Dias et al.

BMC Nursing (2024) 23:322 BMC Nursing

https://doi.org/10.1186/s12912-024-01962-5

RESEARCH Open Access

Nursing students’ stressors and coping

strategies during their first clinical training:
a qualitative study in the United Arab Emirates
Jacqueline Maria Dias1*, Muhammad Arsyad Subu1, Nabeel Al-Yateem1, Fatma Refaat Ahmed1,
Syed Azizur Rahman1,2, Mini Sara Abraham1, Sareh Mirza Forootan1, Farzaneh Ahmad Sarkhosh1 and
Fatemeh Javanbakh1

Abstract
Background 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.
Methods 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.
Results 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.
Keywords Adaptation, Clinical practicums, Coping strategies, Nursing students, Stressors

1
*Correspondence: Department of Nursing, College of Health Sciences, University of Sharjah,
Jacqueline Maria Dias POBox, Sharjah 272272, UAE
2
[email protected] Health Care Management, College of Health Sciences, University of
Sharjah, Sharjah, United Arab Emirates

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Dias et al. BMC Nursing (2024) 23:322 Page 2 of 11

Background [15]. Furthermore, stress has been identified as a cause of

Nursing education programmes aim to provide students attrition among nursing students [16].
with high-quality clinical learning experiences to ensure Most sources of stress have been categorized as aca-
that nurses can provide safe, direct care to patients [1]. demic, clinical or personal. Each person copes with stress
The nursing baccalaureate programme at the Univer- differently [17], and utilizes deliberate, planned, and
sity of Sharjah is a four year program with 137 credits. psychological efforts to manage stressful demands [18].
The programmes has both theoretical and clinical com- Coping mechanisms are commonly termed adaptation
ponents withs nine clinical courses spread over the four strategies or coping skills. Labrague et al. [19] noted that
years The first clinical practicum which forms the basis of students used critical coping strategies to handle stress
the study takes place in year 2 semester 2. and suggested that problem solving was the most com-
Clinical practice experience is an indispensable com- mon coping or adaptation mechanism used by nursing
ponent of nursing education and links what students students. Nursing students’ coping strategies affect their
learn in the classroom and in skills laboratories to real- physical and psychological well-being and the quality of
life clinical settings [2–4]. However, a gap exists between nursing care they offer. Therefore, identifying the coping
theory and practice as the curriculum in the classroom strategies that students use to manage stressors is impor-
differs from nursing students’ experiences in the clinical tant for early intervention [20].
nursing practicum [5]. Clinical nursing training places (or Studies on nursing students’ coping strategies have
practicums, as they are commonly referred to), provide been conducted in various countries. For example,
students with the necessary experiences to ensure that Israeli nursing students were found to adopt a range of
they become proficient in the delivery of patient care [6]. coping mechanisms, including talking to friends, engag-
The clinical practicum takes place in an environment that ing in sports, avoiding stress and sadness/misery, and
combines numerous structural, psychological, emotional consuming alcohol [21]. Other studies have examined
and organizational elements that influence student learn- stress levels among medical students in the Arab region.
ing [7] and may affect the development of professional Chaabane et al. [15], conducted a systematic review of
nursing competencies, such as compassion, communi- sudies in Arab countries, including Saudi Arabia, Egypt,
cation and professional identity [8]. While clinical train- Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain,
ing is a major component of nursing education curricula, and reported that stress during clinical practicums was
stress related to clinical training is common among stu- prevalent, although it could not be determined whether
dents [9]. Furthermore, the nursing literature indicates this was limited to the initial clinical course or occurred
that the first exposure to clinical learning is one of the throughout clinical training. Stressors highlighted dur-
most stressful experiences during undergraduate stud- ing the clinical period in the systematic review included
ies [8, 10]. Thus, the clinical component of nursing edu- assignments and workload during clinical practice, a feel-
cation is considered more stressful than the theoretical ing that the requirements of clinical practice exceeded
component. Students often view clinical learning, where students’ physical and emotional endurance and that
most learning takes place, as an unsupportive environ- their involvement in patient care was limited due to lack
ment [11]. In addition, they note strained relationships of experience. Furthermore, stress can have a direct effect
between themselves and clinical preceptors and perceive on clinical performance, leading to mental disorders.
that the negative attitudes of clinical staff produce stress Tung et al. [22], reported that the prevalence of depres-
[12]. sion among nursing students in Arab countries is 28%,
The effects of stress on nursing students often involve which is almost six times greater than the rest of the
a sense of uncertainty, uneasiness, or anxiety. The litera- world [22]. On the other hand, Saifan et al. [5], explored
ture is replete with evidence that nursing students experi- the theory-practice gap in the United Arab Emirates and
ence a variety of stressors during their clinical practicum, found that clinical stressors could be decreased by pre-
beginning with the first clinical rotation. Nursing is a paring students better for clinical education with quali-
complex profession that requires continuous interaction fied clinical faculty and supportive preceptors.
with a variety of individuals in a high-stress environ- The purpose of this study was to identify the stressors
ment. Stress during clinical learning can have multiple experienced by undergraduate nursing students in the
negative consequences, including low academic achieve- United Arab Emirates during their first clinical training
ment, elevated levels of burnout, and diminished per- and the basic adaptation approaches or coping strategies
sonal well-being [13, 14]. In addition, both theoretical they used. Recognizing or understanding different coping
and practical research has demonstrated that increased, processes can inform the implementation of corrective
continual exposure to stress leads to cognitive deficits, measures when students experience clinical stress. The
inability to concentrate, lack of memory or recall, misin- findings of this study may provide valuable information
terpretation of speech, and decreased learning capacity for nursing programmes, nurse educators, and clinical

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Dias et al. BMC Nursing (2024) 23:322 Page 3 of 11

administrators to establish adaptive strategies to reduce 2. In what ways did you find the first clinical rotation to
stress among students going clinical practicums, particu- be stressful?
larly stressors from their first clinical training in different 3. What factors hindered your clinical training?
healthcare settings. 4. How did you cope with the stressors you
encountered in clinical training?
Methods 5. Which strategies helped you cope with the clinical
Design stressors you encountered?
A qualitative approach was adopted to understand clini-
cal stressors and coping strategies from the perspective
of nurses’ lived experience. Qualitative content analysis Data collection
was employed to obtain rich and detailed information Semi-structured interviews were chosen as the method
from our qualitative data. Qualitative approaches seek for data collection. Semi structured interviews are a
to understand the phenomenon under study from the well-established approach for gathering data in quali-
perspectives of individuals with lived experience [23]. tative research and allow participants to discuss their
Qualitative content analysis is an interpretive technique views, experiences, attitudes, and beliefs in a positive
that examines the similarities and differences between environment [27]. This approach allows for flexibility in
and within different areas of text while focusing on the questioning thereby ensuring that key topics related to
subject [24]. It is used to examine communication pat- clinical learning stressors and coping strategies would
terns in a repeatable and systematic way [25] and yields be explored. Participants were given the opportunity to
rich and detailed information on the topic under inves- express their views, experiences, attitudes, and beliefs in a
tigation [23]. It is a method of systematically coding and positive environment, encouraging open communication.
categorizing information and comprises a process of These semi structured interviews were conducted by one
comprehending, interpreting, and conceptualizing the member of the research team (MAS) who had a mental
key meanings from qualitative data [26]. health background, and another member of the research
team who attended the interviews as an observer (JMD).
Setting and participants Neither of these researchers were involved in teach-
This study was conducted after the clinical rotations ing the students during their clinical practicum, which
ended in April 2022, between May and June in the nurs- helped to minimize bias. The interviews took place at
ing programme at the College of Health Sciences, Uni- the University of Sharjah, specifically in building M23,
versity of Sharjah, in the United Arab Emirates. The study providing a familiar and comfortable environment for
population comprised undergraduate nursing students the participant. Before the interviews were all students
who were undergoing their first clinical training and who agreed to participate were provided with an expla-
were recruited using purposive sampling. The inclusion nation of the study’s purpose. The time and location of
criteria for this study were second-year nursing students each interview were arranged. Before the interviews were
in the first semester of clinical training who could speak conducted, all students who provided consent to partici-
English, were willing to participate in this research, and pate received an explanation of the purpose of the study,
had no previous clinical work experience. The final sam- and the time and place of each interview were arranged
ple consisted of 30 students. to accommodate the participants’ schedules and prefer-
ences. The interviews were conducted after the clinical
Research instrument rotation had ended in April, and after the final grades had
The research instrument was a semi structured inter- been submitted to the coordinator. The timings of the
view guide. The interview questions were based on an interviews included the month of May and June which
in-depth review of related literature. An intensive search ensured that participants have completed their practi-
included key words in Google Scholar, PubMed like the cum experience and could reflect on the stressors more
terms “nursing clinical stressors”, “nursing students”, and comprehensively. The interviews were audio-recorded
“coping mechanisms”. Once the questions were created, with the participants’ consent, and each interview lasted
they were validated by two other faculty members who 25–40 min. The data were collected until saturation was
had relevant experience in mental health. A pilot test was reached for 30 students. Memos and field notes were also
conducted with five students and based on their feedback recorded as part of the data collection process. These
the following research questions, which were addressed additional data allowed for triangulation to improve the
in the study. credibility of the interpretations of the data [28]. Memos
included the interviewers’ thoughts and interpretations
1. How would you describe your clinical experiences about the interviews, the research process (including
during your first clinical rotations? questions and gaps), and the analytic progress used for

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Dias et al. BMC Nursing (2024) 23:322 Page 4 of 11

the research. Field notes were used to record the inter- in Building M23that were private and quiet to ensure
viewers’ observations and reflections on the data. These that the participants felt at ease and confident in verbal-
additional data collection methods were important to izing their opinions. No participant was paid directly for
guide the researchers in the interpretation of the data involvement in this study. In addition, participants were
on the participants’ feelings, perspectives, experiences, assured that their data would remain anonymous and
attitudes, and beliefs. Finally, member checking was per- confidential. Confidentiality means that the information
formed to ensure conformability. provided by participants was kept private with restric-
tions on how and when data can be shared with others.
Data analysis The participants were informed that their information
The study used the content analysis method proposed by would not be duplicated or disseminated without their
Graneheim and Lundman [24]. According to Graneheim permission. Anonymity refers to the act of keeping peo-
and Lundman [24], content analysis is an interpretive ple anonymous with respect to their participation in a
technique that examines the similarities and differences research endeavor. No personal identifiers were used in
between distinct parts of a text. This method allows this study, and each participant was assigned a random
researchers to determine exact theoretical and opera- alpha-numeric code (e.g., P1 for participant 1). All digi-
tional definitions of words, phrases, and symbols by elu- tally recorded interviews were downloaded to a secure
cidating their constituent properties [29]. First, we read computer protected by the principal investigator with
the interview transcripts several times to reach an overall a password. The researchers were the only people with
understanding of the data. All verbatim transcripts were access to the interview material (recordings and tran-
read several times and discussed among all authors. We scripts). All sensitive information and materials were
merged and used line-by-line coding of words, sentences, kept secure in the principal researcher’s office at the Uni-
and paragraphs relevant to each other in terms of both versity of Sharjah. The data will be maintained for five
the content and context of stressors and coping mecha- years after the study is completed, after which the mate-
nisms. Next, we used data reduction to assess the rela- rial will be destroyed (the transcripts will be shredded,
tionships among themes using tables and diagrams to and the tapes will be demagnetized).
indicate conceptual patterns. Content related to stress
encountered by students was extracted from the tran- Results
scripts. In a separate document, we integrated and cate- In total, 30 nursing students who were enrolled in the
gorized all words and sentences that were related to each nursing programme at the Department of Nursing, Col-
other in terms of both content and context. We analyzed lege of Health Sciences, University of Sharjah, and who
all codes and units of meaning and compared them for were undergoing their first clinical practicum partici-
similarities and differences in the context of this study. pated in the study. Demographically, 80% (n = 24) were
Furthermore, the emerging findings were discussed with females and 20% (n = 6) were male participants. The
other members of the researcher team. The final abstrac- majority (83%) of study participants ranged in age from
tions of meaningful subthemes into themes were dis- 18 to 22 years. 20% (n = 6) were UAE nationals, 53%
cussed and agreed upon by the entire research team. This (n = 16) were from Gulf Cooperation Council countries,
process resulted in the extraction of three main themes while 20% (n = 6) hailed from Africa and 7% (n = 2) were
in addition to two subthemes related to stress and coping of South Asian descent. 67% of the respondents lived
strategies. with their families while 33% lived in the hostel. (Table 1)
Following the content analysis, we identified three
Ethical considerations main themes: (1) managing expectations, (2) theory-
The University of Sharjah Research Ethics Commit- practice gap and 3)learning to cope. Learning to cope had
tee provided approval to conduct this study (Reference two subthemes: positive coping strategies and negative
Number: REC 19-12-03-01-S). Before each interview, coping strategies. An account of each theme is presented
the goal and study procedures were explained to each along with supporting excerpts for the identified themes.
participant, and written informed consent was obtained. The identified themes provide valuable insight into the
The participants were informed that participation in the stressors encountered by students during their first clini-
study was voluntary and that they could withdraw from cal practicum. These themes will lead to targeted inter-
the study at any time. In the event they wanted to with- ventions and supportive mechanisms that can be built
draw from the study, all information related to the partic- into the clinical training curriculum to support students
ipant would be removed. No participant withdrew from during clinical practice.
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

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Dias et al. BMC Nursing (2024) 23:322 Page 5 of 11

Table 1 Demographic data participant descriptive statistics “… you ask the hospital staff for some guidance or the
Gender location of equipment, and they tell us to ask our clini-
Female 24 80% cal tutor …but she is not around … what should I do? It
Male 6 20% appears like we do not belong, and the sooner the shift is
Marital Status over, the better” (P18).
Single 30 100% “The staff are unfriendly and expect too much from us
Married 0 -
students… I feel like I don’t belong, or I am wasting their
Age
(the hospital staff ’s) time. I want to ask questions, but
18–22 25 83%
they have loads to do” (P26).
23–27 5 17%
Other students were concerned about potential fail-
27 + 0 -
ure when working with patients during clinical training,
Ethnicity
which impacted their confidence. They were particularly
UAE Nationals 6 20%
afraid of failure when performing any clinical procedures.
GCC countries 16 53%
“At the beginning, I was afraid to do procedures. I
Africa 6 20%
South East Asia 2 7%
thought that maybe the patient would be hurt and that I
Year of Study
would not be successful in doing it. I have low self-confi-
Year 1 0 -
dence in doing procedures” (P13).
Year 2 30 100% The call bell rings, and I am told to answer Room No.
Year 3 0 - XXX. The patient wants help to go to the toilet, but
Year 4 0 - she has two IV lines. I don’t know how to transport the
Residence patient… should I take her on the wheelchair? My eyes
Living with family 20 67% glance around the room for a wheelchair. I am so con-
Living in hostel 10 33% fused …I tell the patient I will inform the sister at the
nursing station. The relative in the room glares at me
Theme 1: managing expectations angrily … “you better hurry up”…Oh, I feel like I don’t
In our examination of the stressors experienced by nurs- belong, as I am not able to help the patient… how will I
ing students during their first clinical practicum and the face the same patient again?” (P12).
coping strategies they employed, we identified the first Another major stressor mentioned in the narratives
theme as managing expectations. was related to communication and interactions with
The students encountered expectations from various patients who spoke another language, so it was difficult
parties, such as clinical staff, patients and patients’ rela- to communicate.
tives which they had to navigate. They attempted to fulfil “There was a challenge with my communication with
their expectations as they progressed through training, the patients. Sometimes I have communication barriers
which presented a source of stress. The students noted because they (the patients) are of other nationalities. I
that the hospital staff and patients expected them to had an experience with a patient [who was] Indian, and
know how to perform a variety of tasks upon request, he couldn’t speak my language. I did not understand his
which made the students feel stressed and out of place language” (P9).
if they did not know how to perform these tasks. Some Thus, a variety of expectations from patients, relatives,
participants noted that other nurses in the clinical unit hospital staff, and preceptors acted as sources of stress
did not allow them to participate in nursing procedures, for students during their clinical training.
which was considered an enormous impediment to clini-
cal learning, as noted in the excerpt below: Theme 2: theory-practice gap
“…Sometimes the nurses… They will not allow us to do Theory-practice gaps have been identified in previous
some procedures or things during clinical. And some- studies. In our study, there was complete dissonance
times the patients themselves don’t allow us to do proce- between theory and actual clinical practice. The clinical
dures” (P5). procedures or practices nursing students were expected
Some of the students noted that they felt they did to perform differed from the theory they had covered in
not belong and felt like foreigners in the clinical unit. their university classes and skills lab. This was described
Excerpts from the students are presented in the following as a theory–practice gap and often resulted in stress and
quotes; confusion.
“The clinical environment is so stressful. I don’t feel like “For example …the procedures in the hospital are dif-
I belong. There is too little time to build a rapport with ferent. They are different from what we learned or from
hospital staff or the patient” (P22). theory on campus. Or… the preceptors have different

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Dias et al. BMC Nursing (2024) 23:322 Page 6 of 11

techniques than what we learned on campus. So, I was One student made the following comment:
stress[ed] and confused about it” (P11). “I was assisting a doctor with a dressing, and the sight
Furthermore, some students reported that they did not and smell from the oozing wound was too much for me.
feel that they received adequate briefing before going to I was nauseated. As soon as the dressing was done, I ran
clinical training. A related source of stress was overload to the bathroom and threw up. I asked myself… how will
because of the volume of clinical coursework and assign- I survive the next 3 years of nursing?” (P14).
ments in addition to clinical expectations. Additionally,
the students reported that a lack of time and time man- Theme 3: learning to cope
agement were major sources of stress in their first clini- The study participants indicated that they used cop-
cal training and impacted their ability to complete the ing mechanisms (both positive and negative) to adapt to
required paperwork and assignments: and manage the stressors in their first clinical practicum.
“…There is not enough time…also, time management at Important strategies that were reportedly used to cope
the hospital…for example, we start at seven a.m., and the with stress were time management, good preparation for
handover takes 1 hour to finish. They (the nurses at the clinical practice, and positive thinking as well as engaging
hospital) are very slow…They start with bed making and in physical activity and self-motivation.
morning care like at 9.45 a.m. Then, we must fill [out] our “Time management. Yes, it is important. I was encour-
assessment tool and the NCP (nursing care plan) at 10 aging myself. I used time management and prepared
a.m. So, 15 only minutes before going to our break. We myself before going to the clinical site. Also, eating good
(the students) cannot manage this time. This condition food like cereal…it helps me very much in the clinic”
makes me and my friends very stressed out. -I cannot do (P28).
my paperwork or assignments; no time, right?” (P10). “Oh yeah, for sure positive thinking. In the hospital, I
“Stressful. There is a lot of work to do in clinical. My always think positively. Then, after coming home, I get
experiences are not really good with this course. We have [to] rest and think about positive things that I can do.
a lot of things to do, so many assignments and clinical So, I will think something good [about] these things, and
procedures to complete” (P16). then I will be relieved of stress” (P21).
The participants noted that the amount of required Other strategies commonly reported by the par-
coursework and number of assignments also presented a ticipants were managing their breathing (e.g., tak-
challenge during their first clinical training and especially ing deep breaths, breathing slowly), taking breaks to
affected their opportunity to learn. relax, and talking with friends about the problems they
“I need to read the file, know about my patient’s condi- encountered.
tion and pathophysiology and the rationale for the medi- “I prefer to take deep breaths and breathe slowly and to
cations the patient is receiving…These are big stressors have a cup of coffee and to talk to my friends about the
for my learning. I think about assignments often. Like, case or the clinical preceptor and what made me sad so I
we are just focusing on so many assignments and papers. will feel more relaxed” (P16).
We need to submit assessments and care plans for clini- “Maybe I will take my break so I feel relaxed and feel
cal cases. We focus our time to complete and finish the better. After clinical training, I go directly home and take
papers rather than doing the real clinical procedures, so a long shower, going over the day. I will not think about
we lose [the] chance to learn” (P25). anything bad that happened that day. I just try to think
Another participant commented in a similar vein that about good things so that I forget the stress” (P27).
there was not enough time to perform tasks related to “Yes, my first clinical training was not easy. It was dif-
clinical requirements during clinical placement. ficult and made me stressed out…. I felt that it was a very
“…there is a challenge because we do not have enough difficult time for me. I thought about leaving nursing”
time. Always no time for us to submit papers, to com- (P7).
plete assessment tools, and some nurses, they don’t help I was not able to offer my prayers. For me, this was dis-
us. I think we need more time to get more experiences tressing because as a Muslim, I pray regularly. Now, my
and do more procedures, reduce the paperwork that we prayer time is pushed to the end of the shift” (P11).
have to submit. These are challenges …” (P14). “When I feel stress, I talk to my friends about the
There were expectations that the students should be case and what made me stressed. Then I will feel more
able to carry out their nursing duties without becom- relaxed” (P26).
ing ill or adversely affected. In addition, many students Self-support or self-motivation through positive self-
reported that the clinical environment was completely talk was also used by the students to cope with stress.
different from the skills laboratory at the college. Expo- “Yes, it is difficult in the first clinical training. When I
sure to the clinical setting added to the theory-practice am stress[ed], I go to the bathroom and stand in the front
gap, and in some instances, the students fell ill. of the mirror; I talk to myself, and I say, “You can do it,”

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Dias et al. BMC Nursing (2024) 23:322 Page 7 of 11

“you are a great student.” I motivate myself: “You can do managing expectations, paves the way for clinical agen-
it”… Then, I just take breaths slowly several times. This is cies to realize that the students of today will be the nurses
better than shouting or crying because it makes me tired” of tomorrow. It is important to provide a welcoming
(P11). environment where students can develop their identities
Other participants used physical activity to manage and learn effectively. Additionally, clinical staff should
their stress. foster an environment of individualized learning while
“How do I cope with my stress? Actually, when I get also assisting students in gaining confidence and com-
stressed, I will go for a walk on campus” (P4). petence in their repertoire of nursing skills, including
“At home, I will go to my room and close the door and critical thinking, problem solving and communication
start doing my exercises. After that, I feel the negative skills [8, 15, 19, 30]. Another challenge encountered by
energy goes out, then I start to calm down… and begin the students in our study was that they were prevented
my clinical assignments” (P21). from participating in clinical procedures by some nurses
Both positive and negative coping strategies were uti- or patients. This finding is consistent with previous stud-
lized by the students. Some participants described using ies reporting that key challenges for students in clinical
negative coping strategies when they encountered stress learning include a lack of clinical support and poor atti-
during their clinical practice. These negative coping tudes among clinical staff and instructors [31]. Clinical
strategies included becoming irritable and angry, eating staff with positive attitudes have a positive impact on
too much food, drinking too much coffee, and smoking students’ learning in clinical settings [32]. The presence,
cigarettes. supervision, and guidance of clinical instructors and the
“…Negative adaptation? Maybe coping. If I am stressed, assistance of clinical staff are essential motivating com-
I get so angry easily. I am irritable all day also…It is nega- ponents in the clinical learning process and offer positive
tive energy, right? Then, at home, I am also angry. After reinforcement [30, 33, 34]. Conversely, an unsupport-
that, it is good to be alone to think about my problems” ive learning environment combined with unwelcoming
(P12). clinical staff and a lack of sense of belonging negatively
“Yeah, if I…feel stress or depressed, I will eat a lot of impact students’ clinical learning [35].
food. Yeah, ineffective, like I will be eating a lot, drink- The sources of stress identified in this study were con-
ing coffee. Like I said, effective, like I will prepare myself sistent with common sources of stress in clinical training
and do breathing, ineffective, I will eat a lot of snacks in reported in previous studies, including the attitudes of
between my free time. This is the bad side” (P16). some staff, students’ status in their clinical placement and
“…During the first clinical practice? Yes, it was a diffi- educational factors. Nursing students’ inexperience in
cult experience for us…not only me. When stressed, dur- the clinical setting and lack of social and emotional expe-
ing a break at the hospital, I will drink two or three cups rience also resulted in stress and psychological difficul-
of coffee… Also, I smoke cigarettes… A lot. I can drink ties [36]. Bhurtun et al. [33] noted that nursing staff are
six cups [of coffee] a day when I am stressed. After drink- a major source of stress for students because the students
ing coffee, I feel more relaxed, I finish everything (food) feel like they are constantly being watched and evaluated.
in the refrigerator or whatever I have in the pantry, like We also found that students were concerned about
chocolates, chips, etc” (P23). potential failure when working with patients during their
These supporting excerpts for each theme and the clinical training. Their fear of failure when perform-
analysis offers valuable insights into the specific stress- ing clinical procedures may be attributable to low self-
ors faced by nursing students during their first clini- confidence. Previous studies have noted that students
cal practicum. These insights will form the basis for the were concerned about injuring patients, being blamed
development of targeted interventions and supportive or chastised, and failing examinations [37, 38]. This was
mechanisms within the clinical training curriculum to described as feeling “powerless” in a previous study [7,
better support students’ adjustment and well-being dur- 12]. In addition, patients’ attitudes towards “rejecting”
ing clinical practice. nursing students or patients’ refusal of their help were
sources of stress among the students in our study and
Discussion affected their self-confidence. Self-confidence and a sense
Our study identified the stressors students encounter in of belonging are important for nurses’ personal and pro-
their first clinical practicum and the coping strategies, fessional identity, and low self-confidence is a problem for
both positive and negative, that they employed. Although nursing students in clinical learning [8, 39, 40]. Our find-
this study emphasizes the importance of clinical train- ings are consistent with a previous study that reported
ing to prepare nursing students to practice as nurses, it that a lack of self-confidence was a primary source of
also demonstrates the correlation between stressors and worry and anxiety for nursing students and affected their
coping strategies.The content analysis of the first theme, communication and intention to leave nursing [41].

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Dias et al. BMC Nursing (2024) 23:322 Page 8 of 11

In the second theme, our study suggests that students the problem), emotion-focused (regulating emotion),
encounter a theory-practice gap in clinical settings, which and dysfunctional (e.g., venting emotions) stress cop-
creates confusion and presents an additional stressors. ing mechanisms to alleviate stress during clinical train-
Theoretical and clinical training are complementary ele- ing [15]. Labrague et al. [51] highlighted that nursing
ments of nursing education [40], and this combination students use both active and passive coping techniques
enables students to gain the knowledge, skills, and atti- to manage stress. The pattern of clinical stress has been
tudes necessary to provide nursing care. This is consis- observed in several countries worldwide. The current
tent with the findings of a previous study that reported study found that first-year students experienced stress
that inconsistencies between theoretical knowledge and during their first clinical training [35, 41, 55]. The stress-
practical experience presented a primary obstacle to ors they encountered impacted their overall health and
the learning process in the clinical context [42], causing disrupted their clinical learning. Chaabane et al. [15]
students to lose confidence and become anxious [43]. reported moderate and high stress levels among nursing
Additionally, the second theme, the theory-practice gap, students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan,
authenticates Safian et al.’s [5] study of the theory-prac- Palestine, Saudi Arabia, and Sudan. Another study from
tice gap that exists United Arab Emirates among nursing Bahrain reported that all nursing students experienced
students as well as the need for more supportive clinical moderate to severe stress in their first clinical placement
faculty and the extension of clinical hours. The need for [56]. Similarly, nursing students in Spain experienced a
better time availability and time management to com- moderate level of stress, and this stress was significantly
plete clinical tasks were also reported by the students in correlated with anxiety [30]. Therefore, it is imperative
the study. Students indicated that they had insufficient that pastoral systems at the university address students’
time to complete clinical activities because of the vol- stress and mental health so that it does not affect their
ume of coursework and assignments. Our findings sup- clinical performance. Faculty need to utilize evidence-
port those of Chaabane et al. [15]. A study conducted in based interventions to support students so that anxiety-
Saudi Arabia [44] found that assignments and workload producing situations and attrition are minimized.
were among the greatest sources of stress for students in In our study, students reported a variety of positive
clinical settings. Effective time management skills have and negative coping mechanisms and strategies they
been linked to academic achievement, stress reduction, used when they experienced stress during their clinical
increased creativity [45], and student satisfaction [46]. practice. Positive coping strategies included time man-
Our findings are also consistent with previous stud- agement, positive thinking, self-support/motivation,
ies that reported that a common source of stress among breathing, taking breaks, talking with friends, and physi-
first-year students was the increased classroom workload cal activity. These findings are consistent with those of a
[19, 47]. As clinical assignments and workloads are major previous study in which healthy coping mechanisms used
stressors for nursing students, it is important to promote by students included effective time management, social
activities to help them manage these assignments [48]. support, positive reappraisal, and participation in leisure
Another major challenge reported by the participants activities [57]. Our study found that relaxing and talking
was related to communicating and interacting with other with friends were stress management strategies com-
nurses and patients. The UAE nursing workforce and monly used by students. Communication with friends to
population are largely expatriate and diverse and have cope with stress may be considered social support. A pre-
different cultural and linguistic backgrounds. There- vious study also reported that people seek social support
fore, student nurses encounter difficulty in communica- to cope with stress [58]. Some students in our study used
tion [49]. This cultural diversity that students encounter physical activity to cope with stress, consistent with the
in communication with patients during clinical training findings of previous research. Stretching exercises can
needs to be addressed by curriculum planners through be used to counteract the poor posture and positioning
the offering of language courses and courses on cultural associated with stress and to assist in reducing physical
diversity [50]. tension. Promoting such exercise among nursing stu-
Regarding the third and final theme, nursing students dents may assist them in coping with stress in their clini-
in clinical training are unable to avoid stressors and must cal training [59].
learn to cope with or adapt to them. Previous research Our study also showed that when students felt stressed,
has reported a link between stressors and the coping some adopted negative coping strategies, such as show-
mechanisms used by nursing students [51–53]. In partic- ing anger/irritability, engaging in unhealthy eating habits
ular, the inability to manage stress influences nurses’ per- (e.g., consumption of too much food or coffee), or smok-
formance, physical and mental health, attitude, and role ing cigarettes. Previous studies have reported that high
satisfaction [54]. One such study suggested that nursing levels of perceived stress affect eating habits [60] and are
students commonly use problem-focused (dealing with linked to poor diet quality, increased snacking, and low

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Dias et al. BMC Nursing (2024) 23:322 Page 9 of 11

fruit intake [61]. Stress in clinical settings has also been Organizational level
linked to sleep problems, substance misuse, and high-risk At the organizational we relooked at the available student
behaviors’ and plays a major role in student’s decision to support structures, including counseling, faculty advis-
continue in their programme. ing, and career advice, throughout the nursing program
emphasizing the importance of holistic support for stu-
Implications of the study dents’ well-being and academic success as well as reten-
The implications of the study results can be grouped at tion in the nursing program. Also, offering language
multiple levels including; clinical, educational, and orga- courses as electives recognizes the value of communica-
nizational level. A comprehensive approach to address- tion skills in nursing practice and provides opportunities
ing the stressors encountered by nursing students for personal and professional development.
during their clinical practicum can be overcome by offer-
ing some practical strategies to address the stressors Conclusions
faced by nursing students during their clinical practi- For first-year nursing students, clinical stressors are
cum. By integrating study findings into curriculum plan- inevitable and must be given proper attention. Recog-
ning, mentorship programs, and organizational support nizing nursing students’ perspectives on the challenges
structures, a supportive and nurturing environment that and stressors experienced in clinical training is the first
enhances students’ learning, resilience, and overall suc- step in overcoming these challenges. In nursing schools,
cess can be envisioned. providing an optimal clinical environment as well as
increasing supervision and evaluation of students’ prac-
Clinical level tices should be emphasized. Our findings demonstrate
Introducing simulation in the skills lab with standardized that first-year nursing students are exposed to a variety
patients and the use of moulage to demonstrate wounds, of different stressors. Identifying the stressors, pressures,
ostomies, and purulent dressings enhances students’ and obstacles that first-year students encounter in the
practical skills and prepares them for real-world clinical clinical setting can assist nursing educators in resolving
scenarios. Organizing orientation days at clinical facilities these issues and can contribute to students’ professional
helps familiarize students with the clinical environment, development and survival to allow them to remain in the
identify potential stressors, and introduce interventions profession. To overcome stressors, students frequently
to enhance professionalism, social skills, and coping abili- employ problem-solving approaches or coping mecha-
ties Furthermore, creating a WhatsApp group facilitates nisms. The majority of nursing students report stress at
communication and collaboration among hospital staff, different levels and use a variety of positive and negative
clinical tutors, nursing faculty, and students, enabling coping techniques to manage stress.
immediate support and problem-solving for clinical The present results may not be generalizable to other
situations as they arise, Moreover, involving chief nurs- nursing institutions because this study used a purposive
ing officers of clinical facilities in the Nursing Advisory sample along with a qualitative approach and was limited
Group at the Department of Nursing promotes collabo- to one university in the Middle East. Furthermore, the
ration between academia and clinical practice, ensuring students self-reported their stress and its causes, which
alignment between educational objectives and the needs may have introduced reporting bias. The students may
of the clinical setting [62]. also have over or underreported stress or coping mecha-
nisms because of fear of repercussions or personal rea-
Educational level sons, even though the confidentiality of their data was
Sharing study findings at conferences (we presented the ensured. Further studies are needed to evaluate stu-
results of this study at Sigma Theta Tau International in dent stressors and coping now that measures have been
July 2023 in Abu Dhabi, UAE) and journal clubs dissemi- introduced to support students. Time will tell if these
nates knowledge and best practices among educators and strategies are being used effectively by both students
clinicians, promoting awareness and implementation and clinical personnel or if they need to be readdressed.
of measures to improve students’ learning experiences. Finally, we need to explore the perceptions of clinical
Additionally we hold mentorship training sessions annu- faculty towards supervising students in their first clini-
ally in January and so we shared with the clinical mentors cal practicum so that clinical stressors can be handled
and preceptors the findings of this study so that they pro- effectively.
actively they are equipped with strategies to support stu-
dents’ coping with stressors during clinical placements. Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12912-024-01962-5.

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Dias et al. BMC Nursing (2024) 23:322 Page 10 of 11

9. Stubin C. Clinical stress among undergraduate nursing students: perceptions

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