Journal of Taibah University Medical Sciences (2019) 14(1), 60e66

Taibah University

Journal of Taibah University Medical Sciences

www.sciencedirect.com

Original Article

Psychosocial stress factors among mental health nursing students in

KSA
Seham M. Alyousef, PhD

Community and Psychiatric Mental Health Nursing Department, Nursing College, King Saud University, Riyadh, KSA

Received 3 October 2018; revised 8 November 2018; accepted 11 November 2018; Available online 13 December 2018

‫ﺺﺨﻠﻤﻟﺍ‬ Abstract

‫ﺚﺤﺒﻟﺍ ﻑﺍﺪﻫﺃ‬: ‫ﺮﻴﺒﻛ ﻂﻐﻀﻟ ﻦﺿﺮﻌﺘﻳ ﺪﻗ ﺕﺎﺿﺮﻤﻤﻟﺍ ﻥﺃ ﻰﻟﺇ ﺔﻴﻟﺎﺤﻟﺍ ﺔﻟﺩﻷﺍ ﺮﻴﺸﺗ‬
‫ﻦﻬﺒﻳﺭﺪﺗ ﺀﺎﻨﺛﺃ‬، ‫ﻖﻴﻀﻟﺍ ﻦﻋ ﺔﻟﻭﺆﺴﻤﻟﺍ ﺔﺴﻴﺋﺮﻟﺍ ﺮﺻﺎﻨﻌﻟﺍ ﻦﻋ ﻑﺮﻌﻳ ﻞﻴﻠﻘﻟﺍ ﻦﻜﻟﻭ‬
‫ﺔﻴﺴﻔﻨﻟﺍ ﺔﺤﺼﻟﺍ ﻝﺎﺠﻣ ﻲﻓ ﺾﻳﺮﻤﺘﻟﺍ ﺕﺎﺒﻟﺎﻃ ﻪﻨﻣ ﻲﻧﺎﻌﺗ ﻱﺬﻟﺍ‬. ‫ﺔﺳﺍﺭﺪﻟﺍ ﻩﺬﻫ ﺖﻟﻭﺎﻨﺗ‬
‫ﻲﻓ ﺾﻳﺮﻤﺘﻟﺍ ﺕﺎﺒﻟﺎﻄﻟ ﺔﻴﺴﻔﻨﻟﺍ ﺔﺤﺼﻟﺍ ﻰﻠﻋ ﺮﺛﺆﺗ ﻲﺘﻟﺍ ﻲﺴﻔﻨﻟﺍ ﺩﺎﻬﺟﻻﺍ ﻞﻣﺍﻮﻋ‬
.‫ﺔﻳﺩﻮﻌﺳ ﺔﻌﻣﺎﺟ‬
‫ﺚﺤﺒﻟﺍ ﻕﺮﻃ‬: ‫ﻪﺒﺷ ﺕﻼﺑﺎﻘﻤﻟﺍ ﻡﺍﺪﺨﺘﺳﺎﺑ ﺎﻴﻋﻮﻧ ﺎﻳﺮﻴﺴﻔﺗ ﺎﺠﻬﻧ ﺔﺳﺍﺭﺪﻟﺍ ﻩﺬﻫ ﺕﺪﻤﺘﻋﺍ‬
‫ ﻊﻣ ﺔﻤﻈﻨﻤﻟﺍ‬١٠ ‫ﺔﻌﺑﺍﺮﻟﺍ ﺔﻨﺴﻟﺍ ﻲﻓ ﺔﻴﺴﻔﻨﻟﺍ ﺔﺤﺼﻟﺍ ﺾﻳﺮﻤﺗ ﺕﺎﺒﻟﺎﻃ ﻦﻣ‬. ‫ﺪﻌﺑ‬
‫ﺕﻼﺑﺎﻘﻤﻠﻟ ﻲﻤﻗﺮﻟﺍ ﻞﻴﺠﺴﺘﻟﺍ‬، ‫ﻝﻼﺧ ﻦﻣ ﻯﻮﺘﺤﻤﻟﺍ ﻞﻴﻠﺤﺘﻟ ﺔﻠﺠﺴﻤﻟﺍ ﺕﻼﺑﺎﻘﻤﻟﺍ ﺖﻌﻀﺧ‬
.‫ ﻮﻔﻴﻔﻴﻧ ﻖﻴﺒﻄﺗ‬١٠.١ ‫ﺔﺳﺍﺭﺪﻟﺍ ﻩﺬﻫ ﻦﻣ ﺔﺌﺷﺎﻨﻟﺍ ﻊﻴﺿﺍﻮﻤﻟﺍ ﺪﻳﺪﺤﺗ ﻪﻟﻼﺧ ﻦﻣ ﻢﺗ ﻱﺬﻟﺍ‬
‫ﺞﺋﺎﺘﻨﻟﺍ‬: ‫ﺕﺎﺒﻟﺎﻄﻟﺍ ﻡﺪﻘﺗ ﻖﻴﻌﺗ ﻲﺘﻟﺍ ﺕﺎﻴﻣﺎﻨﻳﺪﻟﺍ ﺔﺳﺍﺭﺪﻟﺍ ﻩﺬﻫ ﺭﻮﺼﺗ ﻥﺃ ﻦﻜﻤﻤﻟﺍ ﻦﻣ‬
‫ﻲﺋﺎﻬﻨﻟﺍ ﻲﻤﻳﺩﺎﻛﻷﺍ ﻡﺎﻌﻟﺍ ﺔﻳﺎﻬﻧ ﻦﻣ ﻦﺑﺮﺘﻘﻳ ﻲﺗﻼﻟﺍ‬. ‫ﺔﻌﺑﺭﺃ ﻮﺤﻧ ﺰﻴﻛﺮﺘﻟﺍ ﻪﻴﺟﻮﺗ ﻢﺗ‬
‫ﻱﺮﻳﺮﺴﻟﺍ ﻢﻠﻌﺘﻟﺍ ﻕﺎﻴﺳ )ﺃ( ؛ﺔﺴﻴﺋﺭ ﻊﻴﺿﺍﻮﻣ‬، (‫ﺔﺿﺮﻤﻤﻟﺍ ﺪﺿ ﺰﻴﻴﻤﺘﻟﺍ )ﺏ‬، (‫)ﺝ‬
‫ﺔﻴﺼﺨﺸﻟﺍ ﺕﺎﻗﻼﻌﻟﺍ‬، (‫ﺔﻴﻋﺎﻤﺘﺟﻻﺍ ﺕﺎﻳﺪﺤﺘﻟﺍ )ﺩ‬. ‫ﺎﻬﺑ ﻰﻟﺩﺃ ﻲﺘﻟﺍ ﺕﺎﻧﺎﻴﺒﻟﺍ ﻞﻴﻠﺤﺗ ﻢﺗ‬
.‫ﺔﻴﻋﺮﻓ ﻊﻴﺿﺍﻮﻣ ﺔﻴﻧﺎﻤﺛ ﻲﻓ ﻚﻟﺫ ﺪﻌﺑ ﻦﻬﺑﺭﺎﺠﺗ ﻊﻴﻤﺠﺗ ﻢﺗﻭ ﺔﺌﺷﺎﻨﻟﺍ ﻊﻴﺿﺍﻮﻤﻠﻟ ﺕﺎﺒﻟﺎﻄﻟﺍ‬
‫ﺕﺎﺟﺎﺘﻨﺘﺳﻻﺍ‬: ‫ﻦﻬﺗﺎﻗﻼﻋ ﺰﻳﺰﻌﺗ ﻰﻠﻋ ﺕﺎﺒﻟﺎﻄﻟﺍ ﻊﻴﺠﺸﺗ ﺔﻴﻤﻫﺃ ﺔﺳﺍﺭﺪﻟﺍ ﺞﺋﺎﺘﻧ ﺕﺯﺮﺑﺃ‬
‫ ﻲﻨﺒﺗﻭ ﺕﺎﻴﺠﻴﺗﺍﺮﺘﺳﺍ ﺓﺭﺍﺩﻹ ﺕﺎﻳﻮﺘﺴﻣ‬، ‫ ﻦﻴﺴﺤﺗﻭ ﻦﻬﺘﺤﺻ ﺔﻴﺴﻔﻨﻟﺍ‬،‫ﻦﻬﻧﺍﺮﻗﺄﺑ‬
‫ﻲﻤﻳﺩﺎﻛﻷﺍﻭ ﻲﺼﺨﺸﻟﺍ ﺩﺎﻬﺟﻹﺍ‬. ‫ﺕﺎﺒﻻﻄﻟﺍ ﺕﺎﻌﻗﻮﺗ ﻢﻬﻓ ﻥﺃ ﻚﻟﺬﻛ ﺔﺳﺍﺭﺪﻟﺍ ﻩﺬﻫ ﺖﻔﺸﻛ‬
‫ﻁﻮﻐﻀﻻﺑ ﻑﺍﺮﺘﻋﻼﻟ ﺔﺼﻨﻣ ﺮﻓﻮﻳ‬. ‫ﻢﻬﻓ ﻦﻴﺴﺤﺘﻟ ﺔﻟﺎﻌﻓ ﺕﻼﺧﺪﺗ ﺩﺎﻤﺘﻋﺍ ﻦﻜﻤﻳ ﺎﻤﻛ‬
.‫ﺔﻴﺴﻔﻨﻟﺍ ﺔﺤﺼﻟﺍ ﺾﻳﺮﻤﺗ ﺕﺎﺒﻻﻃ ﻦﻴﺑ ﺔﻘﺣﻼﻟﺍ ﻂﻐﻀﻟﺍ ﻞﻌﻓ ﺩﻭﺩﺭﻭ ﻂﻐﻀﻟﺍ ﻞﻣﺍﻮﻋ‬
‫ﺔﻳﺮﻳﺮﺴﻟﺍ ﺕﺎﺒﻟﺎﻄﻟﺍ ﺞﺋﺎﺘﻧ ﻦﻴﺴﺤﺘﻟ ﺓﺪﻴﻔﻣ ﻥﻮﻜﺗ ﺪﻗ ﺞﺋﺎﺘﻨﻟﺍ ﻩﺬﻫ‬، ‫ﺔﻴﻋﺎﻤﺘﺟﻻﺍﻭ‬
.‫ﺔﻴﻤﻳﺩﺎﻛﻷﺍﻭ‬
‫ﺔﻴﺣﺎﺘﻔﻤﻟﺍ ﺕﺎﻤﻠﻜﻟﺍ‬: ‫ﺾﻳﺮﻤﺘﻟﺍ ؛ﺕﺎﺒﻟﺎﻄﻟﺍ ؛ﻞﻣﺍﻮﻌﻟﺍ ؛ﻂﻐﻀﻟﺍ ؛ﻲﺴﻔﻧ‬
Corresponding address: Community and Psychiatric Mental
Health Nursing Department, Nursing College King Saud Univer-
sity, Riyadh, KSA
E-mail: smansour@ksu.edu.sa
Peer review under responsibility of Taibah University.
Production and hosting by Elsevier
Objectives: Although existing evidence suggests that
nurses may experience significant stress during their
training, less is known about the key elements responsible
for the distress experienced by mental-health nursing
students. This study has examined the psychosocial stress
factors that influence mental-health nursing students in a
Saudi University.
Methods: This study has adopted a qualitative interpre-
tive approach, using semi-structured interviews with 10
female fourth-year mental-health nursing students. After
the interviews were digitally recorded and transcribed,
they underwent content analysis using the NVIVO 10.1
application, generating the themes that emerge in this
study.
Results: The results of the present study make it possible
to conceptualise the dynamics that impede the progress of
students nearing the end of their final academic year. The
analysis focuses on four main themes: (a) the clinical
learning context; (b) discrimination against nurses; (c)
interpersonal relationships; and (d) social challenges. The
statements made by students were analysed for emerging
themes; their experiences were subsequently grouped into
eight sub-themes.
Conclusions: The study findings highlight the importance
of encouraging students to strengthen peer relationships,
improve their own psychological wellbeing, and embrace
strategies for managing both personal and academic
stress levels. They also reveal that understanding the ex-
pectations of students can provide a platform for recog-
nising stressors. Effective interventions can be adopted to
improve understanding of stress factors and subsequent
stress responses among mental-health nursing students.

1658-3612 2018 The Author.

Production and hosting by Elsevier Ltd on behalf of Taibah University. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.jtumed.2018.11.006
S.M. Alyousef 61
 62 Stress of mental health nursing students
These results may help to improve students’ clinical, so-
cial, and academic outcomes.
Keywords: Factors; Nursing; Psychosocial; Stress; Students
2018 The Author.
Production and hosting by Elsevier Ltd on behalf of Taibah
University. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).
Introduction
There is a large body of research on the implications of
distress among nurses and nursing students and its subse-
quent effect on their overall wellbeing.1 Although there is
also a growing literature on stress and its implications for
nurses and nursing students, few studies have focused on
the sources or factors that could help to prevent such
stress. Stress has been shown to be strongly associated with
attrition among mental-health nursing students. 2,3
Tankink and Bubenzer4 have explained that stress results
from challenging situations that individuals fail to resolve.
Although it can be elicited and aggravated by various
physical or psychological catalysts, stress varies across
individuals based on their own perspective. Perceived stress
can therefore be defined as an event believed to stimulate
stress.5 As Clement et al.6 have pointed out, stress-inducing
events are usually subjective. Culbert, Racine, and Klump7
have suggested that stress consists of the following phases:
the context, the behavioral response stage, and the
emotional reaction phase. Evidence from studies conducted
8 9 1
by Van Gordon et al., Galvin et al., and Morse indicates
that little research has been carried out globally on the
issue of stress among mental-health nursing students. How-
ever, a few studies have addressed issues related to the an-
tecedents of stress among mental-health nursing students.10
In their study of undergraduates, Jameson and Fusco11
found that many students experienced stress throughout the
academic year. Other studies have highlighted the extent to
which the shortage of nurses has contributed to a worsening
12,13
situation for the world’s population. These problems are
further compounded by the high rates of stress reported by
14,15 16
mental-health nurses. Dardas and Ahmad have argued
that a heightened stress response will cause the physical and
mental health of mental-health nursing students to deterio-
rate. Stress causes nursing students to feel more detached and
apathetic, contributing to their failure to manage and resolve
10 17
situations. Chou et al. have supported these findings,
suggesting that stress inevitably influences problem-solving,
memory, attention to detail, and learning processes.
Al-Zayyat and Al-Gamal18 have identified other stressors
experienced by nursing students, including interactions with
colleagues, the fear of making errors, a poor work and life
balance, financial issues, and family problems. Chernomas
19
and Shapiro have discussed instances where mental-health
nursing students found it difficult to manage situations or
felt unable to confide in others. The severe stress experienced
by mental-health nursing students underlines the need to
understand the factors that increase their stress levels.
The literature review found no previous studies on the
sources of stress among mental-health nursing students in
KSA. Given the identified stressors that impact this group,
and the lack of research on these stress factors among nurses,
further research is needed to understand the different types
and levels of stress experienced by nurses in the Middle East
and KSA. The present study aims to determine the psycho-
social stress factors that impact mental-health nursing stu-
dents attending the King Saud University College of Nursing
in Riyadh, KSA. Rich and Nugent20 and Almalki, FitzGerald,
21
and Clark have argued that well-trained healthcare workers
are particularly needed in KSA, where the performance of
nursing students tends to be affected by social stress.
Materials and Methods
Research design
This study has adopted an interpretive qualitative approach.
According to Lewis,22 interpretive qualitative research explores
the perceptions, interests, and experiences of research subjects.
23
As Brooks and Normore have pointed out, phenomenology
is the key to describing experiences, as it reveals not only
the
perceptions, but also the thought processes of
individuals experiencing various phenomena. In this
approach, interviews are the main method used to collect
data.
Setting/participants
The participants were selected from a cohort of fourth-
year mental-health nursing students at the King Saud
University College of Nursing in Riyadh, KSA. The
participants were 10 women with a mean age of 24; all were in
their final year. Four participants reported that they shared a
house with peers, while six lived with their parents. Six
participants stated that their in- come was almost
equivalent to their expenses, while the remainder had
expenses that exceeded their income. No partic- ipant involved
in the study was currently working or married.
Data analysis
The collected data were analysed using NVivo 10.1 soft-
22
ware. Themes derived from this analysis identified factors
that affected individuals in the mental-health nursing
department. These themes were subsequently divided into 8
sub-themes. Thick description, using narratives obtained
from the students, was used to illuminate the themes.
Saturation
The present study used theoretical sampling; interview
probes, based on data from previous interviews, were
continuously revised to explore emerging themes. Each
interview was ended when the participant stopped expressing
any new inductive codes, as this indicated saturation.
Data collection instruments
A tailored information form was used during the inter-
view process to collect data from the students. As Creswell
 24
et al. have noted, the use of individual, face-to-face, semi-
structured interviews has the greatest potential for obtaining,
not simply the respondents’ views, but also their underlying
motivations.
During the interviews, the participants were asked open-
ended questions. One of the general questions was ‘what
are some of the sources of stress affecting students within the
clinical context?’ Additional questions in the questionnaire
were based on the research participants’ statements and re-
sponses.25 When the interviews were completed, the audio
recordings were transcribed as written narratives. Each
interview (lasting an average of 55 min) was held in a
meeting room in the mental-health nursing department of
the nursing college. The interviews continued until data
saturation was achieved.26
Methodological rigor
Throughout this study, all necessary steps were taken to
ensure the credibility, dependability, confirmability, and
transferability of the investigation. Interviewer bias and ex-
pectations were managed, and a degree of subjectivity was
adopted during the data review and coding process, thereby
27
safeguarding what Palinkas et al. have referred to as the
interpretive epistemology of the findings.
During the interviews, the subjects were asked for addi-
tional explanations to ensure that their answers were clearly
salient. A parallel, partial data evaluation conducted by the
authors validated the results and identified embryonic nar-
ratives; a subsequent reappraisal of the transcripts eliminated
error and ensured reliability. The authors carried out a
comparative assessment and substantiated the coding clas-
sifications, as well as carrying out routine consistency checks
of both coding and subject areas. Following the six-week
period when data were amassed, two researchers reviewed
the data codes and categories to reach agreement on their
importance and implications. Questions concerning the
generalisability of results were addressed by offering a
meticulous summary of the investigation and its context.
Semi-structured interviews and unstructured dialogues
generated valuable insights into the interviewees’ opinions,
perceptions, and subjective interpretations. For these rea-
sons, it was possible to gain a wide-ranging appreciation of
the participants’ experiences.
Results
Four over-arching themes were derived from the content
analysis and 8 sub-themes. These themes encompassed the
students’ own views of psychosocial stress and issues related
to their own experiences (Table 1).
A- Clinical learning context
A1. Skills need
In their responses, most students characterised the clinical
learning context as a place where the skills needed to care for
patients were learned. Some of these skills were categorised
as basic healthcare skills, which, if not acquired, would have
a negative effect on quality of care. One of the students said,
‘I think that throughout the training period we received
Table 1: Themes encompassing the students’ own views of
psychosocial stress factors.
Main theme Sub-theme
A- Clinical learning context Skills needed
Insufficient knowledge and training
B- Discrimination against Feeling underappreciated
nurses Society lacks confidence in the
nursing role
C- Interpersonal Family interpersonal stress
relationships Educational interpersonal stress
D- Social challenges Financial constraints
Social pressure
inadequate training, and the information given was not sub-
stantive enough. Thus, most students refrain from taking on
patients and only work on the nursing procedures’.
A2. Insufficient knowledge and training
Many participants made the point that nursing students
needed access to scientific sources to build confidence e
before being deployed to training centres. When questioned
on this topic, one student maintained that ‘there is a need to
evaluate the source periodically, as most students lack the
uninterrupted training to enhance their knowledge’.
These findings indicate that mental-health nursing stu-
dents experience distress and become overwhelmed when they
encounter new experiences in the clinical learning context.
The participants attributed the stress they experienced to the
complexity of providing care to patients. As one student
recalled, ‘I was in much distress, and I was scared of providing
any care to the patient for fear of causing harm. For example,
when giving the patient some medication, I was frightened and
prayed for him to stay alive’.
B- Discrimination against nurses
B1. Feeling underappreciated
The mental-health nursing students also reported having
experienced discrimination. One participant said that she felt
underappreciated in KSA. Another, who had encountered
this problem with some of her friends, said, ‘I have a feeling
that the nursing role does not play any significant role in so-
ciety or in the hospital because what we do is only taking orders
from the doctor’.
B2. Society lacks confidence in the nursing role
Another student stated that society perceived the actions
of nurses negatively. When society lacks confidence in nurses,
the situation worsens. For example, when conducting follow-
up appointments with patients, one student observed, ‘our
society fails to give nurses, particularly the Saudi women,
respect and fails to utilise them or even to seek their advice
regarding patient care needs’.
C- Interpersonal relationships
C1. Family interpersonal stress
Most participants revealed that they were stressed as a
result of interpersonal relationships. In the words of one
student, ‘my relationship with my family members and friends
led to stress that affected me and my studies negatively!’
C2. Stress in the educational environment
Most of the mental-health nursing students revealed that
they were stressed by aspects of the educational environment.
As one participant said, ‘most of the stress impacting me came
from the educational setting, such as in school and from my
peers’.
D- Social challenges
D1. Financial constraints
Some participants highlighted factors associated with
social challenges as a source of stress. One participant cited
financial constraints as a social challenge, saying: ‘in addition
to the social responsibilities I had from my family, I experi-
enced challenges as there were competing expenses I needed to
sort out but I could not manage because I did not have enough
money and this left me stressed’.
D2. Social pressure
Another participant implicated social pressure: ‘the issue
of committing myself to attending certain activities and events
has not been fruitful’. Both social and educational activities
were understood to be a source of psychological pressure for
most mental-health nursing students.
Discussion
In summary, the qualitative data revealed several factors
associated with psychosocial stress among mental-health
nursing students. These factors related to four thematic
areas, namely, the clinical learning context, discrimination
against nurses, interpersonal relationships, and social chal-
lenges. This finding confirms the work of Vivekananda-
Schmidt,28 who recognised that the actual experience of
psychosocial stress must be taken into account. For this
reason, the prevalence of psychosocial stress among
mental-health nursing students is an important topic. Most
of the experiences uncovered in this study were consistent
with the evidence presented in Singh, Sharma, and Sharma29
and Chernomas and Shapiro,19 who identified clinical and
academic learning, financial support, relationships, and
environmental social stress factors as stressors. It is evident
from the results of the current study that these themes are
significant and endorsed by the present participants. They
are also consistent with the work of Bahadır-Yılmaz,30 who
observed the impact of these factors among Turkish
mental-health nursing students. Their stress levels were
linked to psychological and behavioural issues, as well as to
poor clinical and academic performance. Research has
shown that mental-health nursing students experience a
different level of stress from medical, graduate, or under-
31,32
graduate students.
The findings of the current study also corroborate ele-
33
ments of the work of Jimenez et al. and Gibbons,
35.
Dempster, and Moutray. These studies reported that the
academic environment, social distress, financial constraints,
and interpersonal relationships were sources of stress
among mental-health nursing students. It is important to
note that the present findings are likewise consistent with
research conducted in the Philippines, where similar levels of
stress were reported by students.35
The findings of the present study confirm outcomes re-
36
ported by Adriaenssens, De Gucht, and Maes, who studied
mental-health nursing students in the UK. Szpak and
Kameg37 have highlighted factors that affect nursing
performance, such as financial constraints, health
problems, and interpersonal complications. Previous
studies have also supported the current finding that stress
factors affect the learning performance of students and
even practicing nurses.38 Nurses encounter challenges,
including work conflicts with staff members, the care of
critical patients, and patients with interpersonal
39,40
problems.
41
According to Christiansen and Bell and Connor et al.,42
mental-health nursing students are likely to experience
stressors while developing their clinical skills. Other stressors
are associated with the learning context, for example, failures
to adopt or learn practical skills.34,43,44
Tight deadlines during placements, coupled with evalua-
tions and frequent performance activities, also cause stress.
This finding is consistent with studies that have identified
nursing-staff attitudes as a source of stress for students on
32,45,46
placement. Further evidence indicates that placement
organisations fail to address the source of stressors
46,47
typically found in such institutions.
The participants experienced discrimination during their
clinical training, which contributed to their psychosocial
stress. Further research is needed to illuminate the multi-
faceted impact of discrimination on individuals, and its
psychological, social, and biological consequences. It is well
established that health is negatively affected by discrimina-
tion. Additional evidence shows that health and wellbeing
are adversely impacted by discriminatory interactions, such
as ill-treatment in educational settings and when seeking
employment, housing, or healthcare.48 Individuals with
unconscious prejudices may display discriminatory
49
behavior. Interactions may cause other individuals to
internalise discrimination, which is known to have severe
repercussions for health, including restriction of social
50 51 52
networks, poorer quality of life, low self-esteem, signs
of depression,
53
and loss of job and income.
54
Furthermore, studies of discrimination have highlighted the
importance of predicting chronically triggered
psychological stress reactions that can disrupt inter-
55
personal social interactions.
The participants in this study noted that interpersonal
relationships and social and financial constraints contributed
56
to their psychosocial stress. This is consistent with Murff,
57 58 59
Zhao et al., Tovar, and Sanchez et al., who confirmed
that existing responsibilities and social relationships were
key stress factors for individuals. The present study also
confirms Ghaderi and Rangaiah’s60 research on Indian and
Iranian mental-health student nurses, who associated stress
with social challenges and responsibilities. However, Reeve
61 62
et al. and Gropel, Kuhl, and Work have shown that
social support derived from family and friends can help
mental-health nursing students manage their stress,
reducing poor academic performance.
The participants in this study described various ways in
which financial stress affected them in the academic
environment. Garrosa et S which also permitted
al.,63 Goff,47 and Kang, C o interviews to be recorded
o u during the
Choi, and Ryu64 have r
likewise shown that n
c c
financial constraints can e
have a major negative l
impact on mental-health u
nursing students, s o
engendering poor i f
academic performance. o
Aca- n f
demic achievement is u
affected by financial The study participants n
problems, work- load, identified problematic d
socio-personal instances of psychosocial i
relationships, and stress associated with n
emotional factors.43,65 their chosen field of g
Numerous studies have study. The forms of
highlighted personal stress experienced by None declared.
sources of stress, mental-health nursing
associated primarily with
students have been C
financial concerns and
grouped into the following o
tight deadlines.42,44,45
four thematic areas: the n
While these issues are
clinical learning context, f
common among all
discrimination against l
students, they are more
prominent nurses, interpersonal i
relationships, and social c
among mental-health
chal- lenges. Findings have t
nursing students, as
Adriaenssens et al.
36
have revealed the interactions
shown, due to specific among stress factors, o
issues relating to family attributing many of the f
commitments, change students’ challenges and
processes, and career feelings of distress to stress i
demands. factors and their respective n
cau- t
37
S ses. It is thus essential e
t to provide students with r
u a clear e
d work-life balance, so that s
y they can maintain good t
relation- ships with family
l and friends. Programmes The author has no
i must adopt a clear conflict of interest to
m strategy to provide declare.
i physical and
t psychological man- E
a agement strategies to t
t those experiencing stress. h
i Future research is needed i
o to explore the implications c
n of stress within this cohort. a
s The present study findings l
concur with literature on
This study does have the factors that link stress a
some limitations, due to and the wellbeing of p
the nature of the research mental- p
30
design and the sample health nursing students. r
selected. For this reason, Students are advised to o
its findings may not be use v
easily generalisable to social and peer a
nurses in other specialties. relationships to relieve and l
Nevertheless, the present cope with stress. Future
study provides new studies may focus on Permission and
information on the stress student concerns, showing approval for this study
experienced by mental- empathy and providing were granted by the
health nursing students in guidance.66 Institutional Review Board
KSA. of King Saud University,
research process. Before Understanding Morgan C, O’Connell EJ,
taking part, participants adolescence as a period of Smith AP.
were brie- fed on the social-affective engagement Mental health nursing
and goal flexibility. Nat students’ experiences of
purpose of the study and
Rev Neu- rosci 2012; 13: stress during training: a
informed that their in- thematic analysis of
636.
formation and personal 3. Hamaideh SH, Al- qualitative interviews. J
details would be kept Ashram SA, Al-Modallal H. Psychiatr Ment Health
confidential and Premenstrual Nurs 2015; 22: 773e783.
anonymous. All syndrome and 10. Spence Laschinger HK,
participants signed an premenstrual dysphoric Nosko A. Exposure to
informed consent form, disorder among Jorda- workplace bullying and
which confirmed that they nian women. J Psychiatr post-traumatic stress
Ment Health Nurs 2014; disorder symptomology:
could withdraw from the
21: 60e68. the role of protective
study at any time, could not
4. Tankink M, Bubenzer F. psychological resources. J
be identified by their Building sustainable peace Nurs Manag 2015;
responses, and would have through an 2
enough time to complete integrated approach to 3
the process; in addition, peacebuilding and mental :
their participation or non- health and psychosocial
participation would not support: a literature 2
affect any academic review. Intervention 2017; 5
assessment. The researcher 15: 2
1 e
has obtained the approval 9 2
of king Saud University 9 6
internal review board to e 2
collect the data. 2 .
1 11. Jameson MM, Fusco BR.
4 Math anxiety, math self-
A . concept, and math self-
c 5. Keyes KM, Hatzenbuehler efficacy in adult learners
k ML, Hasin DS. Stressful compared to traditional
n life expe- riences, alcohol undergraduate students.
o consumption, and alcohol Adult Educ Q 2014; 64:
w use disorders: the 306e322.
l epidemiologic evidence for 12. Abele C, Penprase B,
e four main types of Ternes R. A closer look
d stressors. Psy- at academic probation and
g chopharmacology 2011; attrition: what courses are
m 218: 1e17. predictive of nursing
6. Clement S, Schauman O, student success? Nurse
e
Graham T, Maggioni F, Educ Today 2013; 33:
n Evans-Lacko S,
t 258e261.
Bezborodovs N, et al. What 13. Storrie K, Ahern K,
is the impact of mental Tuckett A. A systematic
The author thanks the health-related stigma on review: students
Deanship of Scientific help-seeking? A systematic with mental health
Research, College of review of quantitative and problemsda growing
Nursing Research Centre at qualitative studies. Psychol problem. Int J Nurs
King Saud University for Med 2015; 45: 11e27. P
funding this research. 7. Culbert KM, Racine SE, r
Klump KL. Research review: a
what we c
R have learned about the t
e causes of eating
f disordersea synthesis of 2
e sociocultural, 0
r psychological, and 1
e biological research. J 0
Child Psychol Psychiatry ;
n
2015; 56: 1141e1164.
c
8. Van Gordon W, 1
e Shonin E, Sumich A, 6
s Sundin EC, Griffiths :
MD. Meditation
1. Morse JM. Critical awareness training (MAT)
1
analysis of strategies for for psy- chological well- e
determining rigor in being in a sub-clinical 6
qualitative inquiry. Qual sample of university stu- .
Health Res 2015; 25: dents: a controlled pilot
12e22. study. Mindfulness 2014;
2. Crone EA, Dahl RE. 5: 381e391.
9. Galvin J, Suominen E,
14. Dickinson T, Wright outcome, and 6
KM. Stress and burnout complications for clinical 0
2 .
in forensic mental-health orthopedic studies in
0 30. Bahadır-Yılmaz E.
nursing: a literature 1 veterinary medicine. Vet
review. Br J Nurs 2008; Surg Academic and clinical
3
17: 2 stress, stress resources and
;
8 0 ways of coping among
2 1 Turkish first-year nursing
1 0 students in their first
e
0 ; clinical practice. Kontakt
8
:
7 2016; 18: 145e151.
. 3 31. Demir S, Demir SG,
15. Hanna T, Mona E. 2 9 Bulut H, Hisar F. Effect of
5 : mentoring
Psychosocial work
environment, stress factors 5 program on ways of coping
e 9
and individual with stress and locus of
2 0
characteristics among 5 control for nursing
6 students. Asian Nurs Res
nursing staff in e
6
psychiatric in-patient care. 9 2014; 8: 254e260.
.
Int J Env Res Pub Health 0 32. Pulido-Martos M,
20. Rich KL, Nugent KE.
2014; 11: 8 Augusto-Landa JM, Lopez-
A United States Zafra E. Sources
1 .
perspective on the of stress in nursing
1 26. Chowdhury MF. Coding,
challenges in nursing students: a systematic
6 sorting and sifting of
education. Nurse Educ review of quantitative
1 qualitative data analysis:
e Today 2010; 30:
debates and discussion. studies. Int Nurs Rev 2012;
1 2
Qual Quant 2015; 49: 59: 15e25.
1 2
1135e 33. Jimenez C, Navia-Osorio
7 8
e 1 PM, Diaz CV. Stress and
5 1 health in novice and
. 2
3 4 experienced nursing
16. Dardas LA, Ahmad MM. 3 students. J Adv Nurs 2010;
2
Coping strategies as . 66:
.
mediators and 27. Palinkas LA, Horwitz SM, 4
21. Almalki M, FitzGerald
moderators between stress Green CA, Wisdom JP, 4
G, Clark M. Health care
and quality of life among Duan N, Hoagwood K. 2
system in Saudi Arabia:
parents of children with Purposeful sampling for e
an overview/Apercu du
autistic disorder. Stress qualitative data collec- 4
systeme de sante en
Health 2015; 31: 5e12. tion and analysis in 5
Arabie saoudite. East
17. Chou WP, Ko CH, mixed method 5
Mediter Health J 2011;
Kaufman EA, Crowell SE, implementation research. .
17: 784.
Hsiao RC, Admin Policy Ment Health
22. Lewis S. Qualitative
Wang PW, et al. Mental Health Serv Res
inquiry and research
Association of stress 2015; 42:
design: choosing among
coping strategies with 5
five approaches. Health
Internet addiction in 3
Promot Pract 2015; 16:
college students: the 3
473e475.
moderating effect of e
23. Brooks JS, Normore AH.
depression. Compr 5
Qualitative research and
Psychiatry 2015; 62: 4
educational
27e33. 4
leadership: essential
18. Al-Zayyat AS, Al-Gamal .
dynamics to consider
E. Perceived stress and coping 28. Vivekananda-Schmidt P,
when designing and Marshall M, Stark P,
stra-
conducting studies. Int J Mckendree J, Sandars J,
tegies among Jordanian
Educ Manag 2015; 29: Smithson S. Lessons
nursing students during
798e806. from medical students’
clinical prac- tice in
24. Creswell JD, Taren AA, per- ceptions of learning
psychiatric/mental health
Lindsay EK, Greco CM, reflective skills: a multi-
courses. Int J Mental
Gianaros PJ, Fairgrieve A, institutional study. Med
Health Nurs 2014; 23:
et al. Alterations in Teach 2011; 33: 846e850.
326e335.
resting-state functional 29. Singh C, Sharma S,
19. Chernomas WM, Shapiro
con- nectivity link Sharma RK. Level of
C. Stress, depression, and
anxiety mindfulness meditation stress and coping
among undergraduate with reduced interleukin-6: strategies used by nursing
nursing students. Int J a randomized controlled interns. Nurs Midwifery
Nurs Educ trial. Biol Psychiatry 2016;
Res J 2011;
S 80: 53e61. 7
c 25. Cook JL, Evans R, :
h Conzemius MG, Lascelles
o BDX, 1
l McIlwraith CW, Pozzi 5
a A, et al. Proposed 2
r definitions and criteria for e
s reporting time frame, 1
34. Gibbons C, Dempster M, 0 JC, Link BG. Stigma as a
Moutray M. Stress and 1 funda- mental cause of
eustress in nursing 0 population health
students. J Adv Nurs ; inequalities. Am J Pub
2008; 61: 282e290. Health 2013; 103:
35. Labrague LJ, Gloe DS, 1 813e821.
McEnroe-Petitte DM, 9 49. Wee CC, Davis RB, Chiodi
Tsaras K, Colet PC. : S, Huskey KW, Hamel MB.
Factors influencing Sex,
turnover intention among 8 race, and the adverse
regis- tered nurses in 0 effects of social stigma vs.
Samar Philippines. Appl 3 other quality of life factors
Nurs Res 2018; 39: e among primary care
2 8 patients with moderate to
0 1 se- vere obesity. J Gen
0 0 Intern Med 2015; 30:
e . 229e235.
2 42. Connor PD, Nouer SS, 50. Kilgo CA, Sheets JK,
0 Speck PM, Mackey SN, Pascarella ET. The link
6 Tipton NG. between high-
. Nursing students and impact practices and
36. Adriaenssens J, De intimate partner violence student learning: some
Gucht V, Maes S. education: improving and longitudinal evi- dence.
Determinants and integrating knowledge into Higher Educ 2015; 69:
prevalence of burnout in health care curricula. J 509e525.
emergency nurses: a Prof Nurs 2013; 29: 51. Buseh AG, Kelber ST,
systematic re- view of 25 233e239. Stevens PE, Park CG.
years of research. Int J 43. Watson R, Gardiner E, Relationship of
Nurs Stud 2015; 52: 649e Hogston R, Gibson H, symptoms, perceived
6 Stimpson A, Wrate R, et health, and stigma with
6 al. A longitudinal study of quality of life among
1 stress and psychological urban HIV-infected
. distress in nurses and African American men.
37. Szpak JL, Kameg KM. nursing students. J Clin Public Health Nurs 2008;
Simulation decreases Nurs 2009; 18: 25: 409e419.
nursing student anxiety 2 52. Corrigan PW, Bink AB,
prior to communication 7 Schmidt A, Jones N, Rusch N.
with mentally ill patients. 0 What is
Clin Simul Nurs 2013; 9: e the impact of self-stigma?
13e19. 2 Loss of self-respect and the
38. Hayes B, Douglas C, 7 “why try”
Bonner A. Work 8 eff
environment, job satis- . ec
faction, stress and burnout 44. Li HC, Wang LS, Lin YH, t.
among haemodialysis Lee I. The effect of a peer- J
nurses. J Nurs Manag mentoring strategy on M
2015; 23: 588e598. student nurse stress en
39. Blanchard-Fields F, reduction in clinical t
Mienaltowski A, Seay RB. practice. Int Nurs Rev H
Age differences in 2011; 58: 203e210. ea
everyday problem-solving 45. Seyedfatemi N, Tafreshi lth
M, Hagani H. 20
effectiveness: older adults
Experienced stressors and 16
select more effective
coping strategies among ;
strategies for interpersonal 25
problems. J Gerontol Ser Iranian nursing students.
:
B Psychol Sci Soc Sci BMC Nurs 2007; 6:
10
2007; 62: 61e64. 11e12. e
40. Lange RT, Brickell TA, 46. Shaban IA, Khater WA, 15
Lippa SM, French LM. Akhu-Zaheya LM. .
Clinical utility of the Undergraduate nursing 53. Rosenstein LS, Ramos
Neurobehavioral students’ stress sources MA, Torre M, Segal JB,
Symptom Inventory and coping behaviours Peluso MJ, Guille C, et
validity scales to screen during their initial period al. Prevalence of
for symptom of clinical training: a depression, depressive
exaggeration following Jordanian perspective. symp- toms, and
traumatic brain injury. J Nurse Educ Pract 2012; suicidal ideation among
Clin Exp Neuropsychol 12: 204e209. medical students: a
2015; 37: 853e862. 47. Goff AM. Stressors,
41. Christiansen A, Bell A. academic performance,
Peer learning and learned
partnerships: exploring resourcefulness in
the experience of pre- baccalaureate nursing
registration nursing students. Int J Nurs Educ
students. J Clin Nurs Scholarsh 2011; 8: 1.
2 48. Hatzenbuehler ML, Phelan
 systematic review and R 61. Reeve KL, Shumaker
meta-analysis. JAMA e CJ, Yearwood EL, 2
2016; 316: 2214e s Crowell NA, Riley JB. 0
2 Perceived stress and social 1
2 2 support in undergraduate 0
3 0 nursing students’ ;
6 1 educational experiences.
. 1 Nurse Educ Today 4
54. Thornicroft G, Mehta ; 2
N, Clement S, Evans- 7
0 :
Lacko S, Doherty M, 1
6
Rose D, et al. Evidence 3
:
for effective interventions ; 1
to reduce mental-health- 2
related stigma and 2 3 9
discrimination. Lancet 3 3 9
2016; 387: 1123e1132. 1 : e
55. Vartanian LR, Novak . 1
4 3
SA. Internalized societal
1 0
attitudes moderate the
9 9
impact of weight stigma
e .
on avoidance of exercise.
4 66. Laal M, Aliramaie N.
Obesity 2011; 19: 2 Nursing and coping with
757e762. 4 stress. Int J Collab Res
56. Murff SH. The impact of . Int Med Pub Health 2010;
stress on academic success 62. Gropel P, Kuhl J. 2: 168e181.
in college students. ABNF Workelife balance and
J 2005; 16: 102. subjective well-being:
57. Zhao FF, Lei XL, He the mediating role of need How to cite this
W, Gu YH, Li DW. fulfilment. Br J Psychol article: Alyousef SM.
The study of perceived 2009; 100: Psychosocial stress
stress, coping strategy 3 factors among mental
and self-efficacy of 6 health nursing
Chinese undergraduate 5 students in KSA. J
nursing students in clinical e
Taibah Univ Med Sc
practice. Int J Nurs Pract 3
2019;14(1):60e66.
2015; 21: 401e409. 7
58. Tovar E. The role of 5
faculty, counselors, and .
support programs on 63. Garrosa E, Moreno-
Latino/a community Jimenez B, Liang Y,
college students’ success Gonzalez JL. The
relationship between
and intent to persist.
socio-demographic
Community Coll Rev 2015;
variables, job stressors,
43: 46e71.
burnout, and hardy
59. Sanchez B, Esparza P,
Colon Y, Davis KE. Tryin’ to personality in nurses: an
make it explor- atory study. Int J
during the transition from Nurs Stud 2008; 45:
high school: the role of 418e427.
family obli- gation 64. Kang YS, Choi SY, Ryu
attitudes and economic E. The effectiveness of a
context for Latino- stress coping program
emerging adults. J based on mindfulness
Adolesc Res 2010; 25: meditation on the stress,
858e884. anxi- ety, and depression
60. Ghaderi AR, Rangaiah B. experienced by nursing
Influence of self-efficacy on students in Korea. Nurse
depres- Educ Today 2009; 29:
sion, anxiety and stress 538e543.
among Indian and 65. Gibbons C. Stress, coping
Iranian students. and burn-out in nursing
J students. Int
J
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