Aspects of nurse education programmes that frequently cause stress to nursing students ± fact-finding sample survey

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1 Article Aspects of nurse education programmes that frequently cause stress to nursing students ± fact-finding sample survey Fiona Timmins and M. Kaliszer Fiona Timmins RGN, BNS, FFNRSCI, MSc, Lecturer/ Course Leader, School of Nursing and Midwifery, Trinity College Dublin, Trinity Centre for Health Sciences, St. James's Street, Dublin 8. Tel: ; tcd.ie M. Kaliszer MSc, Lecturer in Statistics, Department of Community Health, Trinity College, Dublin 2, Ireland Manuscript accepted: 19 September 2001 This study examined reported stress in 12 areas commonly reported to cause stress to nursing students. A questionnaire was distributed to 110 third-year nursing students, and the results indicate that stress exists for students in both the clinical and academic aspects of the programme. Financial constraints and academic-related concerns emerged as the most stressful areas for the students. A third of the students reported that relationships with teachers and staff on the ward cause some degree of stress. Factor analysis revealed that five factors emerged as sources of stress. Firstly, `academic' stress factors. The second and third components concern relationships, the former involving teaching-related staff, and the latter involving the clinical experience. The last two components suggest that finance and death of patients are independent sources of stress. Major restructuring is about to take place in nurse education in Ireland, with the introduction of degree preparation for all nursing students in It is imperative that those involved with nursing students, both in the clinical area and in education settings, take cognisance of the stress that current students face. Recommendations for educators include adequate support structures for clinical areas, preceptorship programmes and the availability of student counselling services. & 2002 Published by Elsevier Science Ltd Introduction Nursing students up and down the country are facing unprecedented stress levels... nursing students have never had it so bad. They are feeling the fall out from the `revolution in nurse education' and it is starting to take its toll. (Snell 1995) This anecdotal piece by a journalist published in the Nursing Times indicates concern with the effect that the changes in the structure in nurse education are having on the student nurse population (Snell 1995). Although the overall effects are not empirically tested, several researchers indicate that the programme is stressful and some suggest that this stress is greater than that experienced by certificate nursing students (Hamill 1995, Lindop 1999). Nursing is recognized as a stressful occupation. It was reported in 1993 that nurses, doctors and other UK health service staff suffered from mental health problems each year, with a total loss of 80 million working days (News Report 1993). Hence the issue of stress is an important & 2002 Published by Elsevier Science Ltd 1 Nurse EducationToday (2002) 22, 203± doi: /nedt , available online at http: // on

2 consideration for educators of nursing students, who, although supernumery to the workforce and not officially employees of the hospital, undoubtedly engage in a wide range of patient care interventions. In addition, of course, these students are faced with a wide range of academic commitments, which may further contribute to the development of stress. Literature review A review of the literature was performed to examine the nature of stress experienced by student nurses. The information for this review was obtained from a search of the databases Medline and the Cumulative Index to Nursing Allied Health Literature (CINAHL). A combination of key terms `student nurse', `student' and `stress' were used. Manual searching of relevant nursing journals and sourcing of secondary references extended the search. The literature review process involved critically reviewing the studies. Nurse education programmes were identified as a source of stress to students in several studies (Lindop 1991, Clarke & Ruffin 1992, Thyer & Bazeley 1993, Hamill 1995, Rhead 1995, Mahat 1996). The dearth of literature examining this topic in Ireland and the lack of consensus regarding the definition of stress in this group requires an exploration of the literature that examines the phenomenon of stress in the student nurse population. Lindop (1991) explored the stress experiences of 413 student nurses at various stages of training. Data were collected using a 144-item questionnaire devised by the author, based on a previous study. Twenty-eight student nurses validated the instrument. It was administered during study periods in the school of nursing. The results indicated that most learners saw nursing as a good career and as a means of personal fulfilment. The findings also revealed a general agreement that stressful situations exist in nurse education. Stressors included examinations, and the intense amount of work. Learners generally agreed that stress was also present in the clinical area due to the conflict between `ideal' and `real' and the pressure of time when performing duties. Specific experiences that caused stress included `unfriendly atmosphere in the ward', `lack of teaching and interest in learners', and being reprimanded in front of staff and patients. Dealing with death and dying also produced stress and was experienced by third-year students more than other levels of student. Exhaustion was also a common manifestation of stress. Lindop (1991) concluded that it was the responsibility of managers of education, including ward staff, to encourage student morale. The need for an `open management style' was emphasized and replacement of the traditional `hierarchy of nursing' with `supportive leadership'. In a follow-up study, Lindop (1999) compared the reported stress of 146 student nurses undertaking a diploma programme to the reported stress of the traditional students who were studying at the college in 1988 (Lindop 1991). The same questionnaire was used to collect data. The findings revealed that the `intense amount of work' was more stressful for the diploma students. However, stress related to the clinical area was similar in both groups. Clarke and Ruffin (1992) examined perceived sources of stress among 306 student nurses from three institutions in the USA. Data were collected using two self-reporting questionnaires. The response rate was 72%. The initial questionnaire assessed demographic data and perceived stressors, which were then used to form the basis of the second questionnaire assessing 28 potential stressors. The analysis of the mean results indicated that the major stressors for nursing students were the `total amount of work to be completed', `coping with exams', `handling emergencies in the clinical area', `fear of making mistakes', `coping with the theoretical course work' and `coping with terminally ill patients'. The factors causing least concern included `living away from home', `interaction with fellow students', `interaction with academic staff', `handling excreta' and `interaction with patients'. The area with the highest score for stress was study. Thyer and Bazeley (1993) explored stressors of 79 student nurses commencing a nurse education programme in Australia. Data were collected using a 38-item questionnaire containing a series of items describing aspects 204 Nurse EducationToday (2002) 22, 203±211 & 2002 Published by Elsevier Science Ltd

3 of student life which may be stressful. These items were constructed from a previously used questionnaire designed from a qualitative study of student nurses' stress (Silus & Cooper 1985, cited in Thyer & Bazeley 1993). The questionnaire contained six broad headings: general matters, assignments, study, lecturers' time for consultation, coursework and the course programme. This was distributed during class time with a 100% response rate. The subjects responded to each item using a five-point likert scale. Analysis of mean scores revealed that students reported all areas as a source of anxiety. Submission and assessment of required work were areas where the greatest anxiety was reported. Personal/interpersonal items did not rate highly as a source of stress, with the exception of finance, which was rated as moderately stressful. Hamill (1995) examined 35 third-year student nurses' perceived stress in relation to their diploma programme, utilizing a qualitative approach. Data were collected using an initial self-reporting questionnaire followed by an in-depth recorded interview. The questionnaire elicited information on students' perceived stress, which was used to guide the interviews. The interviews were conducted using a grounded theory approach. The questionnaire yielded a 52% response rate. The major finding arising from the study suggested that student nurses' perceived stress related directly to two main areas: college-based stressors and ward-based stressors. These themes were labelled `non-integration with tertiary education' and `non-integration with the ward team'. Non-integration with tertiary education involved `not being treated as an adult learner', `confusing assignment guidelines', and, `the amount of self-directed learning'. `Non-integration with the ward team' involved the students' `lack of practical skills', `negative attitudes' of the ward staff' and `misunderstanding of supernumerary status'. A core variable was identified which explained this `non-integration' and was called the `dependence/independence continuum'. Hamill (1995) suggested that the students experienced stress due to a total contrast between their expectations of the programme and the actual reality of the programme. However, generalizing from the results of this qualitative study is difficult given the contextually subjective nature of the data, and the author acknowledges this. There was also poor response rate to the initial questionnaire. Rhead (1995) compared stress among 55 students undertaking a nursing certificate programme and 51 students undertaking a diploma programme at two different venues in the UK. Data were collected using a 34-item questionnaire. The questionnaire was an adaptation of the nurse stress scale questionnaire (Graytoft & Anderson 1981 cited in Rhead 1995) with 16 extra items derived from two in-depth interviews. Mean results indicate that diploma students were significantly more stressed than certificate nursing students. This stress related to practical and academic aspects of the course equally. Factor analysis of the items on the questionnaire revealed three overall factors relating to stress. These were `the practical elements of the programme', `the academic elements', and, `issues of death and suffering within nursing'. Mahat (1996) examined events in the clinical setting which 104 first-year nursing students in Nepal identified as stressful. Data were collected using critical incident technique, where students were asked to recall and write down the most stressful event that they have experienced during their clinical experience. From the findings and a review of the literature, data were classified into four categories: interpersonal relationships, initial experiences, feeling helpless and demeaning experiences. Descriptive analysis was then applied. The most frequently reported stressful event was interpersonal relationships (50%). The teacher±student relationship was cited by the author as one of the major sources of stress in the clinical setting. However, only 35% of respondents report this. Interpersonal relationships with staff nurses were reported stressful by only 4% of the respondents and 29% reported clinical experiences as stressful. Reliability and validity of the findings were not assured and the role of the teacher in the clinical area was not outlined. & 2002 Published by Elsevier Science Ltd Nurse EducationToday (2002) 22, 203±

4 Using the same methodology, Mahat (1998) examined all junior baccalaureate nursing students' perceived stressors at one US university. Descriptive analysis revealed five categories: initial ward experiences, interpersonal relationships, ability to perform, heavy workload and feelings of helplessness. Initial ward experiences were identified as the stressor most frequently reported by the students (34%). Twenty-seven percent of students report interpersonal relationships as a source of stress, 45% of these students report problems interacting with their teachers and 28% experience problems interacting with staff nurses on the wards. However, in the discussion the author states that 45% of the sample report problems interacting with their teachers and this is misleading, as the true percentage is only 12.1%. This leads Mahat (1998) to conclude that, `no matter where the study was done, nursing students perceived negative interpersonal relationships with teachers', although this statement was not supported by the data. Cavanagh and Snape (1997) explored sources of stress experienced by 72 student midwives at various stages of training. Data were collected using a self-reporting questionnaire containing a grid enabling the student to record stressful experiences under three headings: a little, much and very much. The response rate was 40%. The findings revealed that tutors were a major source of `very much' stress to the students. This included tutors being insensitive to students' needs, criticism in front of peers, and being made to feel inadequate. Clinical placements were another source of `very much' stress due to the behaviour of staff, dealing with procedures for the first time and working with insensitive staff. Course work including examinations and assignments, emerged as a source of `a little' stress. Although generalizing from qualitative studies is difficult due to issues of reliability, this study employed a large sample, thus adding credibility to the results. Illuminating the students' lived experience of stress from the programme was also very informative. Jones and Johnson (1997) measured levels of stress and distress in first-year student nurses using a quantitative approach. The sample comprised 220 nurses at one hospital. Instruments used to collect data include the General Health Questionnaire (GHQ) and the Beck and Sirvastava Stress Inventory (BSSI), and were administered to students attending a lecture, with a 100% response rate. The findings revealed that common sources of stress included academic items such as `fear of failing', `lack of free time', `long hours of study' and `college response to student need'. Levels of distress identified in the study were higher than that of fourth-year medical students and the general female population (Jones & Johnson 1997). Limitations of the study include convenience sampling and lack of a pilot study. Kirkland (1998) examined stressors among 23 female African US baccalaureate nursing students in the USA. Demographic data and information about stressors were collected using a questionnaire and structured interview. The findings revealed that the reported priority stressors are academic (37%), environmental (21%), financial (17%) and interpersonal (12%). The most frequently reported academic stressors were `failure' and `uncertainty related to performance', `expectations for written work' and `clinical practice'. Four main themes emerged, namely stress-related factors that are present in the clinical learning environment, academic stress, stress among nursing diploma students, and stress due to interpersonal relationships. As a consensus emerged regarding items, these themes were used to develop the instrument used in the study that is described in this paper. The clinical learning experience was identified by several studies as one of the main stressors to nursing students (Lindop 1991, 1999, Clarke & Ruffin 1992, Hamill 1995, Rhead 1995, Mahat 1996, 1998, Jones & Johnson 1997). There was also general agreement that academic stressors exist (Lindop 1991, Clarke & Ruffin 1992, Thyer & Bazeley 1993, Hamill 1995, Rhead 1995) and some writers suggested that there was an increase in academic-related stress since the advent of the diploma programme (Rhead 1995, Lindop 1999). Interpersonal relationships with both ward staff and teachers have also been identified as potential stressors 206 Nurse EducationToday (2002) 22, 203±211 & 2002 Published by Elsevier Science Ltd

5 (Mahat 1996, 1998). The themes emerging from the literature were as follows. Stress-related factors that are present in the clinical learning environment Many factors have been identified that cause stress to nursing students in the clinical area. Witnessing death and dying emerges frequently in the literature (Lindop 1991, Clarke & Ruffin 1992, Rhead 1995). Demeaning experiences have also been reported as stressors (Lindop 1991, Mahat 1996). Other stressors that have been identified include handling emergencies in the clinical area, fear of making mistakes (Clarke & Ruffin 1992), an unfriendly atmosphere in the ward (Lindop 1991), initial ward experiences (Mahat 1996, 1998) and feelings of helpless (Mahat 1996, 1998). Academic stress Academic stressors that have been identified among nursing students include examinations and assignments (Lindop 1991, Thyer & Bazeley 1993, Jones & Johnson 1997), the intense amount of work (Lindop 1991), theoretical course work (Clarke & Ruffin 1992), study associated with the programme (Clarke & Ruffin 1992, Thyer & Bazeley 1993, Jones & Johnson 1997), general academic elements (Rhead 1995) and lack of free time (Jones & Johnson 1997). In some studies, academic stressors scored more highly than stress associated with the clinical learning environment (Clarke & Ruffin 1992, Thyer & Bazeley 1993). In addition, Lindop (1999) demonstrated that academic stress and theoretical workload associated with the new diploma programme, Project 2000, were more stressful for the current diploma students compared with the certificate-nursing predecessors. Stress among nursing diploma students versus traditionally trained students Rhead (1995) and Lindop (1999) demonstrated that both academic- and ward-related stressors exist for diploma nursing students. This stress may be the intrinsic stress associated with both of these domains, but may in part be caused by `non-integration' into the university sector as described by Hamill (1995). He suggested that students who spend their time alternating between hospital and community placements and the university setting often fail to identify sufficiently with one institution or the other. Another source of stress that emerged for diploma students is that of financial constraints. In the past, as hospital employees, students received a salary. Now they survive on a maintenance grant. This is normal for undergraduates, but these students attend the programme for up to 48 weeks of the year, leaving little time for students to earn extra money to support themselves. Although Thyer & Bazeley (1993) state that finance as a source of stress, `is not a matter for concern to educators'. However, given on-going structural changes in nurse education in Ireland, financial hardship may be a reality for some students. If this impacts on the educational programme through absenteeism, drop-out, poor examination performance or poor clinical performances, it is likely to become a nurse educator's concern. Stress due to interpersonal relationships Mahat (1996) reported that interpersonal relationships arise as the most frequently reported stressful events in the clinical setting for half the students in a study of 104 nursing students in Nepal. Mahat (1998) stated, `no matter where the study was done, nursing students perceived negative interpersonal relationships with teachers' [sic]. However, relationships did not appear to be a major source of stress in other studies. Nurse education in Ireland has undergone tremendous change in the last 6 years with the advent of the diploma programme for nurse education. It has yet to face its greatest challenge to date, with the implementation of a 4-year degree programme for nurse preparation commencing in 2002 (Government of Ireland 1988). In order to develop a student-friendly curriculum, it is necessary to have an insight into and some understanding of current stressors faced by & 2002 Published by Elsevier Science Ltd Nurse EducationToday (2002) 22, 203±

6 nursing students. It is important to ascertain whether current diploma students in Ireland find certain items stressful. From the literature it is evident that nursing students at both certificate and diploma-based programmes experience stress as a result of their academic commitments and their experiences in the clinical environment (Lindop 1991, 1999, Clarke & Ruffin 1992, Thyer & Bazeley 1993, Hamill 1995, Rhead 1995, Mahat 1996, 1998, Jones & Johnson 1997). There is also some evidence to suggest that the stress due to the academic component of the programme is greater than previously demonstrated in certificate student nurses (Rhead 1995, Lindop 1999). Some studies also identify interpersonal relationships with both staff nurses and teachers as another source of stress (Mahat 1996, 1998). It is important to ascertain whether current diploma students in Ireland find these items stressful: clinical learning environment, academic stress, stress among nursing diploma students, and stress due to interpersonal relationships. Materials and methods One of the research objectives of this study, which formed part of a larger study (Egan, 2000), was to investigate factors that cause stress to nursing students. The population addressed by the study are student nurses undertaking the 3-year diploma in nursing studies in Ireland. A sample survey of these student nurses was carried out in November A 12-item questionnaire, based on themes from the literature on stress in student nurses, was used to collect data and the respondents were asked to record their response to each item on a four-point Likert scale. The questionnaire was distributed to all third-year students except 10, at two separate hospital sites in Dublin, who were present in class on the day of the study (n ˆ 110), and assumed to be representative of the target population. Six students were absent on the day. The ten excluded students were randomly selected from the main sample of 120 to form the pilot group for the purpose of testing the main questionnaire. The pilot study was used to identify problems in data collection and analysis that could be rectified before commencement of the main study. `Travelling to secondments' was identified as an additional stressor during the pilot, and the questionnaire was modified accordingly. A statistical package SPSS was used to analyse the questionnaire responses. Data were analysed by means of frequency distributions of responses, mean scores, and principal component analysis (PCA). The pilot questionnaire was readministered after 1 week. The test and retest pilot questionnaires were highly correlated despite the small sample sizes, indicating high reproducibility. The values of the correlation coefficient (Pearson r) for 14 of the 19 questions were large and statistically significant (r > 0.5, P < 0.05). It was assumed there was no systematic change in the responses between the two administrations. A panel of six nurse experts ensured the content validity of the questionnaire and one item was added: relationships with clinical placement coordinators (CPCs). CPCs are employed in hospital-based nursing practice development units in Ireland, and work alongside staff in the clinical areas to facilitate student learning. There was 100% take-up of the main questionnaire and all the students responded to all the stress-related questions. Permission to conduct the study was granted by Principal Tutors in each of the schools of nursing and the Director of Nursing where appropriate. Assurances of confidentiality and anonymity of subjects and hospitals involved was given and written consent was obtained from all the students involved. It was emphasized to the students that the information obtained would be used for the purposes of the study only and questionnaires would be destroyed upon completion of the study. Results Students were asked to consider statements about factors that may cause stress, and to select one of four stress levels in response to each statement. The overall results for this section are presented on Table 1. The levels of stress were scored from 1 (not at all stressful) to 4 (extremely stressful). Factors associated 208 Nurse EducationToday (2002) 22, 203±211 & 2002 Published by Elsevier Science Ltd

7 Table 1 Distribution of percentage and mean responses to factors that may cause stress No Stress factor Levels of stress ± percent breakdown Mean score Description Not at all stressful Moderately stressful Very stressful Extremely stressful 1 Theory Examinations Assignments Workload Classroom hours Financial constraints Secondments: travel Clinical placements The death of a patient Relationships with ward staff 11 Relationships with nurse tutors Relationships with clinical placement coordinators with academic performance, clinical placements, financial constraints, death of a patient and relationships with staff on the wards cause considerable stress (mean > 2), whereas relationships with nurse tutors and clinical placement coordinators were reported to be at most moderately stressful (mean < 1.5). Financial stress received the highest mean score and most students found this factor extremely stressful. All subjects agreed that the assignments on the course, the workload of the course and the financial constraints of the course caused some degree of stress. The majority of subjects agreed that scheduled examinations (99%), being involved in the death of a patient (97%), the theoretical content (96%), travelling to secondments (92%), clinical placements (84%), the classroom contact hours (81%), and relationships with staff on the ward (68%) caused some degree of stress. A small proportion of subjects indicated that relationships with nurse tutors (33%) and relationships with clinical placement coordinators (28%) caused stress. Factor analysis (PCA) was carried out on the 12 stress factors and five components were extracted from the 12 original stress factors (using varimex rotation, and retaining all components with eigen values >1. All and only the retained component loadings were >0.05 and were statistically significant at P < 0.01). The factors were as follows: 1. Theory, exams, assignments, workload, contact hours 2. Relationships with tutors, relationships with CPCs 3. Clinical placements, relationships with staff on wards 4. Finance 5. Death of a patient. The first component combines all the `academic' stress factors. The second and third components concern relationships, the former involving teaching related staff, and the latter involving the clinical experience. The last two components suggest that finance and death of patient are independent sources of stress. Discussion This study supports the view that factors concerning both the academic and clinical component of nurse education programmes are sources of stress to nursing students. Academic commitments and financial constraints emerge as the greatest source of stress to students in this study. Academic stress is well documented (Berman 1981, Jones & Johnson 1997, Kirkland 1998, Lindop 1991, 1999, Clarke & Ruffin 1992, & 2002 Published by Elsevier Science Ltd Nurse EducationToday (2002) 22, 203±

8 Thyer & Bailey 1993, Hamill 1995, Rhead 1995) and some studies of diploma nursing students demonstrate that students find this component of the programme more stressful than the clinical area (Clarke & Ruffin 1992, Thyer & Bailey 1993). Consideration needs to be given when programme planning to ensure that academic `overload' does not occur. Most students report that clinical placements, being involved with the death of a patient and relationships with staff on the wards are sources of stress, and this concurs with previous findings in this area (Berman 1981, Lindop 1991, Clarke & Ruffin 1992, Hamill 1995, Mahat 1995, 1998, Rhead 1995). There is a high correlation between reported stress from relationships with staff on the ward and reported stress from the clinical area, suggesting that the experience of difficulty with interpersonal relationships with the ward staff is likely to affect the students' overall perception of the placement. Furthermore, since 68% of the students report relationships with staff on the ward as causing some degree of stress, this is an area that requires closer attention. Clinical placements by their very nature confront students with many stressors. Witnessing death and suffering among patients, have an emotional impact on learners. Supportive relationships with staff on the ward need to be developed to lessen the impact of these events, and equip students to deal with them. The exact nature of current difficulties may require further examination, to identify the nature of the relationships on the ward that students may find stressful. In the meantime, however, it is essential that ward-based teachers and clinical placements coordinators develop strategies to strengthen student±staff relationships. This may include the introduction or further development of preceptorship programmes, facilitating communication between the university and the clinical area and continuous education of staff in student-related matters. These findings support those of Mahat (1996, 1998) that teachers are a source of stress to students. Approximately a third of the students in this study reported that relationships with teachers and clinical placements coordinators cause some degree of stress. Most students do not report stress from interpersonal relationships. For those who do, they are more likely to report stress in all three relationship categories (tutors, clinical placements coordinators and staff on the ward). In addition, although most students find the academic component of the course stressful, there is no correlation between reported stress from relationships and academic stress. Students who report academic stress are likely to report stress in all categories (scheduled examinations, the theoretical content, classroom contact hours, the workload of the programme). This individual nature of stress that is displayed may necessitate the need for greater student support structures, such as student counselling to be available to students. The most striking feature of the study is that the financial constraints of the programme are a source of stress to 99% of the students. Finance as a source of stress is a relatively new phenomenon, possibly because students were paid employees in the past. Older studies indicate that students have little concern with pay (Clark 1975, Price 1984), however more recent studies (Thyer & Bailey 1993) report finance as a moderate source of stress. Thyer and Bailey (1993) suggest that this factor is not a concern for nurse educators, however the overall effect of financial stress on the students may require further examination. Consideration may also need to be given to reducing the total student contact hours to allow students to fulfil financial obligations though part-time work. This study has limitations that must be considered when interpreting the results. Firstly, it was a small exploratory study that only considered 12 common student stressors. Each of these individual stressors could be explored in more detail, for example the clinical area may have a multitude of stressors and this was examined as one item. Secondly, quantitative analysis of the stressors limited information. More detail would be attainable by qualitative techniques. However, despite these limitations the results of the study appear to concur with previous findings on this topic. 210 Nurse EducationToday (2002) 22, 203±211 & 2002 Published by Elsevier Science Ltd

9 Conclusion Many academic aspects of current nurse education programmes appear to cause stress to nursing students. Those educators responsible for curriculum design need to take cognizance of the possible emotional consequence of a challenging curriculum. Teacher±student relationships are another source of stress to many students and adequate support structures for students while on clinical placements is essential. Furthermore, all personnel involved with teaching nursing students need to be adequately prepared for dealing with students, and become aware of their own impact on students. These potential stressors, together with the fact that most students of today are experiencing considerable financial pressure, require that student counselling services are readily available to equip students early on to face the challenges entailed in a demanding profession such as nursing. Acknowledgements We would like to acknowledge the assistance of An Bord Altrainais, Dublin, who provided a scholarship towards this project. References Berman A 1981 Stress and sickness absence in a group of student nurses. Unpublished MSC dissertation, University of Surrey Cavanagh SJ, Snape J 1997 Education stress in student midwives: an occupational perspective. British Journal of Midwifery 5(9): 528±533 Clark JM 1975 Time-Out? A Study of Absenteeism among Nurses. Royal College of Nursing, London Clarke VA, Ruffin CL 1992 Sources of stress for student nurses. Contemporary Nurse 1(1): 35±40 Egan FM 2000 An Investigation of Absenteeism Among Third Year Student Nurses. University of Dublin Trinity College, Unpublished MSc Dissertation, Dublin Government of Ireland 1998 Report of the Commission on Nursing ± A Blueprint for the Future. The Stationery Office, Dublin Hamill C 1995 The phenomenon of stress as perceived by project 2000 student nurse: a case study. Journal of Advanced Nursing 21: 528±536 Jones MC, Johnston DW 1997 Distress, stress and coping in first-year student nurses. Journal of Advanced Nursing 26: 475±482 Kirkland MLS 1998 Stressors and coping strategies among successful female African baccalaureate nursing students. Journal of Nursing Education 37(1): 5±12 Lindop E 1991 Individual stress among nurses in training: why some leave and others stay. Nurse Education Today 2: 10±120 Lindop E 1999 A comparative study of stress between pre and post Project 2000 students. Journal of Advanced Nursing 29(4): 967±973 Mahat G 1996 Stress and coping: first year Nepalese nursing students in clinical settings. Journal of Nursing Education 35(4): 163±169 Mahat G 1998 Stress and coping: junior baccalaureate nursing students in clinical settings. Nursing Forum 22(1): 11±19 News Report health professionals suffer from mental illness. Nursing Standard 7(18): 11 Price KM 1984 A study of short-term absence from work among a group of third year student nurses. Journal of Advanced Nursing 9(5): 493±503 Rhead MM 1995 Stress among student nurses: is it practical or academic? Journal of Clinical Nursing 4(6): 69±376 Snell J 1995 It's tough at the bottom. Nursing Times 91(43): 55±58 Thyer SE, Bazeley P 1993 Stressors to student nurses beginning tertiary education: an Australian study. Nurse Education Today 13(5): 336±42 & 2002 Published by Elsevier Science Ltd Nurse EducationToday (2002) 22, 203±