Nurse Education Today 90 (2020) 104440

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Nurse Education Today

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Review

Resilience, stress, and psychological well-being in nursing students: A T

systematic review
Zhuang-Shuang Lia, Felicity Hassonb,
⁎

a
School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, Belfast BT37 0QB, Ireland
b
School of Nursing, Institute of Nursing and Health Sciences Research, Ulster University, Newtownabbey, Belfast BT37 0QB, Ireland

ARTICLE INFO ABSTRACT

Keywords: Objective: Synthesize the evidence relating to the interaction of resilience, stress, and well-being in under-
Resilience graduate nursing students across countries.
Stress Design: Systematic review
Well-being Data sources: Peer reviewed studies published from 2008 to December 2018 were searched in CINAHL, Web of
Nursing students
Science, Medline (OVID), PsycINFo and four biomedical databases originating from China (China National
Undergraduate
Knowledge Infrastructure, WanFang Data, VIP and CMB).
Systematic review
Review methods: Adhering to the preferred reporting items for Systematic Reviews and Meta-analyses guidelines,
eight databases were searched. Twelve studies, which met the inclusion criteria, were extracted, and subject to
quality appraisal by two researchers.
Results: In total, 12 papers were included. Outcome analysis revealed the level of resilience as moderate; stress
levels were high and the incidence of negative psychological health accounts for a proportion of nursing stu-
dents. The interaction between resilience and stress and well-being was high. Resilience and low stress were
found to better predict well-being. All the studies cited recommendations to inform educational policy and
practice in relation to resilience, well-being, and stress among undergraduate nursing students.
Conclusions: This was the first systematic review to synthesize the evidence relating to the interaction of resi-
lience, stress, and well-being in undergraduate nursing students across cultural settings. Evidence confirms the
importance of resilience in nursing students influencing stress and psychosocial morbidity. Nursing educational
strategies that foster and enhance resilience is recommended.

1. Introduction lives (MacDonald et al., 2016; Turner and McCarthy, 2017).

Globally the study of nursing is reported by students to be stressful
(Edwards et al., 2010; Chernomas and Shapiro, 2013; Oner Altiok and
Ustun 2013; Walker and Mann, 2016; Tung et al., 2018), more so than
by students from any of the other trainee healthcare disciplines (Pulido-
Martos et al., 2012; Reeve et al., 2013; Turner and McCarthy, 2017).
During clinical education, nursing students are exposed to the realities
of nursing in practice. They must learn to provide care for acutely ill
patients (Zhao et al., 2015) often in situations with staff and resource
shortages, and with an overriding fear of making mistakes (Yıldırım
et al., 2017). Academically, high intensity workloads have led to
competitive and stressful learning environments (Evans, 2008; Reeve
et al., 2013). On a personal level, nursing students are facing increased
financial pressure as well as the demands of balancing their private
Stress can have a myriad of negative effects on the quality of student
learning (Goff, 2011; Ten Hoeve et al., 2017; Ayaz-Alkaya et al., 2018),
on physical (Cantrell et al., 2017; Al-Gamal et al., 2018; Labrague et al.,
2018a; Labrague et al., 2018b) and on psychological well-being
(Ratanasiripong and Wang, 2011; Tee et al., 2016; Yıldırım et al.,
2017). A protection factor, presented in academic literature (Thomas
et al., 2012; Thomas and Revell, 2016), and in educational and work-
force policy (Challen et al., 2011a, 2011b; Howell and Voronka, 2012;
Çam and Büyükbayram, 2017; McFadden et al., 2018) is resilience.
Although various definitions of resilience have been formulated. It is
generally described as a complex and dynamic phenomenon relating to
the ability of a person to overcome adversity (Windle, 2011; Hegney
et al., 2015). However, despite the importance of resilience and its close
relationship with stress and psychological well-being it remains an

⁎
Corresponding author.
E-mail addresses: li-z17@ulster.ac.uk (Z.-S. Li), f.hasson@ulster.ac.uk (F. Hasson).
@Felicity_Hasson (F. Hasson)

https://doi.org/10.1016/j.nedt.2020.104440
Received 15 November 2019; Accepted 14 April 2020
0260-6917/ © 2020 Elsevier Ltd. All rights reserved.
Z.-S. Li and F. Hasson Nurse Education Today 90 (2020) 104440

unexplored area (Thomas and Asselin, 2018). While individual reviews Table 1
of resilience (Aburn et al., 2016; Thomas and Revell, 2016), psycho- CINAHL Search Strategy.
logical well-being (Walker et al., 2016) and stress (Turner and Interface - EBSCOhost Research Databases
McCarthy, 2017; Tung et al., 2018) among nursing students do exist, Search Screen - Advanced Search
knowledge of the interaction of these concepts is lacking. Database: CINAHL with Full Text
Search
Limiters - Published Data: 2008 January-2018 December; Scholarly (Peer Reviewed)
2. Background Journals
Search modes - Find all my search terms
Stress is considered a global feature among nursing students, with ID Query Results
levels ranging from moderate to severe (Amr et al., 2011; Geslani and S15 S3 AND S6 AND S10 AND S14 79
S14 S11 OR S12 OR S13 311,920
Gaebelein, 2013; Shukla et al., 2013; Labrague et al., 2017; Smith and
S13 wellbeing or well-being or well being or quality of life or 308,110
Yang, 2017; He et al., 2018; Ozsaban et al., 2019). Stress has wide- wellness or positive affect or mental health or happiness or life
ranging implications, impacting on sleep, memory, attention and ap- satisfaction
petite (Goff, 2011; Kurebayashi et al., 2012). Psychological health can S12 (MH “Mental Health”) 28,790
be affected by making students feel unsafe, nervous, irritable, sad, an- S11 (MH “Quality of Life+”) 96,378
S10 S7 OR S8 OR S9 269,921
xious and depressed (Fröjd et al., 2008; Hjern et al., 2008). Academi-
S9 stress or financial strain or anxiety or distress or burnout 263,967
cally, it can affect attrition within nurse education (Pryjmachuk et al., S8 (MH “Anxiety+”) 36,395
2009), student performance (Gibbons et al., 2009; Grobecker, 2016), S7 (MH “Stress+”) 80,210
and the ability to cope (Goff, 2011). Consequently, it impacts nega- S6 S4 OR S5 260,425
S5 resilien* or strength or cop* or adaptation 258,411
tively on the ability to learn which is indispensable in academic en-
S4 (MH “Hardiness”) 8066
vironments (Dinse et al., 2017). Upon qualification it also has re- S3 S1 OR S2 43,455
percussions on the effectiveness of communication and work effort, S2 nurs* n2 student or undergraduate nurse 43,298
ultimately, decreasing the quality of health-care services (Rafati et al., S1 (MH “Students, Nursing+”) OR (MH “Students, Nursing, 32,727
2017). Therefore, maintaining a good level of psychological well-being Practical”)

is considered a vital component in the training and development of

future nurses (Ratanasiripong and Wang, 2011).
Resilience is believed to counteract the negative effects of stress and
enhance a person's well-being. In nursing, researchers have found re-
silience to be an influence on the adverse psychological outcomes, such
as anxiety, depression and post-traumatic stress disorder (Mealer et al.,
2012; Taylor and Reyes, 2012), as well as poor health outcomes and
difficult management of chronic diseases (Dyer et al., 2004; Bradshaw
et al., 2007; Jackson et al., 2007). There is wide agreement among
researchers that resilience has a significant correlation with positive
psychological well-being (Gibbons et al., 2011; He et al., 2018; Rios-
Risquez et al., 2018).
However, the prevalence rates of resilience, stress and psychological
well-being among nursing students have shown variabilities inter-
nationally, attributed to the inconsistency of the definition of the con-
cept, the type of collection tools utilised (Shukla et al., 2013; Zhao
et al., 2015; He et al., 2018; Ozsaban et al., 2019) and cultural differ-
ences (Chow et al., 2018). However, there is little evidence from cross
cultural and/or cross country of the relationship between these vari-
ables or the interaction of resilience, stress, and well-being. To date,
most research focuses on studies reporting individual concepts mainly
from western countries (Brennan, 2017; Pines et al., 2012; Lo, 2002)
however increasing attention is originating from Asian settings (Zhao
et al., 2015; Chow et al., 2018). It is therefore important to expand our
understanding of different cultural backgrounds in which research on
these topics is being undertaken. Thus, the aim of this review is to
collate the evidence relating to the interaction of resilience, stress, and
psychological well-being among undergraduate nursing students across
countries.
3. Methods
A systematic search was conducted in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta Analyses (PRISMA)
guidelines (Moher et al., 2010) of quantitative and qualitative studies.
3.1. Data sources
The following academic databases were searched from January
2008 to December 2018, of CINAHL, Web of Science, Medline (OVID),
PsycINFo, CNKI, WanFang Data, VIP and CMB. Search terms were de-
veloped and Boolean operators OR and AND were applied (Whittmore
and Knafl 2005). Selected medical subject headings were combined
with free text terms following MeSH (medical subject heading) terms
relating to resilience. These included: (MH “Hardiness”, resilien*,
strength*, cop*, adaptation), stress (MH “Anxiety+”, MH “Stress+”,
MH “Hardiness”, stress*, financial strain, anxiety, distress, burnout),
well-being (well-being, well being, well-being, wellness, positive affect,
happiness, MH “quality of life”, MH “mental health”, life satisfaction),
nursing student (nurs* n2 student, undergraduate nurse, MH “Students,
Nursing+”, MH “Students, Nursing, Practical”). This was adjusted for
use in other databases using appropriate search symbols and Boolean
operators (see Table 1). Meanwhile, cited reference retrievals were also
performed. In addition, reference lists of included studies were checked
for potentially relevant studies.
3.2. Eligibility criteria
All methodological studies which have reported the effects of resi-
lience, stress, and well-being in undergraduate nursing students were
included. Key study eligibility criteria included: (a) Undergraduate
nursing student; (b) Primary outcomes included resilience, stress, and
well-being in undergraduate nursing student; (c) Peer reviewed studies
available in full text; (d) Published from 2008 to 2018; (e) Published in
the English or Chinese language.
3.3. Study selection and data extraction
All retrieved articles were imported into Endnote software and du-
plicate articles were removed. According to the eligibility criteria, two
reviewers (ZSL and FH) independently read and eliminated irrelevant
studies from title and abstract. The remaining full texts were obtained
and critically reviewed by both reviewers independently for inclusion.
Any discrepancies in data extraction or study selection were discussed
by both reviewers and adjudicated by a third reviewer (KM). Two re-
viewers (ZSL and FH) independently extracted the data into a pre-de-
signed form: (a) author and location of research; (b) publication year;
(c) aim; (d) characteristics of the subjects, including course year,
technique, total population and number that took part; (e) design and
method; (f) data collection; (g) reliability and validity; (h) major
finding and (i) limitations (see Table 2).

2
 Table 2
Characteristics of Included Studies.
Authors, Year Aim
Country
García-Izquierdo To analyse the role of
et al., 2018 resilience in the dimensions of
Spain academic burnout syndrome
and psychological health in a
sample of nursing students.
Gibbons et al. To explore the relationship
(2011) between sources of stress and
UK psychological well-being and
to consider how different
sources of stress and coping
resources might function as
moderators and mediators on
3
well-being.
He et al. (2018) To examine the predictors of
Australia psychological wellbeing
among undergraduate nursing
students in an Australian
regional university
Subjects Design/Method Data Collection Reliability (Internal Major findings Limitations
consistency coefficients :
Cronbach's alpha, Test–retest
Z.-S. Li and F. Hasson
reliability: R)/validity
(Exploratory and Confirmatory
Factor Analysis)
— Convenience Quantitative method: — CD-RISC — CD-RISC (α = 0.86) ① A significant relationship ① The collected data came
sample Survey — MBI-SS — MBI-SS between resilience and exclusively from self-reported
— Total n=218 — GHQ-12 Emotional burnout, emotional evidence, which can bias the
— Participants exhaustion(α =0.85) exhaustion, and self-efficacy, answers of the participants, as
n=218 (Second cynicism(α =0.81) as well as with psychological well as artificially increase the
year) Efficacy (α =0.73) health. chance of finding correlations
— Average age: 22.74 ② Three burnout dimensions between variables.
— Age range: 19-50 — GHQ-12 (α =0.83) were found to be significantly ② The design of the study limits the
— women accounted — No validity test linked to psychological health. possibility of establishing causal
for 75.7% ③ The moderating role of relationships between the
resilience on psychological analysed variables.
health in emotionally
exhausting situations.
— Convenience Quantitative method: — ISSN — None reported ① Sources of stress likely to lead ① More academic and clinical
sample Survey — Generalized Self- to distress were more often experience would be likely to
— Total n=280 Efficacy Scale predictors of well-being than affect their appraisals and
— Participants — GHQ-12 likely to lead to positive, responses compared with
n=171 (Final year) — Marlowe-Crowne eustress states, with the students earlier in their
— Average age: None Social Desirability exception of clinical studies.
reported — Brief COPE placement demands.
— Age range: 21-50 ② Self-efficacy, dispositional
— women accounted control and support were
for 87% important predictors, and
avoidance coping was the
strongest predictor of adverse
well-being.
③ Approach coping was not a
predictor of well-being.
④ The mere presence of support
appeared beneficial as well as
the utility of that support to
help a student cope.
— Convenience Quantitative method: — CD-RISC — CD-RISC (α =0.9) ① All three hypotheses were ① A lower than expected
sample A cross sectional — six-dimensional — six-dimensional supported. response rate
— Total n=1760 descriptive predictive Psychological Well- Psychological Well-being ② Non-traditional cohorts will ② Participants may have responded
— Participants model being Scale Scale: P-PWB (α =0.79) N- have stronger coping skills in ways that they consider to be
n=538 (all three — PSS PWB (α =0.54) due to life experiences, this socially desirable rather than
years) — GSE — PSS (α =0.89) should not be assumed. reflecting their actual situation.
— Average age: 36.23 — The Multi-Dimensional — GSE (α =0.89) ③ Participants had higher stress ③ A cross-sectional approach used
— Age range: 18-57 Scale of Perceived — The Multi-Dimensional scores and lower in this study could not provide a
— women accounted Social Support Scale of Perceived Social psychological wellbeing, deeper understanding of their
for 85.1% — Mindfulness Attention Support (α =0.94, α compared to the younger psychological well-being from a
Awareness Scale =0.94, α = 0.87) groups (nursing or health developmental perspective.
— Mindfulness Attention allied) reported in previous
Awareness Scale (α studies. It was perhaps due to
=0.91) their difficulties in juggling
— No validity test responsibilities between
study, work and family and
(continued on next page)
Nurse Education Today 90 (2020) 104440
 Table 2 (continued)
Authors, Year Aim
Country
Klainin-Yobas To test the impact of stress on
et al. (2014) psychological and physical
Thailand health, and examine the
mediating effects of coping on
the stress–health relationships
among nursing students.
Luo and Wang To explore the factors
4
(2009) affecting nurse students’
China psychological status, and the
interactions between mental
symptoms and stressful
factors, coping style and
social support in their early
clinical experiences.
Subjects Design/Method Data Collection Reliability (Internal Major findings Limitations
consistency coefficients :
Cronbach's alpha, Test–retest
reliability: R)/validity
Z.-S. Li and F. Hasson
(Exploratory and Confirmatory
Factor Analysis)
the nature of studying
externally online.
— Convenience Quantitative method: — SOPH — SOPH (α =0.75) ① Nursing students with high ① The use of convenience
sample a cross-sectional, — Thai-version General — Thai-version General levels of stress reported poorer sampling might limit
— Total n=1210 descriptive Health Questionnaire Health Questionnaire (α physical health and higher generalizability of research
— Participants correlational research — Thai-version =0.89) psychological distress. findings.
n=214 (all four Jalowiec’s coping scale — Thai-version Jalowiec’s ② Stress had a stronger effect ② The use a cross-sectional
years) coping scale (α =0.75) and explained more variances research design did not provide
— Average age: 24 — Validity: acceptable or well on psychological distress than an opportunity to draw causal
— Age range: 17-50 fit on poor physical health. relationships among study
— women accounted ③ The partial mediation of variables.
for 97% coping was observed. ③ The effects of extraneous
Specifically, 77.00% of the variables (such as demographic
effects of stress on poor variables) were not tested and
physical health and 11.30% thus limit a full understanding of
on psychological distress were the phenomena of interest.
mediated by coping. ④ Uneven gender distribution in
this study impeded a possibility
of testing gender-related effects
on study variables.
— Convenience Quantitative method: — CSSS — None reported ① Positive correlations were ① None reported
sample Survey — TCSQ found between stressful
— Total n=288 — Support Questionnaire events, negative coping style
— Participants — SCL-90 and the total scores of SCL-90 ,
n=150 (clinical while negative correlations
period) related to positive coping
— Average age: None style, social support and the
reported total scores of SCL-90
— Age range: None ② Stressful factors, negative
reported coping style and social support
— women account: all have main effects on
None reported mental symptoms and positive
coping style has no main effect
on mental symptoms but
interactions relate to stressful
factors and positive coping
style, as well as negative
coping style and social
support.
(continued on next page)
Nurse Education Today 90 (2020) 104440
 Table 2 (continued)

Authors, Year Aim Subjects Design/Method Data Collection Reliability (Internal Major findings Limitations
Country consistency coefficients :
Cronbach's alpha, Test–retest
reliability: R)/validity
Z.-S. Li and F. Hasson

(Exploratory and Confirmatory

Factor Analysis)

Ríos-Risquez To examine the relationship
et al. (2016) between resilience, academic
Spain burnout and psychological
health in a sample of nursing
students.
Smith and Yang To examine the relationship
(2017) between stress and resilience
China on psychological well-being in
— Convenience Quantitative method: — CD-RISC — None reported ① A statistically significant ① The information was collected
sample A cross-sectional study — MBI-SS relationship between by means of self-administered
— Total n=116 — GHQ-12 resilience and both emotional questionnaires, it can bias the
— Participants exhaustion and psychological participants’ answers and
n=113 (Final year) health, as well as between all exacerbate common variance
— Average age: 24.42 three dimensions of burnout as well as artificially increase
— Age range: 21-46 and psychological health. the correlations between
— women accounted ② High scores for resilience and variables.
for 75.2% low scores for emotional ② The low internal consistency
exhaustion predict better obtained in the subscale of
perceived psychological academic efficacy may also have
health. contributed to a bias in the
results of the analysis performed
for this variable.
③ The cross-sectional design used
restricts the possibility of
establishing causal relationships
between variables.
— Convenience Quantitative method: — SINS — None reported ① A significant relationship ① A convenience sample was
sample A cross-sectional study — RS between resilience and used in this study raising the
— Total n=1586 — GHQ-12 burnout, emotional potential risk of restricted

5
a cohort of Chinese
undergraduate student nurses.
— Participants exhaustion, and self-efficacy,
n=1538 (All four as well as with psychological
years) health.
— Average age: ② Three burnout dimensions
18.62-21.34 were found to be significantly
— Age range: 17-25 linked to psychological health.
— women accounted ③ The moderating role of
for 97.3% resilience on psychological
health in emotionally
exhausting situations.
generalizability.
② Using self-report questionnaires
there is the potential risk of
response distortions.
③ Data was collected over a
relatively short period of time, as
such it may not be truly
reflective of the entire program.
④ Data was only collected in one
geographical region of China,
known for high socio-economic
status, therefore it may not be
fully representative of all
Chinese undergraduate
baccalaureate nursing students.
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Nurse Education Today 90 (2020) 104440
 Table 2 (continued)
Authors, Year Aim
Country
Yildirim et al. To investigate the
(2017) relationships between nursing
Turkey students' education-related
stress and stress coping, self-
esteem, social support, and
health status.
Ríos‐Risquez To explore the longitudinal
et al. (2018) associations between
Spain academic burnout and
resilience and psychological
well‐being, and the stability
of these variables in a sample
of university nursing students.
6
Mathad et al. To evaluate the effectiveness
(2017) of eight week yoga
India intervention on psychological
functioning of nursing
students.
Subjects Design/Method Data Collection Reliability (Internal Major findings Limitations
consistency coefficients :
Cronbach's alpha, Test–retest
reliability: R)/validity
Z.-S. Li and F. Hasson
(Exploratory and Confirmatory
Factor Analysis)
— Convenience Quantitative method: — NESS — NESS (α = 0.781) ① Nursing students' stress coping ① None reported
sample A cross-sectional, — CBI — CBI (α =0.833) levels were affected by self-
— Total n=580 descriptive, and — MSPSS — MSPSS (α =0.876) esteem and social support.
— Participants correlational design — RSES — RSES (α =0.874) ② This interaction appears to
n=571 (All four — GHQ — GHQ (α =0.903) affect general health status.
years) — Validity: acceptable or well Although the direct effect of
— Average age: fit stress on coping was non-
18.28-22.44 significant, its overall effect
— Age range: None was significant within the
reported model.
— women accounted
for 80.8%
— Convenience Quantitative method: — CD-RISC — CD-RISC(T1: α = 0.86 T2: ① The three dimensions that ① The collected data come
sample Longitudinal design. — MBI-SS α = 0.85 r=0.66) make up academic burnout entirely from self‐report scales,
— Total n=331 — GHQ-12 — MBI-SS remained steady over time, which may lead to bias in the
— Participants Emotional while resilience increased and responses of the participants.
n=172 exhaustion(T1: α = 0.85 T2: α psychological well‐being ② A longitudinal pattern was not
(T1=Second and = 0.90 r=0.38) improved. possible to take more than two
T2=Fourth year) cynicism(T1: α = 0.86 T2: α ② Hierarchical regression measurements.
— Average age(T2): = 0.84 r=0.34) analyses revealed the
24.42 Efficacy (T1: α = 0.71 T2: α = longitudinal effect of
— Age range(T2): 21- 0.80 r=0.37) emotional exhaustion at T1
46 and at T2 they showed the
— women accounted — GHQ-12 (T1: α = 0.84 T2: longitudinal effect of
for 75.2%(T2) α = 0.89 r=0.47) resilience on psychological
— No validity test well‐being at T2.
③ The inverse hierarchical
regression analyses did not
reveal significant relationships
for any of the variables
measured at T2 in connection
with psychological well‐being
measured at T1.
— Convenience Quantitative method: — FMI — None reported ① Eight week yoga intervention ① This study is limited in terms
sample A randomised Wait — SCS-SF was significantly effective in of assessment tools as self-
— Total n=150 List Control (WLC) — CD-RISC improving self-compassion reported questionnaires were
— Participants n=80 trial — SWLS and mindfulness among used for data collection
(All four years) — JSE-HPS nursing students in
— Average age: Yoga — PSS experimental group than
group: compared to WLC group.
19.65 ± 1.48, WLC ② There were improvements in
group: resilience, satisfaction in life
19.35 ± 1.03 and perceived stress, results
— Age range: None were not statistically
reported significant.
— women account:
None reported
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Nurse Education Today 90 (2020) 104440
 Table 2 (continued)

Authors, Year Aim Subjects Design/Method Data Collection Reliability (Internal Major findings Limitations
Country consistency coefficients :
Cronbach's alpha, Test–retest
reliability: R)/validity
Z.-S. Li and F. Hasson

(Exploratory and Confirmatory

Factor Analysis)

Galvin et al. A qualitative study focusing — purposive sampling Qualitative method: — Semi-structured one- — trustworthiness ① Participants reported ① None reported.
(2015) specifically on mental health — Total n= Unknown Grounded theory to-one interviews unreasonable demands during
UK nursing students is required — Participants n=12 study clinical blocks, and described
(All three years) how control/support is lowest
— Average age: 25.58 on placements with staff
— Age range: 19-38 shortages.
— women accounted ② Negative attitudes towards
for 66.67% students from staff and related
issues were also discussed.
③ Younger participants
described struggling with
mental health work during the
early stages of training.
Janse van Van To explore and describe the — Purposive, Qualitative method: A — focus group interviews — trustworthiness ① A central storyline emerged ① Only two focus group
Rensburg experiences of student nurses convenient qualitative, (reflective journals, a where student nurses interviews were done because
et al. (2012) working with mentally sampling explorative, reflective letter, naïve described working with of the availability of students
South Africa challenged individuals. — Total n= Unknown descriptive, contextual sketches, drawings and mentally challenged and time constraints.
— Participants n=13 research design with a field notes) individuals as a process of
(final year) case study strategy personal transformation that
— Average age :26 was initiated by an
— Age range: 22-47 engagement on a deeper

7
— women accounted emotional level with these
for 92.31% individuals.
② The process of personal
transformation started a
journey towards the discovery
of meaning for the self, as
student nurses.
③ Student nurses working in
challenging environments
during their training may
experience emotional
discomfort and need
additional support in coping
and adjustment within this
context.

Notes: CD-RISC: Connor-Davidson Resilience Scale, MBI-SS: Maslach Burnout Inventory Student Survey, GHQ-12: General Health Questionnaire, ISSN: Index of Sources of Stress in Nursing, PSS: Perceived Stress Scale,
GSE: General Self-Efficacy Scale, P-PWB: Positive Psychological well-being, N-PWB: Negative Psychological well-being, SOPH: Self-rated Overall Physical Health Scale, CSSS: adopting College Seniors Stress Scale, TCSQ:
Trait Coping Style Questionnaire, SCL-90: Symptom checklist 90, SINS: The Stressors in Student Nursing Scale, RS: The Resilience Scale, NESS: Nursing Education Stress Scale, CBI: The Coping Behavior Inventory,
MSPSS: Multidimensional Scale of Perceived Social Support, RSES: Rosenberg Self-Esteem Scale, GHQ: General Health Questionnaire, FMI: Freiburg Mindfulness Inventory, SCS-SF: Self-Compassion Scale- Short Form,
SWLS: Satisfaction with Life Scale, JSE-HPS: Jefferson Scale of Empathy HPS-Version.
Nurse Education Today 90 (2020) 104440
Z.-S. Li and F. Hasson Nurse Education Today 90 (2020) 104440

Identification
Records identified through database Additional records identified
searching through other sources
(n = 565) (n = 2)

Records after duplicates removed

(n =544)
Screening

Records screened Records excluded

(n = 544) (n = 509)

Full-text articles assessed Full-text articles excluded

Eligibility

for eligibility
(n =35) Unavailable full text (n=5)

Outcome indicators (n=12)

Studies included in Non-peer reviewed Studies

qualitative synthesis (n=3)
(n = 2)
No focus on undergraduate
nursing student (n=3)
Included

Studies included in
quantitative synthesis (Not
meta-analysis)
(n =10)

Total number of studies

Included
(n =12)

Fig. 1. PRISMA Flow Diagram.

3.4. Search outcomes
A total of 567 articles were identified. Twenty-three duplicate ar-
ticles were removed, leaving 544 papers for further screening.
Afterwards, titles and abstracts were evaluated by two reviewers based
on inclusion criteria. In total, thirty-five articles were included for full-
text review. From these, 12 studies met the inclusion criteria as shown
in the PRISMA flowchart in Fig. 1 (Moher et al., 2010).
3.5. Quality appraisal
All studies included in this review were assessed for risk of bias
independently by two reviewers (HF and ZSL) using the CASP tool
(Critical Appraisal Skills Programme (CASP) checklists 2018) for qua-
litative studies and random clinical trial, as well the NHLBI Quality
Assessment Tool (The NHLBI Quality Assessment Tool 2018) for ob-
servational studies. Meanwhile, reliability and validity of quantitative
studies and trustworthiness of qualitative studies were also extracted
for assessment of their methodological rigor. These appraisals were
summarised respectively and presented the grading using a range of
coding systems. In terms of quality grading, of the nine papers accessed
using a grading system developed by Uloko et al. (2018) for the NHLBI
assessment tool, the quality of the study was accessed as `good’ if the
rating was 70%, `fair` if 50% and `poor’ if its rating was less than 50%.
As outlined, three were rated good, five fair and one poor (see Table 3).
The remaining three papers accessed using Hall et al. (2019) coding
system of CASP 0–10, a score of 8–10 is considered high quality, 4–7
moderate quality and below 4 poor quality. In terms of quality, the
CASP Qualitative studies (n = 2) all demonstrated a high quality. Using
the same criteria, CASP RCT was deemed high quality (see Tables 4 and
5).
4. Results
In total, 12 articles were included in this review. Studies were in-
ternationally spread from China (n = 2), UK (n = 2), Spain (n = 3),
India (n = 1), Turkey (n = 1), Australia (n = 1), Thailand (n = 1),
South Africa (n = 1). The findings of these studies are based on a total
of 3736 participants. All 12 studies investigated students either from all
years or from a single year of undergraduate nursing programmes. Only

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Table 3
Quality Assessment Scores According to The NHLBI Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.
Study Q1 Q2 Q3 Q4 Q5 n a/justification b
Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Quality Rating

García-Izquierdo et al. (2018) Yes Yes Yes Yes No/No No No Yes Yes No Yes NR NA Yes 8/14 (Fair)
Gibbons et al. (2011) Yes Yes Yes Yes No/No No No Yes Yes No Yes Yes NA Yes 9/14 (Good)
He et al. (2018) Yes Yes Yes Yes Yes/Yes No No Yes Yes No Yes NR NA Yes 9/14 (Good)
Klainin-Yobas et al. (2014) Yes Yes Yes Yes Yes/Yes No No Yes Yes No Yes NR NA No 8/14 (Fair)
Luo and Wang (2009) Yes Yes No Yes No/No No No Yes NR No NR NR NA NR 4/14 (Poor)
Rios-Risquez et al. (2016) Yes Yes Yes Yes No/No No No Yes Yes No Yes NR NA Yes 8/14 (Fair)
Rios-Risquez et al. (2018) Yes Yes Yes Yes No/No Yes Yes Yes Yes Yes Yes NR NR Yes 11/14 (Good)
Smith and Yang (2017) Yes Yes No NR No/No No No Yes Yes No Yes NR NA Yes 6/14 (Fair)
Yildirim et al. (2017) Yes Yes Yes Yes No/No No No Yes Yes No Yes NR NA Yes 8/14 (Fair)

Note. n a = refers to having a reasonable simple size. Justification b = refers to statistical justification of sample size, estimates of effect size, etc. CD = cannot be
determined; NA = not applicable; NR = not reported; NHLBI = National Heart, Lung, and Blood Institute.

one of these papers included a mixture of educational levels (Klainin- Table 5

Yobas et al., 2014) such as Nursing Specialty (4 months), Master's and Critical appraisal of included randomised controlled trial study using CASP
PhD programmes. Tool.
The 12 articles used a range of methodologies including eight cross- Authors and year of publication (Mathad et al., 2017)
sectional studies, one longitudinal study, two qualitative designs and a
randomised clinical trial. All quantitative studies used validated scales CASP Question Yes Can't Tell No
for data collection. The most popular scales for measuring resilience,
Did the trial address a clearly focused issue? ●
well-being and stress were the Connor-Davidson Resilience Scale (CD- Was the assignment of patients to treatments ●
RISC), the General Health Questionnaire (GHQ-12) and the Perceived randomised?
Stress Scale (PSS) respectively. The two qualitative studies used in- Were all of the patients who entered the trial properly ●
accounted for at its conclusion?
depth and semi-structured interviews and focus groups.
Were patients, health workers and study personnel ●
Of the 12 papers, only one paper, undertaken in China by Smith and ‘blind’ to treatment?
Yang (2017), used a theoretical model, which is Lazarus and Folkman's Were the groups similar at the start of the trial? ●
(1984) Transactional Model of Stress and Coping to guide collection Aside from the experimental intervention, were the ●
and analysis. groups treated equally?
Does the treatment effect largely?
While the 12 papers in this review provide an insight into the in-
●
Does the estimate of the treatment effect precisely? ●
teraction of the three concepts among nursing students, their findings Can the results be applied to the local population, or ●
should be read with caution. For example, five papers (Rios-Risquez in your context?
et al., 2016; Mathad et al., 2017; Smith and Yang, 2017; García- Were all clinically important outcomes considered? ●
Izquierdo et al., 2018; Rios-Risquez et al., 2018) relied on self-reported Are the benefits worth the harms and costs? ●
Grading 10/11
questionnaires to collect the data which may introduce a response bias.
Other studies have adopted a cross-sectional design which ultimately
restricts the possibility of establishing causal relationships between 4.1. Quantitative and qualitative study findings
variables (Klainin-Yobas et al., 2014; Rios-Risquez et al., 2016; García-
Izquierdo et al., 2018) and cannot provide a deeper understanding of Among the 12 studies, five papers reported the levels of resilience
resilience and stress and psychological well-being from a develop- and stress and psychological health (Janse van Rensburg et al., 2012;
mental perspective (He et al., 2018). In qualitative studies, Janse van Galvin et al., 2015; Rios-Risquez et al., 2016; Smith and Yang, 2017; He
Rensburg et al. (2012) have reported that their study limitation was et al., 2018).
with limited focus group interviews because of the availability of stu-
dents and time constraints. Galvin et al. (2015) have pointed out that
4.1.1. The level of resilience, stress, and well-being
the limitation of their study is the difficult of generalization.
Regarding the level of resilience, two cross-sectional studies have
pointed out that the level of resilience was moderate (Rios-Risquez
et al., 2016; Smith and Yang, 2017). Furthermore, Smith and Yang
(2017) in a study of Chinese nursing students (year 1 – year 4) using a

Table 4
Critical appraisal of included qualitative studies using CASP tool.
Authors and year of publication (Galvin et al., 2015) (Janse van Rensburg et al., 2012)

CASP question Yes Can't Tell No Yes Can't Tell No

Was there a clear statement of the aims of the research? ● ●

Is a qualitative methodology appropriate? ● ●
Was the research design appropriate to address the aims of the research? ● ●
Was the recruitment strategy appropriate to the aims of the research? ● ●
Was the data collected in a way that addressed the research issue? ● ●
Has the relationship between researcher and participants been adequately considered? ● ●
Have ethical issues been taken into consideration? ● ●
Was the data analysis sufficiently rigorous? ● ●
Is there a clear statement of findings? ● ●
Is the research valuable? ● ●
Grading 10/10 9/10

9
Z.-S. Li and F. Hasson
cross-sectional survey reported that there were no significant differ-
ences in resilience scores among students in four different grades, but
that there were significant differences in resilience scores between
students who were class leaders or non-class leaders. However, con-
sidering that this study was undertaken in China the transferability of
the findings is questionable given the different educational systems and
cultural context there. Two other studies adopting a qualitative ap-
proach found resilience to be low among UK mental health nursing
students (Galvin et al., 2015) and South African (Janse van Rensburg
et al., 2012) nursing students. Participants from these two studies re-
ported that they struggled to adjust and cope with stress arising from
their nursing programs, and this was particularly felt among third year
student (Janse van Rensburg et al., 2012; Galvin et al., 2015).
Regarding the level of stress, a study undertaken in Spain by Rios-
Risquez et al. (2016) reported that taking the cut-off point proposed for
the Spanish population by Bresó et al. (2006), the prevalence of
burnout was 2.65%. However, a study undertaken in Australia by He
et al. (2018) reported that their participants had higher stress scores
compared to the younger groups (nursing or health allied) reported in
previous studies. However, such findings should be read with caution as
the author, He et al. (2018) suggest that participants may have re-
sponded in ways that they consider socially desirable rather than re-
flecting their actual situation. In China, Smith and Yang (2017) assessed
the level of stress, among Chinese nursing students (year 1–4), and
found it was relatively higher compared with western nursing students.
They also highlighted a significant difference in stress scores between
different years of nursing students, however, no matter whether they
are class leaders or not, there is no significant difference in stress scores.
Two other studies adopting a qualitative approach found that nursing
students experienced stress during their placement study (Janse van
Rensburg et al., 2012; Galvin et al., 2015).
Regarding the level of psychological health, Rios-Risquez et al.
(2016) reported that from the 113 nursing students in their study 8.8%
could be classified as vulnerable or at risk of experiencing more nega-
tive psychological health in accordance General Health Questionnaire-
12 psychological measurement (Goldberg and Williams, 1988). In ad-
dition, Smith and Yang (2017) reported that in their study, the senior
nursing students (year four) experienced poorest psychological well-
being scores than earlier year groups. They also illustrated that the
higher and junior grades reported poorer levels of psychological well-
being. He et al. (2018) have reported that their participants had lower
psychological well-being compared to the previous studies.
4.1.2. The interaction of resilience, stress, and well-being
The interaction of resilience, stress and well-being were reported in
nine observational studies. In terms of stress and resilience, a study
undertaken in Spain by Rios-Risquez et al. (2016) reported a significant
negative correlation between resilience and both emotional exhaustion
and cynicism, while resilience was positively associated with academic
efficacy. However, in contrast a study undertaken in Spain by García-
Izquierdo et al. (2018) highlighted the cynicism has no significant
correction with resilience among second year students. In another
paper, referring to the similar variables, resilience was weakly and
negatively correlated with stress (Smith and Yang, 2017).
In terms of the interaction between resilience and well-being, resi-
lience is significantly and positively correlated with well-being
(Gibbons et al., 2011; He et al., 2018; Rios-Risquez et al., 2018). In the
other words, greater resilience is associated with greater psychological
well-being for the student. In Spain Rios-Risquez et al. (2018) have
found that over the duration of their studies (year 2 and year 4), stu-
dents' resilience increased, and their psychological well-being also im-
proved. However, the results stem from one cohort of students and are
nationally based therefore generalizability is questionable. In addition,
an academic study undertaken in China showed that a positive, coping
style had no significant effect on well-being (Luo and Wang, 2009),
however this study did not report the reliability and validity of the
10
Nurse Education Today 90 (2020) 104440
scales, so the results may not be accurate.
In terms of the interaction between stress and well-being, some
papers showed that stress had a significant effect on psychological
health. In other words, greater level of stress is associated with lower
level of well-being. Additionally, some authors, Rios-Risquez et al.
(2016), Rios-Risquez et al. (2018) have noted that when emotional
exhaustion and cynicism were present, the lower the well-being scores
recorded. In addition, they also found that there was no relationship
between academic efficacy and psychological well-being.
Finally, in terms of the interaction between resilience and stress and
well-being, some papers have pointed out that, overall, there was a
significant relationship between resilience and stress and well-being
(Klainin-Yobas et al., 2014; Rios-Risquez et al., 2016; Smith and Yang,
2017; García-Izquierdo et al., 2018). A study by García-Izquierdo et al.
(2018) has emphasized that nursing students who show lower levels of
resilience and higher levels of stress report the worse well-being.
Meanwhile, Smith and Yang (2017) have also noted that resilience and
stress are moderately and negatively correlated with well-being. How-
ever, a random clinical trial undertaken in India by Mathad et al.
(2017) illustrated that even though there were improvements from
yoga in resilience, satisfaction in life and perceived stress, the results
were not statistically significant.
4.1.3. The predictors of resilience and well-being
The predictors of resilience and psychological well-being have been
mentioned in four papers, but stress was not reported (Rios-Risquez
et al., 2016; García-Izquierdo et al., 2018; He et al., 2018; Rios-Risquez
et al., 2018). One quantitative study by García-Izquierdo et al. (2018)
used hierarchical multiple regression analysis to test the predictors of
resilience. Sex, emotional exhaustion, and academic efficacy was con-
ducted. They concluded that the significant predictors of resilience
were emotional exhaustion and academic efficacy (García-Izquierdo
et al., 2018). However, a study undertaken in Spain by Rios-Risquez
et al. (2016) highlighted that academic efficacy was not significantly
correlated with psychological health. But this finding may have been
affected by the low internal consistency obtained in the subscale of
academic efficacy and may have contributed to bias in the results of the
analysis performed for this variable.
Three papers focused on the predictors of psychological well-being.
For example, in an Australian cross-sectional study with a convenience
sample of 1760 nursing students, He et al. (2018) reported Negative
Psychological Well-being (N-PWB), resilience, perceived stress, support
from significant others, support from family, mindfulness, and support
from friends were predictors. Support from friends was the weakest
predictor. For Positive Psychological Well-being (P-PWB), resilience,
support from significant others and support from family were pre-
dictors. Resilience was the strongest predictor.
In another study, Rios-Risquez et al. (2016) found from the hier-
archical multiple regression analysis that emotional exhaustion and
resilience were predictors of psychological health. Furthermore, an-
other longitudinal study, Rios-Risquez et al. (2018) have indicated that
emotional exhaustion at T1 (nursing students in the second academic
year) is the only variable that predicts psychological health at T2
(nursing students in the fourth academic year). Resilience of nursing
students at T1 was not found to predict psychological health at T2.
5. Discussion
Overall the results of this systematic review suggest that stress is a
feature of a nursing student's life, which affects their psychological
well-being. As a coping strategy, resilience is reported to be variable,
which suggests the need for more attention to be given to student
nurses to help develop this skill. Findings suggests that the interaction
between resilience and stress and well-being was high while resilience
and low stress were found to better predict well-being. Unsurprisingly,
all the studies cited recommendations to inform educational policy and
Z.-S. Li and F. Hasson
practice in relation to resilience, well-being, and stress among under-
graduate nursing students.
The results of the current study, which focused on the levels of re-
silience and stress and well-being, showed levels varied and were in-
fluenced by a range of factors. For example, two papers revealed nur-
sing students' resilience levels as moderate (Rios-Risquez et al., 2016;
Smith and Yang, 2017), however levels were reported to be influenced
by several factors such as class‑leaders (Smith and Yang, 2017). Other
qualitative research by Galvin et al. (2015) highlighted the influence of
maturity and experience as being an influencing factor to resilience.
Overall stress was reported to be high (Janse van Rensburg et al.,
2012; Galvin et al., 2015; Rios-Risquez et al., 2016; Smith and Yang,
2017), a finding consistent with the outcome of previous systematic
review studies (Alzayy and Al-Gamal, 2014; Tung et al., 2018). Smith
and Yang (2017) claim that Chinese nursing students experience rela-
tively higher levels of stress compared to western nursing students,
however a lack of international comparative research make such claims
difficult to verify. Nevertheless, the ramifications of stress on nursing
students' psychological well-being indicated a negative consequence for
a certain proportion of nursing students (Rios-Risquez et al., 2016;
Smith and Yang, 2017).
Analysis of the correlation between the interaction of resilience,
stress, and well-being have highlighted variability across the studies.
Some research reported that high resilience and low stress will predict
better psychological well-being (Klainin-Yobas et al., 2014; Rios-
Risquez et al., 2016; Smith and Yang, 2017; García-Izquierdo et al.,
2018). However, findings from an RCT (Mathad et al., 2017) concluded
that the interaction between resilience, satisfaction and perceived stress
were not statistically significant.
Analysis of the levels of resilience, stress and psychological well-
being by year of study revealed variability. For example, several studies
reported that the level of stress, resilience and burnout experienced by
student nurses varied across student year group (Alzayy and Al-Gamal,
2014; Houpy et al., 2017; Smith and Yang, 2017). Therefore, the year of
study may be a factor future research should consider.
Finally, the results of the systematic review highlighted several re-
commendations that could be made to inform educational policy and
practice in relation to resilience, stress, and well-being. Overall, the
effective predictors of resilience in this review were emotional ex-
haustion and academic efficacy (García-Izquierdo et al., 2018). In ad-
dition, the effective predictors of Negative Psychological Well-being (N-
PWB) were resilience, perceived stress, support from significant others,
support from family, mindfulness, and support from friends, while for
Positive Psychological Well-being (P-PWB), predictors are resilience,
support from significant others and support from family. Quantitative
and qualitative results from the current study in relation to predictors
may be used to inform the development of educational policy and
practice concerning resilience, well-being, and stress among under-
graduate nursing students. Overwhelmingly, the studies recommend
that greater attention be paid to nursing students and equipping them
with resilience coping skills.
5.1. Strengths and limitations of this review
While this review adopted a systematic process and incorporated a
global perspective on the research being undertaken it has several
limitations. First, the review was based on four English language da-
tabases and four Chinese language databases and did not include grey
literature sources. Second, only English and Chinese language papers
were included in the review, limiting the inclusion of other languages.
Finally, the search was conducted from 2008 to 2018 and new studies
may have been published which are not reflected in the analysis.
Therefore, the conclusions should be treated with caution.
11
Nurse Education Today 90 (2020) 104440
6. Conclusion
This is the first systematic review to synthesize the evidence relating
to the interaction of resilience, stress, and well-being in undergraduate
nursing students. Previous reviews have generally only focused on one
concept (resilience or stress or well-being) to synthesize the evidence
while others have reported on the predictors or prevalence rates (Aburn
et al., 2016; Walker et al., 2016; Thomas and Revell, 2016; Turner and
McCarthy, 2017; Tung et al., 2018). This highlights a gap in the re-
search evidence synthesising the interaction between reliance, stress
and psychological well-being.
This review highlights that most research in this area has adopted a
cross-sectional design. However, in order to provide a deeper under-
standing of resilience, stress and psychological well-being, future re-
search should adopt different designs. Furthermore, additional research
is required to build on comparing level of resilience, stress and well-
being among nursing students in different countries to identify the in-
fluencing factors internationally.
Funding source
None declared
Ethical approval
Not applicable
CRediT authorship contribution statement
Zhuang-Shuang Li:Conceptualization, Methodology, Validation,
Formal analysis, Investigation, Data curation, Writing - original
draft, Writing - review & editing, Visualization.Felicity
Hasson:Conceptualization, Methodology, Validation, Formal ana-
lysis, Investigation, Data curation, Writing - review & editing,
Visualization, Supervision, Project administration.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Acknowledgements
The authors greatly appreciate the contribution from specialist li-
brarian Kelly McCoo and Ulster University for their guidance.
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