Clinical Stress and Clinical Performance in
Prelicensure Nursing Students: A Systematic
Review
Susan R. Welch, EdD, RN, CNE, Alumnus CCRN
ABSTRACT
Background: Stress within clinical learning environ-
ments often has been associated with nursing education.
However, in the past decade, the perceived stress levels of
prelicensure nursing students have not only been sustained,
they have actually increased. Increased and sustained
stress levels negatively affect nursing students’ perceptions
of their competence, confidence, and ultimately, their clini-
cal performance. Method: A systematic review of the rela-
tionship between nursing students’ perceived clinical stress
and perceived clinical performance was conducted follow-
ing PRISMA guidelines. Results: The review highlighted
what is currently known about the relationship between
perceived clinical stress in prelicensure nursing students
and perceived clinical performance, providing implications
for future research in clinical education. Three main themes
were identified: nursing student gender, academic year,
and clinical skill preparation. Conclusion: Future research
with rigorous methodological designs is necessary to ex-
amine the relationship between perceived clinical stress in
prelicensure nursing students and perceived clinical per-
formance. [J Nurs Educ. 2023;62(1):36-41.]
H
istorically, stress within clinical learning environments
often has been associated with nursing education as such
environments are crucial for students to transition suc-
cessfully from being a nursing student being a professional nurse
(Campbell, 1985; Clark & Redfern, 1978; Carver & Tamlyn,
1985; Lunn, 1975; Muldary, 1983; Rhead, 1995; Wernick, 1984;
Zryewskyj & Davis, 1987). In fact, nursing students spend more
time in clinical learning environments than in didactic settings
(Moscaritolo, 2009; Newton et al., 2009). Nursing education’s
clinical learning environments contain acute, community, simu-
lation, and skills laboratory settings (Flott & Linden, 2016) with
the attributes of “physical space, psychosocial and interaction
factors, organizational culture, and teaching and learning com-
ponents” (Flott & Linden, 2016, p. 501).
Susan R. Welch, EdD, RN, CNE, Alumnus CCRN, is an Associate Profes-
sor, University of Alabama.
Address correspondence to Susan R. Welch, EdD, RN, CNE, Alumnus
CCRN, 4412 Spring Row, Northport, AL 35473; email: srwelch@ua.edu.
Disclosure: The author has disclosed no potential conflicts of interest,
financial or otherwise.
Received: December 25, 2021; Accepted: June 30, 2022
doi:10.3928/01484834-20221109-03
36
Although nursing students frequently have encountered
stress in clinical learning environments, the “perceived”
stress levels of nursing students have not only sustained but
have actually increased (Admi et al., 2018; Llapa Rodrigues
et al., 2016; Sánchez de Miguel et al., 2019; Senturk &
Dogan, 2018; Suarez-Garcia et al., 2018; Suen et al., 2016).
Stress is defined as “a condition or feeling experienced when
a person perceives that demands exceed the personal and so-
cial resources the individual can mobilize” (Lazarus, 1999,
p. 11) and contains the attributes of “an overwhelming ten-
sion, force, or pressure” (Goodnite, 2014, p. 72).
An increase in students’ “perceived” clinical stress may
be the result of the heightened psychological and technical
demands required to ensure patient safety (Labrague et al.,
2018; Moscaritolo, 2009; Stubin, 2020). In addition, the close
supervision of students, necessary for their successful transi-
tion to professional nurses, also may contribute to increased
stress levels of students within clinical learning environments
(Stubin, 2020). Although elevated stress levels can produce a
positive and protective mechanism within the human body,
increased and sustained stress levels can negatively affect
nursing students’ perceptions of their competence, confi-
dence, and ultimately their clinical performance (Eng & Pai,
2015; Suarez-Garcia et al., 2018). Furthermore, the effects
of increased and sustained stress levels also may negatively
affect students’ ability to develop clinical reasoning, increas-
ing the likelihood of exhaustion, burnout, and future intent to
leave the profession (Admi et al., 2018; Llapa Rodrigues et
al., 2016; Sánchez de Miguel et al., 2020; Senturk & Dogan,
2018; Suarez-Garcia et al., 2018; Suen et al., 2016).
Therefore, it is vital to investigate what is known regarding
the relationship between nursing students’ perceived clinical
stress and perceived clinical performance. A systematic re-
view of the relationship between nursing students’ perceived
clinical stress and perceived clinical performance is essential
to understanding the problem. Systematic reviews provide a
critical appraisal of prior research and help summarize the
state of the science on a topic (Polit & Beck, 2017; Portney,
2020). Systematic reviews also establish the state of knowl-
edge in an area of inquiry to ensure that new research builds
on what knowledge is known versus repeating studies on
what is already known (Polit & Beck, 2017; Portney, 2020).
This systematic review examined the relationship between
perceived clinical stress in prelicensure nursing students and
perceived clinical performance to identify themes that may
support future research and provide future interventions to
reduce perceived clinical stress in prelicensure nursing stu-
dents. The research question was, “What is the relationship
Copyright © SLACK Incorporated
between perceived clinical stress in prelicensure nursing stu-
dents and perceived clinical performance?
METHOD
Search Criteria and Search Procedure
The Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) (2020) guidelines were used
for this systematic review. The literature search consisted of
PubMed®, CINAHL®, and ProQuest® databases for English
language studies. Databases were searched from the last sys-
tematic review on the topic (Alzayyat & Al-Gamal, 2014), and
search dates included January 1, 2014, to October 10, 2021.
An identical search strategy was used for all databases. The
search terms for nursing student consisted of nursing student,
student nurse, and undergraduate nursing student. For clini-
cal, the search terms included clinical, clinical practice, clini-
cal education, and internship. Lastly, terms for stress consist-
ed of stress or distress.
The inclusion criteria were articles published in peer-re-
viewed publications between 2014 and 2022, international
studies in the English language, and research reported on
clinical stress of prelicensure undergraduate nursing students
during their clinical experience. Research studies that reported
stress reduction strategies were excluded as this did not align
with the purpose of the review. According to the inclusion
and exclusion criteria, 10 research studies met the criteria and
were included in the review (Figure 1). This systematic re-
view offered a renewed account of the current nursing student
clinical stress research and included 10 research articles.
RESULTS
Methodological Considerations
Most of the research studies identified were quantitative,
descriptive, and cross-sectional, with one quasiexperimental
study noted (Table A; available in the online version of this
article). A quantitative aspect, which includes self-report ques-
tionnaires, provides an overall picture of a group’s attitudes
or behaviors to describe their characteristics and risk factors
(Dillman et al., 2014; Portney, 2020). Advantages of such
large-scale questionnaires include their efficiency in collect-
ing large amounts of data about a problem, particularly if the
questionnaires offer good psychometric properties (Dillman
et al., 2014; Polit & Beck, 2017; Portney, 2020). However, a
disadvantage of large-scale questionnaires includes articulat-
ing participants’ thoughts as questionnaires tend to be rela-
tively superficial, resulting in incomplete or wrong answers
(Dillman et al., 2014; Polit & Beck, 2017; Portney, 2020). In
addition, because questionnaires do not probe deeply into hu-
man complexities, follow-up interviews or open-ended survey
questions often are necessary (Dillman et al., 2014; Polit &
Beck, 2017).
Synthesis of Findings
This systematic review highlights what is currently known
about the relationship between perceived clinical stress in
prelicensure nursing students and perceived clinical perfor-
Journal of Nursing Education • Vol. 62, No. 1, 2023
mance, and provides implications for future research in clini-
cal education. This review analyzed the studies identified and
revealed three main themes: nursing student gender, academic
year, and clinical skill preparation.
Nursing student gender. Eight of the 10 studies reported
clinical stress in female nursing students (Admi et al., 2018;
D’emeh & Yacoub, 2020; Sánchez de Miguel et al., 2020;
Llapa Rodrigues et al., 2016; Senturk & Dogan, 2018; Suarez-
Garcia et al., 2018; Suen et al., 2016; Yidirim et al., 2016).
Using the KEZKAK questionnaire, significant findings of
clinical stress were associated with female nursing students
(Sánchez de Miguel et al., 2020; Llapa Rodrigues et al., 2016;
Suarez-Garcia et al., 2018). Specifically, Llapa Rodrigues et
al. (2016) and Suarez-Garcia et al. (2018) revealed significant
findings of clinical stress in female nursing students within
all KEZKAK subscales. Using only five KEZKAK subscales,
Sánchez de Miguel et al. (2020) noted significance within the
clinical procedures subscale solely.
Using the Nursing Students Stress Scale (NSSS), Admi et
al. (2018) reported significantly high levels of clinical stress
among female nursing students within the subscales of in-
adequate preparation, patient pain and suffering, and educa-
tion-reality conflict. Solely in the clinical subscale, Suen et
al. (2016) reported significant clinical stress levels of female
nursing students via the Stressors in Nursing Students (SNS)
questionnaire. Other authors used the Stress in Nurse Educa-
tion Questionnaire (SINE) and found significant clinical stress
in female nursing students in both the academic and practical
subscales (Senturk & Dogan, 2018; Yidirim et al., 2016). Us-
ing the Perceived Student Stress (PSS) questionnaire, signifi-
cantly high clinical stress among female nursing students was
reported within the two subscales of clinical assignments and
workload, and stress from nurse educators and nursing staff
(D’emeh & Yacoub, 2020). Female gender significance with-
in clinical procedures also was reported using the KEZKAK
questionnaire (Sánchez de Miguel et al., 2020). Finally, of the
eight studies that reported clinical stress in female nursing
students, only Suarez-Garcia et al. (2018) identified the need
to investigate further; however, a specific methodologic focus
was not provided.
Academic year. Nursing students reported clinical stress
within all academic years across six of the 10 studies (Admi et
al., 2018; D’emeh & Yacoub, 2020; Sánchez de Miguel et al.,
2020; Suarez-Garcia et al., 2018; Suen et al., 2016; Yidirim
et al., 2016); differences in academic year among the studies
were not consistent. In three studies, second-year nursing stu-
dents reported significantly higher clinical stress than students
in other years (Admi et al., 2018; D’emeh & Yacoub, 2020;
Suarez-Garcia et al., 2018). In contrast, two studies reported
significantly high clinical stress levels in the later academic
years (third and fourth academic years) (Sánchez de Miguel et
al., 2020; Suen et al., 2016). Further, a statistically significant
negative correlation between self-efficacy (performance) and
academic overload in third and fourth-year nursing students
was indicated (Sánchez de Miguel et al., 2020). Other authors
differed and revealed that nursing students experienced more
clinical stress in their second and fourth years; however, the
findings were not statistically significant (Yidirim et al., 2016).
37

Figure 1. PRISMA flow diagram.
Finally, nursing students perceived the clinical experience as
moderately to highly stressful in all six studies reviewed and
across all academic years (Admi et al., 2018; Llapa Rodrigues
et al., 2016; Sánchez de Miguel et al., 2020; Suarez-Garcia et
al., 2018; Suen et al., 2016; Yidirim et al., 2016); however,
a correlation between academic year and overall perceived
clinical performance was not identified.
Clinical skill preparation. Significant findings or correla-
tions of high clinical stress were found due to students’ per-
ceptions that they lacked clinical skills (Admi et al., 2018;
D’emeh & Yacoub, 2020; Llapa Rodrigues et al., 2016;
Sánchez de Miguel et al., 2020; Suarez-Garcia et al., 2018).
In addition, significant clinical stressors perceived by students
based on inadequate skill preparation included making a mis-
take or being harmful to patients (D’emeh & Yacoub, 2020;
Suarez-Garcia et al., 2018; Yidirim et al., 2016). Additional
findings that significantly contributed to high clinical stress,
based on inadequate skill preparation, included the clinical en-
vironment, patient assignments, and overall workload via the
PSS questionnaire (Demeh & Yacoub, 2020).
Procedural (skills) stressors were significantly associ-
ated with high clinical stress due to a lack of clinical skill
competency and uncertainty via the KEZKAK questionnaire
(Sánchez de Miguel et al., 2020). In fact, procedural (skills)
stressors were the highest predictor of “perceived” clinical
stress in nursing students, even more than emotional stress
(Sánchez de Miguel et al., 2020). In addition, the long-term ef-
fects of high clinical stress also may affect clinical dishonesty
among students, as a significant correlation was found between
clinical stress and dishonesty regarding clinical skills via the
38
Clinical Dishonesty Questionnaire (Rafati et al., 2020). The
authors defined clinical dishonesty as “a complex problem
that threatens the health and safety of patients” (Rafati et
al., 2020, p. 1).
Clinical satisfaction
Students’ expectations of clinical and actual clinical
experiences differed significantly by the SNS question-
naire (Suen et al., 2016). High clinical stress levels were
associated with low overall student satisfaction in clinical
experiences (Admi et al., 2018; Suen et al., 2016). Satisfac-
tion with clinical experiences was the strongest predictor of
clinical stress across all SNS subscales (Suen et al., 2016).
Using the NSSS questionnaire, negative correlations were
noted between three subscales (i.e., as stress increased, sat-
isfaction decreased) and positive correlations between two
subscales (i.e., as stress increased, satisfaction increased)
(Admi et al., 2018). The correlations offered did not distin-
guish between high versus low levels of stress (Admi et al.,
2018). A significant association existed between high clini-
cal stress and low overall nursing program satisfaction via
the SINE questionnaire (Senturk & Dogan, 2018).
Academic-practice gap
Authors indicated current prelicensure nursing curricula
do not align with the perceived clinical performance expec-
tations or nursing students’ requirements in clinical experi-
ences (Llapa Rodrigues et al., 2016; Suarez-Garcia et al.,
2018). In particular, due to students’ perceptions of a lack
of clinical competence, authors speculated the academic-
practice gap in prelicensure curricula was the most promi-
nent contributor to nursing student clinical stress (Llapa
Rodrigues et al., 2016; Suarez-Garcia et al., 2018). In ad-
dition, the academic-practice gap was perceived as more
stressful among older nontraditional students, correlating
with higher stress levels versus younger traditional students
via the NSSS (Admi et al., 2018). Furthermore, a signifi-
cant correlation between academic stress and clinical stress
via the SINE questionnaire was reported (Senturk & Dogan,
2018).
DISCUSSION
This systematic review examined the relationship be-
tween perceived clinical stress in nursing students and per-
ceived clinical performance. Potential predictors of nursing
students’ perceived clinical stress included nursing stu-
dent gender, academic year, and clinical skill preparation.
However, consistency was not found in either frequency or
significance among the studies. Such discrepancies make
it difficult to compare the research findings and develop
appropriate interventions due to the number of potential
stressors and similar but different instruments. Neverthe-
less, the various instruments used were reliable and valid,
with further descriptions provided in the articles and listed
in Table A.
However, what is known from this systematic review is
that perceived clinical stress for nursing students ranges
from mild to moderately high, with female nursing students
being significantly more stressed than male nursing stu-
Copyright © SLACK Incorporated
dents. Furthermore, perceived clinical stress among nurs-
ing students can negatively affect their overall program and
clinical satisfaction.
The most predominant clinical stressor was the perception
of a lack of clinical competence due to inadequate preparation.
Specifically, students perceived themselves as clinically in-
competent due to insufficient clinical skill preparation, which
resulted in mild to moderately high levels of clinical stress.
IMPLICATIONS FOR RESEARCH,
PRACTICE, AND EDUCATION
Despite the limitations noted in the studies reviewed, nurs-
ing educators can use the findings for future research, practice,
and educational implications. Implications for future research
may include pedagogical research within clinical learning
environments, including the themes identified in this review.
First, results could help develop, implement, and evaluate ro-
bust pedagogical innovations within clinical learning environ-
ments. The pedagogical component of teaching and learning
is an attribute of the clinical learning environment (Flott &
Linden, 2016) and must be evidence-based.
Second, new pedagogical innovations could be developed
to teach clinical skills in prelicensure nursing programs with
the incorporation of simulation. Pedagogical innovations
could include deliberate practice based on Ericsson’s (2004)
deliberate practice framework. Ericsson’s framework supports
skills performance reflective of incremental opportunities for
practice. Integrating a deliberate practice framework through-
out prelicensure nursing programs to guide skills development
is recommended to support clinical competency (Johnson et
al., 2020; O’Brien et al., 2015; Oermann et al., 2016; Ross et
al., 2015). Students’ opportunity to develop and refine their
nursing skills within a deliberate practice framework may im-
prove not only clinical competence but also overall confidence
and clinical performance when initiated before clinical expe-
riences begin (Admi et al., 2018; D’emeh & Yacoub, 2020;
Llapa Rodrigues et al., 2016; Senturk & Dogan, 2018; Suarez-
Garcia et al., 2018).
Third, the themes identified in the review (nursing student
gender, academic year, and clinical skill preparation) could
be used to support future research and thus provide interven-
tions to reduce perceived clinical stress in nursing students.
Future research in the United States is needed; moreover, two
countries identified in this review are ranked by U.S. News
and World Report (2022) as the worst countries for gender
equality.
Implications for practice may include the engagement of
health care stakeholders in the development, implementation,
and evaluation of clinical orientation programs in prelicensure
curricula (Llapa Rodrigues et al., 2016; Suen et al., 2016).
Health care stakeholder engagement in such programs could
help clarify practice demands and provide additional sup-
port measures within clinical learning environments (Llapa
Rodrigues et al., 2016; Suen et al., 2016). For instance, Kim et
al. (2018) conducted a quasiexperimental study and found sig-
nificantly lower perceptions of clinical stress among students
after completing a neonatal skills program to reduce clinical
Journal of Nursing Education • Vol. 62, No. 1, 2023
stress. The authors developed a visual analog scale (VAS) to
assess students’ neonatal clinical stress. The VAS measured
overall nursing student stress within neonatal clinical rota-
tions in the health care facility and the anxiety associated with
the six most common skills used within the neonatal unit (Kim
et al., 2018). After completing the skills development pro-
gram, correlations revealed significantly higher self-efficacy
and clinical practice confidence (Kim et al., 2018). Prior to
the neonatal skills program, higher neonatal practice-related
stress correlated significantly with lower practice self-effica-
cy. Overall, clinical stress decreased (60.9%) and confidence
increased (89.1%) in the majority of students after the neonatal
skills development program (Kim et al., 2018). In addition, it is
possible that the inclusion of a Just Culture within clinical ori-
entation programs may reduce the perception of clinical stress
in nursing students. The Just Culture Assessment Tool for Nurs-
ing Education (JCAT-NE©) (Walker et al., 2019) might assist in
determining whether modifications to clinical learning environ-
ments are needed.
The social climate of the clinical learning environments,
based on the collaboration between clinical faculty and staff
nurses, may also affect students’ perceived clinical stress and
performance. As such, the Collaboration in the Clinical Learning
Environment (CCLE) tool may assist in assessing such collabo-
ration (Hooven, 2017). Based on a nonexperimental descriptive
design, Hooven (2017) revealed areas to improve collaboration
between clinical faculty and nursing staff, such as the equality
of power and understanding of student outcomes. The CCLE
might assess clinical learning environments and the develop-
ment and implementation of future sites (Hooven, 2017). Fur-
thermore, the idea of a dedicated education unit (DEU) allows
for an opportunity for increased collaboration between clinical
faculty and nursing staff (Hooven, 2017). The CCLE possibly
could be used within a DEU to determine the current status of
collaboration between faculty and staff nurses. It is possible that
DEUs with high levels of collaboration between faculty and
staff nurses might result in lower clinical stress levels for nurs-
ing students. Such engagement with health care stakeholders in
developing, implementing, and evaluating clinical learning en-
vironments within prelicensure nursing programs also may help
reduce the academic-practice gap and facilitate the integration
of theory into practice. Lastly, creating a genuine partnership
with health care stakeholders also may improve programmatic
student satisfaction rates and lower overall clinical stress in stu-
dents (Suen et al., 2016).
Implications for nursing education may include the incorpo-
ration of evidence-based stress management programs (Admi
et al., 2018; Llapa Rodrigues et al., 2016; Suarez-Garcia et al.,
2018). However, the lack of evidence-based stress manage-
ment programs or programmatic specifics may contribute to
students’ inability to effectively manage clinical stress (Admi
et al., 2018; Llapa Rodrigues et al., 2016; Suarez-Garcia et al.,
2018). Further questions exist, such as might stress manage-
ment programs potentially increase stress for nursing students
given the intensity of nursing school? Is clinical stress benefi-
cial to nursing students? What is reasonable clinical stress for
prelicensure nursing students? Has nursing education estab-
lished that clinical stress results in untoward outcomes? Also,
39

how clinical stress specifically affects female nursing students
and their overall clinical performance also should be explored
further (Admi et al., 2018; D’emeh & Yacoub, 2020; Miguel et
al., 2020; Llapa Rodrigues et al., 2016; Yidirim et al., 2016).
LIMITATIONS
Synthesis and comparison of the research findings proved
difficult in this systematic review. Participants’ diverse charac-
teristics, variability of cultures (e.g., Brazil, Iran, Israel, Jordan,
Singapore, South Korea, Spain, and Turkey), multiple stress
tools, and the lack of clearly identified theoretical frameworks
led to differences in findings. The various clinical learning en-
vironments also offered challenges in determining precisely the
problem within each study. Most research was conducted in
Europe and the Middle East, confirming that nursing students
worldwide perceive clinical stress. Although a global perspec-
tive of nursing students’ clinical stress was offered, the review’s
absence of research within the U.S. identified a gap. This re-
search gap also was evident in a previous systematic literature
review concerning nursing students’ clinical stress (Alzayyat &
Al-Gamal, 2014).
Methodological limitations also were identified and con-
sisted of the prevalence of descriptive, cross-sectional research
designs that included self-reporting and one-site convenience
samples for data collection. Therefore, robust methodological
approaches must be used to thoroughly examine the relation-
ship between nursing students’ perceived clinical stress and per-
ceived clinical performance. The science of nursing education
must improve measurements of clinical stress and clinical per-
formance, and move beyond descriptive methodologies to well-
developed tools. For instance, research methodologies such as
qualitative, quantitative, and mixed-method with longitudinal
designs across nursing students’ academic years would be nec-
essary to develop reliable and valid tools. Replication studies
also will be essential to confirm previous research findings, cor-
rect design limitations, and study combinations of interventions
and outcomes in multiple-site settings to generalize findings
(Polit & Beck, 2017; Portney, 2020).
CONCLUSION
Clinical stress in prelicensure nursing students was inves-
tigated to examine the relationship between perceived clinical
stress and perceived clinical performance. Several studies of-
fered various findings that influenced nursing student’’ clinical
stress. Based on this systematic review, future research with rig-
orous methodological designs is necessary to examine further
the relationship between clinical stress in prelicensure nursing
students and clinical performance.
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41
TABLE A
Literature Review Matrix
__________________________________________________________________________________________________________
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
Suarez- Framework • RQ not • Descriptive, • Significant • Clinical • Further Level III
Garcia et al. not identified provided cross- findings of practice was investigation
(2018), Spain Tools: • Research sectional (n = clinical stress considered on clinical
• KEZKAK purpose was 450); % of associated with stressful by all stress in
questionnaire “to determine gender not gender (all 9 nursing female
(41 items, 4- the main identified in subscales; students at all nursing
point Likert stressors sample by women, p < academic year students is
scale, nine affecting authors .001) levels needed; the
subscales: nursing • 2nd-year (moderate-to- authors do
lack of students students high levels) not offer
competence, during clinical reported more • Clinical means to
contact with practice” stress (M = stress may investigate
suffering, 78.82) negatively • Establish
relationship • Highest mean affect preventative
with tutors scores by tool student’s well-being
and factors: lack of overall well- programs
companions, competence (M being within
uncertainty = 24.89), • Women prelicensure
and uncertainty (M were undergraduat
impotence, = 23.02), and significantly e curricula
lack of control contact with more stressed based on
in suffering (M = than men additional
relationships 17.32) overall in research (see
with patients, next bullet
emotional • Significant clinical in all for further
involvement, factors for scale factors research)
being harmed stress via a • Most • Additional
by the comparison of predominant research is
relationship KEZKAK clinical needed on
with patients, scale factors (9 stressors were nursing
patients were subscales/ harm to self student
seeking a variable) and harm to clinical stress
close include: patient due to to establish
relationship, relationship lack of effective
and overload) (instructors’ competence preventative
subscale and and student well-
patient seeking uncertainty of being
a close the student programs;
relationship • Need to specific
subscale, p < increase future
.001, p < .001), medication research not
being harmed administration offered by
(p = .013, p < and authors
.001), lack of occupational • Curricula
competence (p risk issues noted
= .001, p = prevention via by authors
.011), contact nursing (lack of skills
with suffering curricula and preparation
(p = .001, p = skill or inadequate
.018), development training
uncertainty (p • Nursing mentioned),
< .001), education specifics for
emotional must decrease curricula,
involvement (p the academic- and nursing
< .001), and practice gap skills
overload (p < overall in development
.001) prelicensure not offered to
 undergraduate reduce
curricula to nursing
decrease student
nursing clinical stress
student •
clinical stress Opportunity
• Limitations: for policy
self-report, development
study design, with health
convenience care
sample, and stakeholders
single regarding
institution preventative
programs, no
mention by
authors to
incorporate
stakeholders
in the
process
• Research
completed in
Spain, cannot
be
generalized
to United
States
Admi et al. • Lazarus & • RQs not • Descriptive, • Higher levels • Clinical • Further • Level III
(2018), Israel Folkman’s provided cross- of clinical practice was investigation
Stress and • Research sectional, stress considered on clinical
Coping theory purpose correlational associated with stressful by stress in
Tools: statement: “to (n = 339); gender nursing female
investigate the 73% female (women, students nursing
• Satisfaction: perceptions of (n = 274) NSSS, all six (mild-to- students
Nursing stress and subscales) moderate (gender was
Students’ satisfaction of • High stress in levels) the only
Professional undergraduate several • Clinical consistent
Satisfaction nursing subscales, low stress finding
(21 items, 5- students student negatively among all
point Likert during satisfaction affects nursing
scale, three different with clinical nursing students to
subscales) clinical experiences (r students’ clinical
• Stress: learning = − .295, overall stress)
NSSS (30 experiences in −.225, and satisfaction • Establish
items, 5-point three higher r = −.218, p = with the preventative
Likert scale, education .001) nursing well-being
six subscales) institutions in • Higher stress program programs
Israel” with patient • Increase within
suffering, program skill prelicensure
higher student development undergraduat
satisfaction in beginning e curricula
with choice of courses of •
profession (r = prelicensure Opportunity
.112, p = .040) undergraduate to investigate
and nursing programs satisfaction
education (r = • Decrease the with the
.146, p = .007) academic- profession
• Significant practice gap and nursing
factors for overall in student
stress via prelicensure program
NSSS scale undergraduate satisfaction/
factors/variable curricula to clinical stress
s (6 subscales): decrease • Further tool
inadequate nursing development
knowledge/trai student is needed in
ning (p < .01; p clinical stress nursing
< .05); adverse • Limitations: education to
and Self-report evaluate CLE
embarrassing Study design and nursing
experiences (p Convenience student
< .01; p < .05); sample clinical stress
close • Research
supervision (p completed in
< .01; p< .05); Israel; unable
insufficient to be
hospital generalized
resources (p < to the United
.01; p < .05); States
patient’s pain
& suffering (p
< .01; p < .05);
education-
reality conflict
(p < .01; p <
.05)
• New (2nd
year) and older
(age ≥31 years)
nursing
students
perceived
inadequate
knowledge of
skills as most
stressful
situation (p <
.01; p < .05)
• Older (age
≥31 years)
 nursing
students
perceived
education-
reality conflict
as most
stressful
situation (p <
.05)
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
Rodrigues et • Framework • RQ not • Descriptive, • Significant • Stress • Nursing • Level III
al. (2016), not identified provided cross- findings of affects quality education
Brazil • Tools: • Research sectional (n = clinical stress of life and must develop
KEZKAK objective was 116), 84% associated with student and
questionnaire “to evaluate female (n = female gender academic incorporate
(40 of 41 risk factors 97) (p = .015) performance effective
items were for stress in • Highest • Researchers stress
used), 4-point nursing means of describe stress management
Likert scale, students in stressful factors as fear and stress
nine subscales clinical situations via of the reduction
(lack of practice” individual unknown, strategies
competence, items on the academic within
contact with KEZKAK overload, and nursing
suffering, questionnaire feelings of curricula
relationship included: being insecurity •
with tutors infected by a • Lack of Clarification,
and patient (M =3.5 stress transparency
companions, on a scale of 1 reduction of clinical
uncertainty to 4), academic strategies in practice
and work overload nursing demands
impotence, (M = 3.5 on a school may prior to
lack of control scale of 1 to 4), contribute to clinical
in and puncture the inability to experiences
relationships with an deal with is critical for
with patients, infected needle stressful students to
emotional (M = 3.4 on a situations in reduce
involvement, scale of 1 to 4) clinical clinical stress
being harmed • Significant environments (perhaps
by the factors for • Appropriate clinical
relationship stress via a preparation orientations
with patients, comparison of before CLE is programs are
patients were KEZKAK needed within needed
seeking a scale factors nursing before
close (F3– curricula clinical
relationship, relationship • Specifically, practice
and overload) with improved begins)
supervisors pedagogical •
and coworkers preparation Development
and F6– that is of new
emotional conducive to teaching and
involvement) actual clinical learning
including lack practice practices is
of competence (reduce necessary
(p < .001), education- within
uncertainty (p practice gap) nursing
< .001), close • Limitations: education in
relationships self-report, terms of
with patients (p study design, skills and
< .001), and simulations,
overload (p < convenience with
.001), harmful sample increased
 (p < .01), emphasis on
suffering (p < clinical
.05 and p < preparation
.01), and and nursing
relationship skills to
(patients, p reduce
<.05) nursing
student
clinical stress
• Research
completed in
Brazil;
unable to be
generalized
to the U.S.
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
Suen et al. • Framework • RQs: 1) • Descriptive, • Higher • Female • Nursing • Level III
(2016), not identified What are the cross- clinical stress, nursing programs
Singapore • Tools: stress levels sectional, female gender students have need to
Stressors in of nursing correlational (p = .02) higher stress incorporate
Nursing students (n = 285); • Higher stress levels than stress
Students during their 85% female (n within clinical male nursing reduction
questionnaire clinical = 243) environment students programs
(43 items, 5- attachment? (M = 2.95 on a • Third-year (mindfulness
point Likert 2) What are scale of 1 to 5; students have and
scale, four the SD = .73) higher stress communicati
subscales) differences • Higher levels than on-based
with between the clinical stress other years programs)
Cronbach’s demographic based on (first-, provided by
alpha ranging characteristics academic years second- and authors
from .82 to (e.g., gender, (clinical, p = fourth-year • Provide
.83 for all four age, race, and .05; students) clinical
domains year of study) confidence, p = • Students opportunities
on nursing .004) with financial close to
students’ • Higher difficulties individual
stress levels? clinical stress have higher students’
3) What are with third-year overall stress residences
the students (M = compared and provide
differences 3.1 [on scale of with students information
between 1 to 5]; SD = who do not on available
actual 0.7) experience funds to
experiences • Higher financial minimize the
and clinical stress hardship financial cost
expectations with >4 weeks • Actual CLE of clinical
of a CLE for of clinical was different experience
nursing experience (p than student on students
students? = .05) expectations • Incorporate
4) What are • Higher as higher all
the clinical stress clinical stress stakeholders
relationships with financial was in the
between the difficulties (p associated development,
stress level = 01) with lower Implementati
and CLE • CLEI student on, and
factors (e.g., questionnaire satisfaction evaluation of
personalizatio (43 items, 5- with the CLE clinical
n, student point Likert (student education to
involvement, scale, four satisfaction clarify
and subscales) with was the expectations,
satisfaction)? Cronbach’s strongest improve
5) What is the alpha ranging predictor of student
most from .73 to .84 clinical stress) satisfaction,
influential for all six • Limitations reduce
factor in the subscales included self- nursing
clinical • CLE report, study student
environment expectations of design, clinical stress
that students not convenience (“onboarding
contributes to met (p < .001, sample, and of nursing
the stress all subscales) one site students”
levels of • Higher before
undergraduate clinical stress, clinical
nursing lower student experience)
students?” satisfaction • Develop
• Higher new teaching
clinical stress, and learning
lower student practices
satisfaction (based on
with CLE (r = stakeholder
0.07, p < .05) data) in
simulation
and skills
laboratory
settings to
increase
knowledge
development
and reduce
nursing
students’
clinical stress
• Future
research
should
evaluate
correlations
between
student
clinical stress
and
achievement
of clinical
outcomes
• Future
research
focused on
“clinical”
aspects of
teaching and
learning
practices
within
prelicensure
nursing
curricula is
necessary
and should
be based on
feedback
from
stakeholders
(nursing
students,
preceptors,
clinical
instructors,
and faculty)
• Research
completed in
 Singapore;
unable to be
generalized
to the U.S.
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
Kim et al. • Framework • RQ not • Quasi- • Lower • Clinical • Need to • Level III
(2018), not identified provided experimental neonatal stress of incorporate
South Korea • Tools: • Research (one group, practice-related nursing neonatal skill
1) VAS purpose “to pretest- stress after students in development
questionnaire measure the posttest neonatal skills neonatal programs in
(7 items, 10- effects of a design), with development practice areas nursing
point Likert neonatal correlational (body decreased education to
scale) with nursing (n = 64); 88% temperature except for reduce
content expert practice female (n = measurement, general nursing
validity solely program on 56) p = .01; pulse practice- student
2) Self- students’ measurement, related stress clinical stress
efficacy stress, self- p = .01; and • To reduce in neonatal
instrument efficacy, and intramuscular nursing specialty
(24 items, 6- confidence to injection, p = student areas
point Likert establish basic .01) clinical stress • Research
scale) data necessary • Higher self- in neonatal gap exists
developed by for efficacy after clinical regarding
the author, developing an neonatal skills learning skill
Cronbach’s effective development environments, development
alpha of .88 neonatal (general self- neonatal skill in other
3) Academic nursing efficacy, t = development specialty
self-efficacy practice 3.84, p < .001; programs areas
questionnaire curriculum” academic self- must be
(28 items, 6- efficacy, t = developed and • Future
point Likert 2.18, p = .033; implemented research is
scale) and social self- before needed on
developed by efficacy, t = students skill
the authors, 3.52, p = .001) attend clinical development
Cronbach’s • Increased • Neonatal programs in
alpha of .86 neonatal skill other
for academic nursing development specialty
self-efficacy practice programs also areas
4) Social self- confidence improved (authors
efficacy after neonatal students’ self- highlight
instrument (8 skills efficacy pediatrics in
items, 6-point development (general self- particular)
Likert scale), (general score efficacy, • Research
developed by after program, academic self- completed in
the author, t = 11.43, p < efficacy, and Korea;
Cronbach’s .001) social self- unable to be
alpha of .83 • Higher efficacy) and generalized
for social self- neonatal confidence to the U.S.
efficacy practice-related levels
5) Neonatal stress, lower • Previous
nursing general self- studies do not
practice efficacy (r = – exist to
confidence .26, p = .039) compare
tool (12 items, • Higher findings
4-point Likert general self- • Specifics of
scale), efficacy, neonatal skill
developed by higher development
the authors, academic self- program not
Cronbach’s efficacy (r = addressed or
alpha of .88 .61, p < .001) included by
for neonatal • Higher authors; only
nursing general self- reference to
practice efficacy, infant
confidence higher social dummy, basic
tool self-efficacy (r skills (as
= .51, p < .001) identified by
• Higher World Health
general self- Organization
efficacy, for newborn
higher social care), and an
self-efficacy (r evaluation
= .51, p < .001) skills
• Higher checklist
confidence in mentioned by
neonatal authors
nursing Limitations:
practice, higher • Self-report
general self- • Study design
efficacy (r = • Convenience
.41, p = .001) sample
• Higher • One site
confidence in
neonatal
nursing
practice and
higher social
self-efficacy (r
= .25, p <
.043).
• Stress
decreased in
the majority of
participants
(60.9%) after
neonatal skills
development
• Increase in
confidence was
89.1% overall
among
participants
after neonatal
skills
development
• After
neonatal skills
development,
participants’
general self-
efficacy
increased
(62.5%),
academic self-
efficacy
increased
(64.1%), and
social self-
efficacy
increased
(60.9%)
• After
neonatal skills
development,
89.1% (on
average) of
participants
with increased
 general self-
efficacy,
89.1% (on
average) with
increased
academic self-
efficacy, and
89.1% (on
average) with
increased
social self-
efficacy
reported an
increase in
confidence
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
Senturk & • Framework • RQs: 1) • Descriptive, • Higher • Female • Further • Level III
Dogan not identified What are the cross- clinical stress, nursing investigation
(2018), Tools: levels of sectional (n = female gender students had on clinical
Turkey • SINE stress 318); 49% (p < .05) higher clinical stress in
questionnaire experienced female (n = • Mean score stress levels female
(32 items, 4- by nursing 152) of not being than males nursing
point Likert students satisfied with • Female students
scale, two during nursing nursing • Establish
subscales– nursing education (M = students had stress
academic education? 64.8) higher overall reduction
stress and 2) What is the • Mean score of stress in programs
practical relationship academic stress nursing throughout
stress) with between the (M = 29.50); education prelicensure
Cronbach’s levels of mean of than males undergraduat
alpha of .87 stress practical stress • Moderate to e curricula
experienced (M = 29.24) high levels of •
during • High stress in Opportunity
nursing academic nursing to investigate
education and stress and high school overall satisfaction
sociodemogra practical stress • Nursing with the
phic (r = 0.927, p = students profession
characteristics .000, and r = overall are not and nursing
of nursing 0.935, p = satisfied with student
students? .000) the nursing program
education satisfaction
• Student and clinical
stress in both stress
academic and •
practice Clarification
settings and full
(CLEs) is transparency
equal, with no of clinical
significant practice
difference demands are
between necessary for
settings nursing
Limitations: students
• Self-report before
• Study design clinical
• Convenience experiences
sample (clinical
orientations
before
clinical
practice)
 •
Orientations
necessary for
clinical
adjuncts and
preceptors
regarding
stress
reduction
techniques
and nursing
student
clinical stress
• Need for
qualitative
research to
investigate
further
nursing
student
clinical stress
• Research
completed in
Turkey;
unable to be
generalized
to the U.S.
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
Rafati et al. • Framework • Research • Descriptive, • Highest • Higher • Establish • Level III
(2020), Iran not identified aim was “to cross- Mean scores perceptions of stress
Tools: investigate the sectional, were clinical stress reduction
• NSPCSS (32 relationship correlational performing (M resulted in programs
items, 5-point between (n = 395); = 0.45) and increased throughout
Likert scale; clinical 59% female (n witnessing clinical prelicensure
Cronbach’s dishonesty = 201) dishonest dishonesty undergraduat
alpha of .90 and perceived behaviors (M = behaviors by e curricula to
• Clinical clinical stress 0.78 (on a 0 to nursing reduce
Dishonesty in nursing 2 scale). The students nursing
Questionnaire students” mean score of within the student
(12 items, 4- perceived CLE clinical stress
point Likert severity of • Authors • Need for
scale in the dishonest concluded future
third subscale; behavior is clinical research on
three unethical (M = dishonesty is the effects of
subscales with 3.34 (1 to 4 a coping nursing
Cronbach’s scale) mechanism to student
alphas of .79, • Witnessing reduce clinical stress
.83, and .83) clinical clinical stress on nursing
dishonesty, by nursing student
dishonest students dishonesty
clinical • Clinical behaviors in
performance (r dishonesty the CLE
= 0.53, p < behaviors by • Research
.001), nursing completed in
dishonest students may Iran, unable
behavior, affect patient to generalize
perceived as outcomes to U.S.
unethical (health and
behavior (r = – safety)
0.40, p < .001) Limitations:
and higher • Self-report
 clinical stress, • Study design
higher clinical • Convenience
dishonesty (r = sample (four
.28, p < .001) nursing
colleges)
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
D’emeh & • Framework • RQs: 1) • Descriptive, • Highest mean • Clinical • Develop • Level III
Yacoub not identified What is the cross- scores include stress among and
(2021), Tools: perceived sectional, stress from nursing strengthen
Saudia • PSS level of stress correlational taking care of students was teaching and
Arabia questionnaire reported by (n = 238); patients (M = high (M = learning
(29 items, 5- nursing 79% female (n 2.81), stress 2.58) practices in
point Likert students = 189) from teachers • Highest simulation
scale scored 0 during their and nursing perceived and skills
to 4 on 6 clinical staff (M = clinical stress labs settings
subscales); training? 2) 2.55), and from taking to increase
subscales What types of stress from care of knowledge
include stress stressors were lack of patients, nurse development
from taking reported by professional educators and and reduce
care of nursing knowledge and nursing staff, nursing
patients, students nursing skills lack of student
teachers, and during their (M = 2.39) professional clinical stress
nursing clinical • Highest knowledge & • Clinical
personnel, training? 3) stressful events skills, and the orientation
assignment What is the for students in CLE programs are
and workload, relationship clinical were • Limitations: needed
peers and between the ability to -Self-report before
daily life, lack perceived discuss -Study design nursing
of level of stress patients’ -Convenience student
professional and selected illnesses with sample (three clinical
knowledge demographic nurse private practice
and skills, and factors? educators and nursing • Qualitative
stress from nursing staff schools in the research is
clinical (M = 3.02), same city) needed to
environment and inability to -Research further
provide completed in investigate
nursing care one clinical stress
and make geographical in nursing
clinical area, limiting students
decisions (M = generalizabilit • Research
2.88) y conducted in
• Beginning Jordan,
nursing unable to
students generalize to
averaged the the U.S.
highest level of
clinical stress
(M = 81.49)
• Higher
clinical stress
due to nurse
educators and
nursing staff (p
< .001),
clinical
assignments
and workload
(p < .01)
• Higher
clinical stress
due to lack of
 professional
knowledge &
nursing skills
(p < .001),
taking care of
patients (p <
.001), clinical
environment (p
< .02).
• Higher
clinical stress
(gender,
females) in
subscales of
clinical
assignments &
workload (p <
.01) nurse
educators and
nursing staff (p
< .03)
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
Miguel et al. • Framework • RQs not • Descriptive, • Higher • Self‐efficacy • Authors -Level III
(2020), Spain not identified provided cross- procedural does not focused on
Tools: • Research sectional, stress, female intervene in emotional
• KEZKAK aim was “to correlational gender procedural stress
questionnaire propose a (n = 330); (female, p < stress findings
(41 items, 4- predictive .02) (self-efficacy
point Likert model for two 86% female (n • Procedural • Provide development
scale, nine different types = 288) stress is the students with ) versus
subscales of of stress in highest self-efficacy procedural
the original clinical predictor of tools stress in the
tool; authors placement.” clinical stress • Transfer conclusion
only used 23 in nursing self-efficacy and summary
items, five students versus to clinical • Lack of
subscales emotional learning and procedural
representative stress (Z = skills stress focus
of procedural −13.609, p < development concerning
and emotional .001) learning nursing
stress, • Procedural environments education
Cronbach’s stressors (beginning of and
alphas of .71 (subscales) curriculum) pedagogy
& .89) most stressful, • Skills offered, yet
• Coping 1 – lack of development procedural
Scale of competence, requires belief stress was
Academic and 2 – and the highest
Stress impotence and competence in predictor for
Questionnaire uncertainty abilities to clinical stress
(10 items, 5- • General self‐ reduce stress in nursing
point Likert efficacy and • Limitations: students
scale, academic not offered by • Future
Cronbach’s overload authors research is
alphas of .83 statistically needed
& .93) significant concerning
• Generalized correlations in procedural
Self-efficacy third- and stress (lack
Scale (10 fourth year of
items, 4-point students, r = competence
Likert scale −.24, p < .05 and
and r = −.18, p uncertainty
< .05 KEZKAK
 • Final model, subscale
academic elements)
overload (p = • Research
.001) and completed in
hospital unit (p Spain, unable
= .001) to generalize
predicted to U.S.
procedural • Sample
stress solely from
• Final model, one
academic university
overload (p =
.001) and
general self‐
efficacy (p =
.02) predicted
emotional
stress
Author, Framework & Purpose or Design, Findings & Conclusions Reviewer Quality
Year, & Tools RQ & Sample Size, Results & Limitations Analysis for Indicator
Country of Hypotheses & Gender Future (Johns
Origin Research & Hopkins
Practice Appraisal
Tool)
Yidirim et al. • Framework • Research • Descriptive, • Higher stress • Authors • Research • Level III
(2016)/ not identified aim was “to cross- overall for concluded completed in
Turkey • SINE determine the sectional (n = nursing female Turkey,
questionnaire degree of 821); 80% students nursing unable to be
(32 items, 4- stress female (n = (practical and students generalized
point Likert experienced 652) academic experience to the U.S.
scale, two by stress, p < higher stress • Authors’
subscales undergraduate .001) (practical and rationale for
(academic nursing academic low clinical
stress and students • Higher stress stress) due to confidence
practical during their overall, female the inability to was nursing
stress) with education in gender share instructors
Cronbach four Turkish (female, p < anxieties, need to
alphas from universities” .001) feelings, and support
.81 to .93. • RQ: 1) Do • Higher stress, vulnerability nursing
stress levels low perceived to students’
experienced academic psychological confidence;
by achievement issues authors did
undergraduate (practical • Authors not consider
nursing stress, p < .04; pointed to the pedagogical
students academic significant aspects to
during their stress, p < .04) practical reduce
education • Lower stressors practical
differ practical stress, (making a stressors
significantly student mistake and (e.g.,
according to smoking (p < instructor curriculum/te
certain socio- .001) criticism) due aching &
demographic • Lower to the lack of learning
attributes? practical stress, confidence in practices for
student clinical and skills
drinking judgmental development
alcohol (p < attitudes of )
.001) clinical • Future
• Highest instructors research
stressors in • Lack of should
clinical explanation include
include: not by authors for interviews
having enough reduced with female
time to practical nursing
complete stress levels in students to
nursing tasks nursing discover their
students who lived
 (M = 2.14), smoked and experiences
patient drank alcohol of clinical
suffering (M = • Limitations: stress within
2.31), making -Self-report the CLE
a mistake in -Study design
patient care (M -Convenience
= 2.17), and sample from
instructor four nursing
criticism (M = programs in
2.17). close
• Authors proximity
indicated
second- and
fourth-year
nursing
students
experience
higher stress
(practical and
academic);
findings not
significant
Note. RQ = research question; NSSS = Nursing Students Stress Scale; CLE = clinical learning environment; CLEI = Clinical Learning
Environment Inventory; VAS = visual analog scale; SINE = Stress in Nurse Education Questionnaire; NSPCSS = Nursing Students’
Perceptions of Clinical Stressors Scale; PSS = Perceived Student Stress; SINE = Stress in Nurse Education Questionnaire