research studies for b.sc nursing students

• Open access
• Published: 11 May 2024

Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

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Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

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Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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Acknowledgements

The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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Simulation-based mastery improves nursing skills in BSc nursing students: a quasi-experimental study

Affiliations.

• 1 Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran.
• 2 Department of medical- surgical nursing, Razi faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran.
• 3 Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran. [email protected].
• 4 Department of pediatrics and neonatal intensive nursing, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran. [email protected].
• PMID: 33407420
• PMCID: PMC7789780
• DOI: 10.1186/s12912-020-00532-9

Background: Clinical education is an essential part of nursing education. Selected clinical teaching methods influence the quality of education. Simulation-based mastery learning has been used to improve clinical skills among nursing students and may provide a novel way to enhance nursing skills. This study aimed to assess the effect of simulation-based mastery learning on the clinical skills of undergraduate nursing students from 2017 to 2019.

Methods: This quasi-experimental study was conducted with two groups (the control and intervention). A hundred and five students were selected by random convenience sampling, and written consent was obtained. The intervention group participated in a simulation-based mastery learning intervention, and the control group received no intervention except for traditional training. The students of both groups completed the demographic information questionnaire and the checklist before and after the intervention. The results were analyzed by SPSS version 21 and descriptive and inferential statistics.

Results: The results showed no significant differences between the two groups before the intervention (p> 0.05). In addition, students' performance in the intervention and control groups improved significantly at the post-test compared with the baseline (p< 0.05). Furthermore, the Cohen test implied that the simulation-based mastery model used by the intervention group was significantly more effective than the traditional training used by the control.

Conclusion: These findings showed that mastery learning was more effective in improving clinical skills in undergraduate nursing students. The results suggest that other nursing and health programs can be developed by implementing a mastery-based learning model.

Keywords: Clinical education; Clinical skills; Nursing students; Simulation-based mastery model.

Grants and funding

• 930241/Kerman University of Medical Sciences

Best Nursing Research Topics for Students

What is a nursing research paper.

• What They Include
• Choosing a Topic
• Best Nursing Research Topics
• Research Paper Writing Tips

Writing a research paper is a massive task that involves careful organization, critical analysis, and a lot of time. Some nursing students are natural writers, while others struggle to select a nursing research topic, let alone write about it.

If you're a nursing student who dreads writing research papers, this article may help ease your anxiety. We'll cover everything you need to know about writing nursing school research papers and the top topics for nursing research.  

Continue reading to make your paper-writing jitters a thing of the past.

A nursing research paper is a work of academic writing composed by a nurse or nursing student. The paper may present information on a specific topic or answer a question.

During LPN/LVN and RN programs, most papers you write focus on learning to use research databases, evaluate appropriate resources, and format your writing with APA style. You'll then synthesize your research information to answer a question or analyze a topic.

BSN , MSN , Ph.D., and DNP programs also write nursing research papers. Students in these programs may also participate in conducting original research studies.

Writing papers during your academic program improves and develops many skills, including the ability to:

• Select nursing topics for research
• Conduct effective research
• Analyze published academic literature
• Format and cite sources
• Synthesize data
• Organize and articulate findings

About Nursing Research Papers

When do nursing students write research papers.

You may need to write a research paper for any of the nursing courses you take. Research papers help develop critical thinking and communication skills. They allow you to learn how to conduct research and critically review publications.

That said, not every class will require in-depth, 10-20-page papers. The more advanced your degree path, the more you can expect to write and conduct research. If you're in an associate or bachelor's program, you'll probably write a few papers each semester or term.

Do Nursing Students Conduct Original Research?

Most of the time, you won't be designing, conducting, and evaluating new research. Instead, your projects will focus on learning the research process and the scientific method. You'll achieve these objectives by evaluating existing nursing literature and sources and defending a thesis.

However, many nursing faculty members do conduct original research. So, you may get opportunities to participate in, and publish, research articles.

Example Research Project Scenario:

In your maternal child nursing class, the professor assigns the class a research paper regarding developmentally appropriate nursing interventions for the pediatric population. While that may sound specific, you have almost endless opportunities to narrow down the focus of your writing. 

You could choose pain intervention measures in toddlers. Conversely, you can research the effects of prolonged hospitalization on adolescents' social-emotional development.

What Does a Nursing Research Paper Include?

Your professor should provide a thorough guideline of the scope of the paper. In general, an undergraduate nursing research paper will consist of:

Introduction : A brief overview of the research question/thesis statement your paper will discuss. You can include why the topic is relevant.

Body : This section presents your research findings and allows you to synthesize the information and data you collected. You'll have a chance to articulate your evaluation and answer your research question. The length of this section depends on your assignment.

Conclusion : A brief review of the information and analysis you presented throughout the body of the paper. This section is a recap of your paper and another chance to reassert your thesis.

The best advice is to follow your instructor's rubric and guidelines. Remember to ask for help whenever needed, and avoid overcomplicating the assignment!

How to Choose a Nursing Research Topic

The sheer volume of prospective nursing research topics can become overwhelming for students. Additionally, you may get the misconception that all the 'good' research ideas are exhausted. However, a personal approach may help you narrow down a research topic and find a unique angle.

Writing your research paper about a topic you value or connect with makes the task easier. Additionally, you should consider the material's breadth. Topics with plenty of existing literature will make developing a research question and thesis smoother.

Finally, feel free to shift gears if necessary, especially if you're still early in the research process. If you start down one path and have trouble finding published information, ask your professor if you can choose another topic.

The Best Research Topics for Nursing Students

You have endless subject choices for nursing research papers. This non-exhaustive list just scratches the surface of some of the best nursing research topics.

1. Clinical Nursing Research Topics

• Analyze the use of telehealth/virtual nursing to reduce inpatient nurse duties.
• Discuss the impact of evidence-based respiratory interventions on patient outcomes in critical care settings.
• Explore the effectiveness of pain management protocols in pediatric patients.

2. Community Health Nursing Research Topics

• Assess the impact of nurse-led diabetes education in Type II Diabetics.
• Analyze the relationship between socioeconomic status and access to healthcare services.

3. Nurse Education Research Topics

• Review the effectiveness of simulation-based learning to improve nursing students' clinical skills.
• Identify methods that best prepare pre-licensure students for clinical practice.
• Investigate factors that influence nurses to pursue advanced degrees.
• Evaluate education methods that enhance cultural competence among nurses.
• Describe the role of mindfulness interventions in reducing stress and burnout among nurses.

4. Mental Health Nursing Research Topics

• Explore patient outcomes related to nurse staffing levels in acute behavioral health settings.
• Assess the effectiveness of mental health education among emergency room nurses .
• Explore de-escalation techniques that result in improved patient outcomes.
• Review the effectiveness of therapeutic communication in improving patient outcomes.

5. Pediatric Nursing Research Topics

• Assess the impact of parental involvement in pediatric asthma treatment adherence.
• Explore challenges related to chronic illness management in pediatric patients.
• Review the role of play therapy and other therapeutic interventions that alleviate anxiety among hospitalized children.

6. The Nursing Profession Research Topics

• Analyze the effects of short staffing on nurse burnout .
• Evaluate factors that facilitate resiliency among nursing professionals.
• Examine predictors of nurse dissatisfaction and burnout.
• Posit how nursing theories influence modern nursing practice.

Tips for Writing a Nursing Research Paper

The best nursing research advice we can provide is to follow your professor's rubric and instructions. However, here are a few study tips for nursing students to make paper writing less painful:

Avoid procrastination: Everyone says it, but few follow this advice. You can significantly lower your stress levels if you avoid procrastinating and start working on your project immediately.

Plan Ahead: Break down the writing process into smaller sections, especially if it seems overwhelming. Give yourself time for each step in the process.

Research: Use your resources and ask for help from the librarian or instructor. The rest should come together quickly once you find high-quality studies to analyze.

Outline: Create an outline to help you organize your thoughts. Then, you can plug in information throughout the research process. 

Clear Language: Use plain language as much as possible to get your point across. Jargon is inevitable when writing academic nursing papers, but keep it to a minimum.

Cite Properly: Accurately cite all sources using the appropriate citation style. Nursing research papers will almost always implement APA style. Check out the resources below for some excellent reference management options.

Revise and Edit: Once you finish your first draft, put it away for one to two hours or, preferably, a whole day. Once you've placed some space between you and your paper, read through and edit for clarity, coherence, and grammatical errors. Reading your essay out loud is an excellent way to check for the 'flow' of the paper.

Helpful Nursing Research Writing Resources:

Purdue OWL (Online writing lab) has a robust APA guide covering everything you need about APA style and rules.

Grammarly helps you edit grammar, spelling, and punctuation. Upgrading to a paid plan will get you plagiarism detection, formatting, and engagement suggestions. This tool is excellent to help you simplify complicated sentences.

Mendeley is a free reference management software. It stores, organizes, and cites references. It has a Microsoft plug-in that inserts and correctly formats APA citations.

Don't let nursing research papers scare you away from starting nursing school or furthering your education. Their purpose is to develop skills you'll need to be an effective nurse: critical thinking, communication, and the ability to review published information critically.

Choose a great topic and follow your teacher's instructions; you'll finish that paper in no time.

Joleen Sams is a certified Family Nurse Practitioner based in the Kansas City metro area. During her 10-year RN career, Joleen worked in NICU, inpatient pediatrics, and regulatory compliance. Since graduating with her MSN-FNP in 2019, she has worked in urgent care and nursing administration. Connect with Joleen on LinkedIn or see more of her writing on her website.

Plus, get exclusive access to discounts for nurses, stay informed on the latest nurse news, and learn how to take the next steps in your career.

By clicking “Join Now”, you agree to receive email newsletters and special offers from Nurse.org. We will not sell or distribute your email address to any third party, and you may unsubscribe at any time by using the unsubscribe link, found at the bottom of every email.

Original Research Article

Year: 2020 | Month: April-June | Volume: 5 | Issue: 2 | Pages: 280-288

A Study to Assess the Perceived Stress and Coping Strategies among B.Sc. Nursing Students of Selected Colleges in Pune during COVID-19 Pandemic Lockdown

Deepika sheroun 1 , dapple d wankhar 2 , amita devrani 3 , lissamma pv 4 , s gita 5 , keka chatterjee 6.

1 MSc Nursing Student (Psychiatric Nursing), Department of Psychiatric Nursing, College of Nursing , AFMC -Pune -40 2 Asst Professor (Psychiatry Nursing), Department of Psychiatric Nursing, College of Nursing, AFMC, Pune -40. 3 Principal and HoD Department of Child Health Nursing, College of Nursing, AFMC Pune -40 4 Professor and Vice Principal, College of Nursing , AFMC Pune-40 5 Professor and HoD, Department of Med &Surg Nursing , College of Nursing, AFMC , Pune-40 . 6 Asst Professor , Department of Obs & Gynae Nursing, College of Nursing, AFMC , Pune -40.

Corresponding Author: Deepika Sheroun

Introduction:  The global pandemic has proven to be challenging for students in more ways than one. Ever since in-person classes moved online and “Stay Home Stay Safe” executive order was implemented; many students have faced a distressing change in their employment status. The present study aimed to assess perceived stress and coping strategies amidst the COVID 19 lockdown, among the BSc Nursing students studying in nursing colleges located in Pune Objectives: The objectives of the study are to assess the perceived stress and coping strategies of the BSc Nursing students of all batches in regard to COVID 19 lockdown, and to determine the association of stress and coping with selected demographic variables. Materials and Methods: This cross-sectional online study was undertaken from 15th to 20th of May 2020. Participants were BSc Nursing Students (1st -4th year), whose perceived stress and coping strategies related to COVID 19, were assessed using an online questionnaire. The tool has 3 sections consisting of demographic data as section A, Perceived Stress Scale as Section B, and Coping Strategies Scale as section C. Score was categorised into three parts as good, moderate and low Results: A total of 427 nursing students completed the questionnaire. Male students had more perceived stress score (22.73) than female students (21.86). Majority of participants were between 21-25 years. The maximum mean perceived stress score (22.56) was observed in 4th year students, and least mean perceived stress score (20.20) was found in 2nd year students. On the whole the maximum mean coping score (78.45) was found among 1st years and least coping score (71.23) was found among 4th year BSc Nursing students Conclusion: The present study indicates moderate level of perceived stress with mean perceived stress score of the students Nurses being 21.88 ( + 4.30) and the mean coping strategies score was 74.38 ( + 12.30). The IV Year Nursing students has the highest stress score with a mean of 22.56 ± 4.207. Hence there is a need to take measures by the authorities to reduce stress among the students.

Keywords: COVID 19, Pandemic, Perceived Stress, Coping Strategies, Nursing Students, Psychological support

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Simulation-based mastery improves nursing skills in BSc nursing students: a quasi-experimental study

Roghayeh mehdipour –rabori.

1 Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran

2 Department of medical- surgical nursing, Razi faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran

Behnaz Bagherian

Monirsadat nematollahi.

3 Department of pediatrics and neonatal intensive nursing, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran

Associated Data

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Clinical education is an essential part of nursing education. Selected clinical teaching methods influence the quality of education. Simulation-based mastery learning has been used to improve clinical skills among nursing students and may provide a novel way to enhance nursing skills. This study aimed to assess the effect of simulation-based mastery learning on the clinical skills of undergraduate nursing students from 2017 to 2019.

This quasi-experimental study was conducted with two groups (the control and intervention). A hundred and five students were selected by random convenience sampling, and written consent was obtained. The intervention group participated in a simulation-based mastery learning intervention, and the control group received no intervention except for traditional training. The students of both groups completed the demographic information questionnaire and the checklist before and after the intervention. The results were analyzed by SPSS version 21 and descriptive and inferential statistics.

The results showed no significant differences between the two groups before the intervention ( p > 0.05). In addition, students’ performance in the intervention and control groups improved significantly at the post-test compared with the baseline ( p < 0.05). Furthermore, the Cohen test implied that the simulation-based mastery model used by the intervention group was significantly more effective than the traditional training used by the control.

These findings showed that mastery learning was more effective in improving clinical skills in undergraduate nursing students. The results suggest that other nursing and health programs can be developed by implementing a mastery-based learning model.

Introduction

Clinical education is an essential part of nursing and midwifery education [ 1 ]. Nursing educators try to create professional learning behaviors in nursing students and respond appropriately to specific clinical situations [ 2 ]. There is a trend in nursing education to adopt competency-based education (CBE) models. Anima and McCoy define competency as acquiring integrated knowledge, skills, values, and attitudes required for a competent nurse [ 3 ]. In addition, the development of nursing students with professional competence is one of the aims of nursing education [ 4 ]. Mastery is one of the competency-based models.

Mastery models differ from traditional curricula in defining progression as achieving a series of competencies [ 5 ]. Educators make a valuable contribution to the learning process by creating competency-based models that can enhance training [ 6 ]. In conclusion, students acquire the ability to do clinical skills [ 7 ].

Mastery is a new applied method for training students in the medical sciences, and it is one of the individual learning styles [ 8 ]. It originates from Carroll’s belief that if sufficient time is given to the full extent of education, the right education level will be achieved [ 9 ]. Mastery learning features frequent formative assessments to provide feedback and evaluate whether students have mastered an instructional standard [ 5 ]. However, some studies indicated that it was time-consuming [ 10 ] and caused student anxiety because of frequent evaluations [ 11 ]. Furthermore, Salvin showed that mastery learning had virtually no effect on student achievement. Still, it was necessary to be assessed by scholars and practitioners well-equipped in mastery learning until questionable aspects of this method were elucidated [ 12 ].

Şenel Elaldı found that the mastery learning model enhanced students’ understanding of what they have learned, and it was an opportunity for students’ development of learning [ 13 ]. Mastery models engage learners in contemplative practice by increasing the difficulty of repetitive tasks while providing coaching to guide their progress [ 14 ]. Furthermore, this method makes students more involved in the teaching-learning process [ 15 ]. For students failing to attain mastery, the assessment provides a diagnostic tool to develop an individualized learning plan to guide corrective action and to address deficiencies. Students who initially fail to demonstrate this skill have more opportunities (According to the curriculum) to take and pass the course [ 16 ]. Using a mastery model offers the potential for greater accountability, flexibility, and focus on learning process [ 17 ].

The advantages of this method are that students perform clinical skills correctly and fulfill professional responsibilities in the future [ 18 ]. Wayne et al. showed that mastery learning influenced CPR skills [ 19 ].

Frogameni et al. also indicated that symbolic mastery learning was an effective strategy in training residents to manage mechanical ventilators. Relying on traditional teaching methods in ICU may leave residents ill-equipped to handle patients receiving mechanical ventilation [ 20 ] safely. Cohen showed that the mastery learning method led to the acquisition of nasogastric tube skills in nursing students [ 21 ]. Based on the findings of a study, the mastery learning method is useful in nursing education [ 22 ]. In addition, Simulation-Based Mastery Learning improved central line maintenance skills of ICU nurses [ 23 ]. However, Roh showed that the mastery learning method did not significantly affect knowledge, self-efficacy scores, and the number of errors related to cardiopulmonary resuscitation skills in nursing students [ 24 ].

However, nursing students must combine knowledge from sociobiological and nursing sciences to make clinical decisions and manage different situations in the clinical settings [ 25 ]. Moreover, as the largest group of caregivers who deal directly with the patients, nurses can provide high-quality care through mastery of nursing skills [ 24 ].

However, there is little in the nursing literature about mastery model-based programs. Most Iranian nursing educators apply traditional learning-teaching methods, which are subject-centered, time-based with summative evaluation, and little feedback. They do not use the mastery method to train skills. Furthermore, Iranian educators do not have much information about mastery models. Regarding the benefits of the method mentioned above, the research team decided to assess the effects of simulation-based mastery on the clinical skills of B.Sc. nursing students.

Research design and setting

This quasi-experimental study was conducted with a pretest-posttest two-group design in the nursing department of Kerman University of Medical Science in Iran from 2017 to 2019. The Kerman University of Medical Science is the most prominent in the Southeast of Iran. The university provides education for undergraduate, postgraduate, and Ph.D. nursing students.

Sampling method

Students were selected using convenience sampling and were then randomly divided into control and intervention groups by numerical table.

The inclusion criteria included the seventh- and eighth-semester nursing students who were not educated with the simulation-based mastery method previously. In addition, students had to pass the theoretical and practical courses such as courses in medicine, surgery, pediatric nursing, community health nursing, intensive care, and psychology.

In this study, the research population consisted of 115 eligible BSc students who met the inclusion criteria. Ten participants were excluded because of absence from training sessions.

In the nursing department of KMU, all nursing students had to pass prerequisite courses before taking the internship course, including theoretical and practical courses. The theoretical course includes the workshop on patient communication, nosocomial infections, nursing ethics, and a practical course includes common nursing skills trained in proficiency workshop, where advanced special moulage and other equipment are available for nurse students to practice the special nursing skills.

Students will take the practical course after completing the workshops. In addition, taking the internship course depends on passing (80% of the checklist) the clinical exam. All students of the nursing department had to take the same curriculum.

The research team selected nursing skills commonly used in nursing and agreed on the following four practical skills: suction, nasogastric tube feeding, packed cell transfusion, change of fluid box.

First, the study goals were explained to the participants. The students participated in the study with full consent and agreement. They were explained that attending or not participating in the study would not affect their educational process. The instructors in the two groups completed the demographic characteristic questionnaire and checklist skills before the intervention, and common nursing skills were assessed in two groups by a checklist.

Intervention group procedure

The intervention began on the second day of the course. The intervention group members experienced a simulation-based mastery intervention in four common clinical skills (suction, nasogastric tube feeding, packed cell transfusion, change of fluid box).

First, the instructor performed each skill on the advanced moulage in the proficiency workshop. Then, the students practiced these skills and were assessed by the instructor, who could identify whether they learned the skill or not (diagnostic feedback) and what they needed to learn better (prescriptive feedback).

A list of student’s mistakes was provided for the relevant instructor and student. The instructors set specific goals for each student based on the deficiencies identified in the first stage. In this program, the instructor used supervisory and observational methods. The instructor observed students and completed checklists every day. The instructor re-evaluated the students through a checklist and re-identified some deficiencies listed in the checklist daily for 12 days (2 days a week). In addition, students, who initially fail to demonstrate the skill, have three more opportunities to pass the course. At the end of the course, the clinical skill scores were checked.

To determine the observer’s accurate judgment on the examination based on the checklist, two observers assessed the inter-rater reliability of the assessors’ scoring for each of the skills. A single-blind method was used so that the students involved in this study were not informed of the type of teaching methods and how they were placed in each group. In this study, the intervention group experienced a simulated mastery learning method.

Control group procedure

Common nursing skills were trained to the control group students in a proficiency workshop during two sessions a week for 6 weeks.

The routine teaching method was as follows: the students were divided into groups of three individuals, and clinical skills were performed on the advanced moulage under the instructor’s supervision. In case of any question or mistake, the instructor, a facilitator, would address it. In this method, the instructor taught students, according to time-based and summative evaluation with little feedback.

The demographic information questionnaire and the checklist were used in this study to collect the data.

Instruments

The demographic questionnaire contained information about age, sex, scale median, passed credits, and grade point average last semester.

The researchers used four nursing skill checklists for both groups (control and intervention). The checklists were extracted from a nursing book: Skill checklists for Tylor’s clinical nursing skills [ 26 ]. The suction checklist, the nasogastric tube feeding checklist, the packed cell transfusion checklist, and the change of fluid box checklist contain 19, 19, 13, and 21 items, respectively. Each item on the checklists is rated using three scales: unsatisfactory (score: 0), satisfactory (score: 1), and excellent (score: 2). The suction, nasogastric tube feeding, packed cell transfusion, change of fluid box checklists were scored 0–38, 0–38, 0–26, and 0–42, respectively. The total score ranges from 0 to 144.

The content validity of the checklists was confirmed by the broad consensus, and their reliability was 0.82 by using a pilot study and the Cronbach’s alpha coefficient showing good reliability.

In addition, medical-surgical nurses, pediatric nurses, and intensive care nurses in Kerman have attempted for 5 months to prepare and select nursing skill checklists.

Data analysis

The collected data were analyzed using descriptive (frequency, percentage, mean and standard deviation) and inferential statistics. According to the Kolmogorov–Smirnov test results, the data of this study had a normal distribution. Thus, parametric tests were used. Furthermore, independent t-test was employed to compare the mean scores of skills between the intervention and control groups before and after the intervention. The paired samples t-test was also used to compare the mean scores of skills in each group before and after the intervention. P -values were considered statistically significant.

The participants in this study were 105 BSc nursing students of Kerman University of medical science. The participants were divided into two groups of intervention ( N =53) and control ( N =52). Students’ mean ages in the intervention, and the control groups were 23.88±2.06 and 23.38 ± 1.78, respectively.

Most of the participants were female (38 individuals in the intervention group and 39 individuals in the control group). A majority of the participants were native (43 individuals in the intervention group and 42 individuals in the control group); most of them had no history of diseases and took good grade point averages in the last semester. No significant difference was found between the control and intervention groups in their demographic data (Table  1 ).

Demographic characteristics of nursing students in intervention and control groups

*Qui square

The total mean scores of the participants’ clinical skills in the intervention group were 101.6±3.69 and 141.6±3.13 before and after the intervention, respectively. In addition, the total mean scores of clinical skills in the control group were 88.17±6.11 and 109.36 ± 4.71, respectively. Independent samples t-test showed a statistically significant difference between the two groups after the intervention ( P < 0.05). The Cohen test also showed a statistically significant difference between them after the intervention (d=5.6).

In addition, the results of this study showed that the mean score of each of the clinical skills was not statistically significant between the control and the intervention groups before the intervention. However, a statistically significant difference was found between them after the intervention (Table  2 ).

Comparison of the Mean scales inter and between the two groups

*independent t-test

**paired t-test

The mean suction scores of the intervention group participants were 26.46±1.51 and 37.20±0.95 before and after the intervention, respectively. The mean scores of suction in the control group were 24.9 ±1.11and 27.85±1.30, respectively. Independent samples t-test showed a statistically significant difference between the two groups after the intervention ( P < 0.05).

By comparison, the mean scores of ng tube feeding in the intervention group were statistically significant before (23.46±1.79) and after the intervention (37.41± 0.49) ( p < 0.05).

Furthermore, the results showed that the mean nasogastric tube feeding scores in the control group were 23.85±1.30 and 28.075±1.5 before and after the intervention, respectively. Independent samples t-test indicated a statistically significant difference between the two groups after the intervention ( P < 0.05).

The mean Pack cell Transfusion scores of the intervention group participants were 17±1.33 and 25.52±1.05 before and after the intervention, respectively. The mean scores of Pack cell transfusion in the control group were 17.79±1.26 and 20.79±0.71, respectively. Independent samples t-test showed a statistically significant difference between the two groups after the intervention ( P < 0.05).

The mean changing fluid box scores of the intervention group participants were 25.68±0.4 and 41.47±0.64 before and after the intervention, respectively. The mean scores of changing fluid box scores in the control group were 24.63±1.23 and 33.57±1.46, respectively. Independent samples t-test showed a statistically significant difference between the two groups after the intervention ( P < 0.05).

This study was one of the few studies in Iran conducted on the effect of symbolic mastery learning on the clinical skills in undergraduate nursing students.

The results of this study indicated that the mean scores of skills in the control group were statistically significant before (22.04±1.22) and after the training program (27.29±1.17) ( P < 0.05). In addition, the mean scores of skills in the intervention group were statistically significant before (25.4±1.27) and after the intervention (35.4±0.46) ( p < 0.05). This study showed that mastery learning was more effective in achieving clinical skills than the traditional method (d=5.6).

Barusk indicated that mastery learning increased the nursing student’s knowledge and skills scores for physical examination. Furthermore, he reported that mastery learning promoted the general competency of the students [ 27 ].

Tang showed that mastery-learning intervention increased nurses’ clinical competencies [ 28 ]. Moreover, Schroedl reported that the mastery learning method was useful to identify the professional competence of nursing practice [ 14 ]. Extensive research evidence shows that mastery learning can have positive effects on student achievement. In addition, Amiruddin (2015) pointed to the positive effects of mastery learning that can help students increase their efforts and ultimately perform academic tasks better [ 29 ].

This result was in line with the results of the present study. Contrary to other teaching methods, this method helps the instructor know the deficiencies of the students, and the students know that they have enough time to learn the skills [ 30 ]. Educators tried to teach the students the knowledge and skills required for competent nurses. Moreover, in this teaching method, instructors can determine students’ learning needs [ 31 ]. According to this study, the instructor identified students’ learning problems in each intervention stage and retested them. In addition, students who initially fail to demonstrate the skill have three more opportunities to take and pass the course.

Repeated assessments of students at given intervals improved the quality of education, and the students were active in the learning process [ 27 ]. In this study, acquiring competency was based on a skills scale.

The instructors in this study also considered this approach time-consuming. They believed that this approach was challenging with many nursing students and the limitations of the laboratory facilities. Roberts et al. indicated that this approach was time-consuming due to the organization of various tests and the high volume of nursing education contents [ 32 ].

Mohd Hasril concluded that mastery learning strategies were significantly associated with increased learning in vocational training compared with traditional mastery models. Trainees mentioned that those who received faster feedbacks were more successful [ 29 ]. In this study, the trainees received their feedback immediately after each skill. The nursing students who received feedback could identify their deficiencies. Applying mastery learning methods is useful in clinical settings to empower nursing students, and mastery learning is considered a new paradigm in medical education [ 9 ]. In addition, the students acquired high-quality skills because of giving feedback along the teaching process. According to the experiences of instructors, some students have anxiety when they receive feedback. Thus, scientific and psychological support to the students improves their clinical skills. Evaluating this model and examining its strengths and weaknesses predisposed different students to apply it in various educational settings.

This study was done only in the nursing department of Kerman University of Medical Science so that the generalizability of the study data was limited to some extent. Because the study method was time-consuming, the effect of the mastery learning method on the practical course was studied. It is suggested that the mastery learning method be evaluated on both theoretical and practical courses.

The results indicated that the mastery learning model had more beneficial effects than the traditional method. Furthermore, our study showed that this model offered rich and in-depth learning opportunities for students. These results, therefore, can encourage nursing authorities to continue their training and development in the research methodology.

In addition, this study would be fruitful for future research to examine the effect of mastery learning on self-esteem, satisfaction, and competency of students.

The study results showed that the implementation of the mastery learning method was more effective in training clinical skills in BSc students. In addition, the findings indicated that students in the mastery learning model group achieved higher grades in clinical skills than those who used the traditional method. In addition, the quality of learning improved in undergraduate nursing students in the simulation-based mastery learning group. Furthermore, it is a flexible and successful approach and enhances students’ skills.

Acknowledgments

The authors wish to sincerely thank all student nurses who participated in the study.

Authors’ contributions

This manuscript is the consequence of the collaboration of all the authors. Author MN designed the study, wrote the study proposal, and conducted data collection and analysis. The author BB analyzed the data, and the Author RM wrote the final draft of the manuscript, prepared tables, and submitted the document to the journal. The author(s) read and approved the final manuscript.

This study was financially supported by Kerman University of Medical Sciences, Iran. The grant number was 930241. The funding of the study was used in the collection and analysis of data.

Availability of data and materials

Ethics approval and consent to participate.

This study was approved by the Ethics Committee of Kerman University of Medical Sciences (IR KMUREC930241). Written informed consent was obtained from each participant. This study was performed on the fourth-year nursing students during fall and spring 2018–2019.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Roghayeh Mehdipour –Rabori, Email: ri.ca.umk@ruopidhem_R .

Behnaz Bagherian, Email: [email protected] .

Monirsadat Nematollahi, Email: [email protected] .

Study Abroad Aide

The Best Study Abroad Site

How to Study Nursing in Germany for International Students

With the global population growth rate on a decline, most countries face the various inevitable problems of an aging population. The low number of working-age people in a country not only affects the economic growth of the country but also influences the quality of welfare and healthcare of the older population in the country.

Germany is one of the top 10 countries in the world with a large population over the age of 65. According to estimation, the nursing sector in Germany will need 150,000 new nurses by 2025. It is not surprising that the country is actively recruiting nurses from abroad to look after its citizens who are in their golden ages.

If you have already gone through a nursing education or you are a nurse looking to work in Germany, you will be able to do so after going through an “Anerkennung”, a recognition process of your professional qualification, and passing it. If you are a student who would like to become a nurse in Germany, there are several paths that you can choose from.

In this article, we will be going over how to study nursing in Germany, so let’s take a look!

What Degrees are there for Nursing in Germany?

In Germany, the common option for most students is to go through an apprenticeship (also known as “Ausbildung”) in a German hospital. This is because nursing is not a common bachelor’s degree program taught in universities in Germany. Before you apply for an apprenticeship at a hospital, you should have at least a B2 level in German proficiency as you would need to be able to interact with your patients in German. Meeting this language requirement is essential to study nursing in Germany as an international student.

Once you are accepted, you will undergo theoretical and practical training for a total of three years while earning a salary between 1,000 to 1,200 euros a month. This full-time training program entails 2,100 hours of classroom instruction at a vocational school (usually at a partner school of the hospital) and 2,500 hours of working experience in the hospital.

At the end of your program, you are required to pass a state examination to successfully conclude your training. Upon the completion of your apprenticeship, you will be able to work at hospitals, nursing homes, outpatient care facilities, health insurance companies, and so on.

Cost of Studying Nursing

Compared to some of its neighbors, the cost of living in Germany is relatively inexpensive. On average, an international student would need about 850 euros a month to cover his or her living expenses, such as rent, food, clothing, books, and others. It is good to note that this figure should be used only as a guide as factors like the city that you are living in and your lifestyle choices will also determine your monthly expenditures.

Unlike other countries where a student has to fork out tens of thousands of dollars to obtain a nursing degree, you are able to immediately start earning when you begin your apprenticeship in Germany. The salary for trainee nurses ranges from 1,000 to 1,200 euros per month.

Most partner universities or vocational schools do not charge any tuition fee but will require their students to contribute a small amount of money each semester. Other than covering administrative costs, the semester contribution is also used for student welfare, such as funding student housing, cafeterias, sports facilities, and others.

Although the cost of studying nursing can be high, there are still many ways that you can study for free. If you are interested, read about How to Study in Germany for Free (8 Steps) .

Requirements to Study Nursing in Germany for International Students

At the beginning of the year 2020, a new German Nursing Professions Act (Pflegeberufegesetz, PflBG) was enforced. Instead of deciding on a specific vocational training program from the start, all applicants who wish to train to become nursing professionals will undergo general nursing training for the first two years. Later in the third year, students will then have the option to continue their training to become general nurses or choose to specialize to become pediatric or geriatric nurses in the third year.

Under the new Act, nursing courses will also be offered in some universities to cover the skills taught under the vocational training program. To study nursing in Germany from these courses, students are required to have a high school graduation certificate and official transcripts that are recognized by the university, proof of proficiency in the German language (B2 level is the norm), and a contract with a training provider, which is usually one of the school’s partner hospitals.

For example, to participate in the nursing program at the Department of Interprofessional Healthcare of Baden-Wuerttemberg Cooperative State University , applicants must have a qualification that is equivalent to the German university entrance qualification (also known as “Abitur”), a contract with a German hospital, and proof of German language proficiency.

If you feel lost on how to apply to nursing programs in Germany, I would recommend reading How to Study in Germany for International Students (4 Steps) . This in-depth guide will help you to know the application procedure and what you should prepare.

Other Popular Countries to Study Nursing

There are many countries that need nurses, and many international students study nursing in these countries. Take a look at some of the most popular destinations to study nursing!

• Study Nursing in Canada
• Study Nursing in Norway
• Study Nursing in Korea

Best Nursing Schools in Germany

1. hamburg university of applied sciences (haw hamburg).

• Nursing Program Link
• Degrees Offered: Bachelor of Science (Nursing – Cooperative Degree Program)

HAW Hamburg is the third-largest applied sciences university in Germany. Located in Hamburg, Germany, this higher education and applied research institute has 4 faculties and 18 departments. Students who are interested in studying nursing here can apply to the university’s nursing (cooperative degree program) under the Department of Nursing and Management.

At this nursing school in Germany, the nursing program will be 7 semesters in duration, and students are required to make a contribution of 335.60 euros for each semester.

Applicants must submit all documents required (such as a higher education entrance qualification, medical report, proof of language proficiency, etc.) to a training provider/ hospital that is partnered with the university. The university will then work with the training provider to go through the selection of applicants.

You will receive enrollment documents from the university’s Student Admissions and Registration Office if you are admitted to the program.

2. Hochschule Bremen City University of Applied Sciences (HSB)

• Degrees Offered: International Degree Program in Nursing (B.Sc.)

This public university located in Bremen, Germany, offers a wide variety of degree programs in fields such as engineering, economic sciences, social sciences, and others. International students who wish to study nursing can apply to the university’s International Degree Program in Nursing (B.Sc.), which is 8-semester long.

The language of instruction for this nursing program is German and therefore, students are required to be proficient in German (level C1). Knowledge in English and proof of proficiency (level B1.2 according to the European Language Reference Framework) is also required.

Even though there is no tuition fee at this German nursing school, students are required to contribute to social services by paying less than 300 euros every semester.

Graduates of the International Degree Program in Nursing will receive a double qualification – a Bachelor of Science degree and a state-recognized professional license as a nurse.

3. Baden-Wuerttemberg Cooperative State University (DHBW)

• Degrees Offered: Bachelor of Science (Applied Health and Nursing Sciences)

We end our list of best nursing schools in Germany with the Baden-Wurttemberg Cooperative State University (DHBW), a higher education institution in Stuttgart, Germany. This university offers dual-education – an education system that combines apprenticeships in a company and education at a vocational school – undergraduate study programs in business administration, engineering, and social sciences.

Aspiring nurses who wish to enroll at DHBW’s nursing program must have a signed contract with a workplace training provider. The duration of this course is 6 semesters and the language of instruction is German.

I hope that this article was helpful. If you are interested, visit the  Europe Scholarships Page.

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