared to students from other disciplines, research has shown found that nursing students experience higher levels of physiological and psychological symptoms than students in other health related disciplines of medicine, pharmacy and social work (Beck et al., 1997). Stecker (2004) found that nursing students reported higher academic and external stress than students in physical therapy, pharmacy, dentistry and medicine. The authors attributed this to the fact that nursing students were more likely to have outside employment during their academic training, leading to less time for studying and more job and financial stress (Stecker, 2004). The number of students from higher education presenting with symptoms of mental ill health in recent years has increased (Andrews and Wilding, 2004) and the mental health of students in the caring and related professions has been an area of concern (Royal College of Psychiatrists, 2003). There is substantial evidence that stress can lead to various negative consequences for individuals, including somatic diseases, mental health disorders or feelings of exhaustion. Nursing students in the study by Evans and Kelly (2004) reported being exhausted, under pressure, upset, worrying about what might happen, rundown, frustrated and worried. This is in keeping with the work of Deary and colleagues (2003) who demonstrated that students who experienced increasing levels of stress and who used more negative coping mechanisms as the programme progressed were more likely to report psychological symptoms. The impact on educational establishments is reflected in the increased attrition rates (Deary et al., 2003; Last and Fulbrook, 2003; Lees and Ellis, 1990; Lindop, 1989) and increased sickness absence (Timmins and Kaliszer, 2002b,c). Lindop (1989) suggests that many of the stress reactions in nursing students go unnoticed, with the consequence that stress levels increase until a person responds by leaving the profession. Research has also shown that nursing staff with low self-esteem and high anxiety levels are more likely to leave nursing (Lees and Ellis, 1990). Limitations While these data are important as a first analysis of this situation, they are nevertheless potentially compromised, for example, by attrition of highly stressed students from the cohort over time. It would also have been advantageous to interview a sample of non respondents to assess their experience and psychological status. Conclusions This paper has reported a longitudinal study of stress and selfesteem in students nurses, during their period of education/training. This research has shown that there is indeed variation in student psychological well being across the academic year. It was found that stress levels were highest at the beginning of the third year of training and that these levels were significantly higher than levels reported at any other time in their education/training and that self-esteem levels were lowest at the end of training. The authors agree with the concluding comments of Pryjmachuk and Richards (2007) that future research into student stress would need to concentrate on effective stress interventions. We need to investigate how stress might be managed effectively and self-esteem improved. Trying to obtain data only at single time point during the course of nurse education/training is inadequate in capturing the complexity of the academic year (Andrews and Wilding, 2004; Cooke et al., 2006). Clearly, times of stress and pressure (assessment and deadlines and exams) occur at discrete times over the course of the year, which undermines the use of a single time point data collection when considering student psychological states. 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