2019, Cilt 9, Sayı 2, Sayfa(lar) 250-255
Nursing Students Education Stress and Academic Achievement: The Impact of Three Different Education Methods
Nuray EGELİOĞLU CETİŞLİ1, Sezer ER GÜNERİ2, Hatice MERT3, Elif ÜNSAL AVDAL1, Yasemin TOKEM1, Hatice YILDIRIM SARI1
1İzmir Katip Çelebi University, Faculty of Health Sciences, Department of Nursing, İzmir, Turkey
2Ege University, Faculty of Nursing, İzmir, Turkey
3Dokuz Eylül University, Faculty of Nursing, İzmir, Turkey
Keywords: Nursing students, Nursing education, Academic achievement, Stress
Nursing education has both theoretical and practical components as well as many stressors. The stress levels of students might be affected
by clinical environment, nursing practices, patients, and team members. The aim of this study was to determine the effect of stress on
nursing students academic achievement related to three different education methods. A descriptive and cross-sectional study was
conducted with 571 nursing students at three universities. A different education method was used at each university. Data were collected
by researchers using the Individual Identity Form and Stress in Nursing Education Questionnaire. According to the education methods,
there is a difference between the academic achievement mean score and the academic stress score of the students. Academic stress was
weakly correlated with academic achievement in the integrated model and Problem Based Learning. Problem Based Learning decreases
stress level and increases the academic achievements of students by enabling them to realize the different capabilities of the study.
Nursing education has stressors that increase nursing students
anxiety levels. The studies have shown that the stress
levels of nursing students increase throughout their education
(Timmins, Corroon, Byrne, & Mooney, 2011). Jiménez,
Martínez, and Vacas (2010) found similar stress levels in all
three training years in nursing students. It has been suggested
that the risk of developing mental health problems is higher
for nursing students compared to other health disciplines
and the general population (Luo & Wang, 2009; Rhead, 1995;
Timmins et al., 2011). The stress levels of nursing students
might be affected by the instructor, clinical environment, nursing
practices, patients, team members and by him or herself.
It is found that stress is related to insufficient theoretical
training, lack of skills in clinical practice, taking responsibility
of the patients, time pressure, lack of motivation and accommodation,
social life, new responsibilities and living in a new
environment (Öner & Üstün, 2013, Seyedfatemi, Tafreshi, &
Hagani, 2007). For nursing education three main stress groups
defined in systematic review study of Pulido-Martos, Augusto-
Landa & Lopez-Zafra (2012): (i) Academic stressors (exam
evaluation, anxiety of failure in education, etc.), (ii) clinical
stressors (atychiphobia, negative reaction to death or patient
pain, relation with team members, etc.), (iii) personal/social
stressors (economic problems etc.). Its known that nursing
students that undergo stress on their education negatively
affected both on their health and professional personality
development. Stress also affects academic success of students
negatively as breaking their thinking and decision taking capabilities
(Karaca, Yıldırım, Ankaralı, Açıkgöz, & Akkuş, 2015).
The academic achievement of students is very important to the
students themselves, as well as to their parents and society.
It is known that academic achievement is related to many
factors, such as cognitive performance, capability, personality
and family characteristics (Khalaila, 2015). Furthermore, in
a study conducted in Australia, it was found that for most
students who were working 16 hours per week in a job related
to nursing, as their working hours increased, their academic
achievement decreased (Salamonson & Andrew 2006). In
the literature it was declared that academic achievement
of nursing students increases as the quality of facilities that
clinical studies conducted increases (Aktaş & Karabulut, 2016).
Also it was declared that self-motivation, high sense of self and
exam anxiety were affecting factor on academic achievement
(Khalaila, 2015). In the literature, it was found that there
was relationship between students academic achievement and their stress level (Elias, Ping, & Abdullah, 2011; Öner &
Üstün, 2013; Pulido‐Martos, Augusto‐Landa, & Lopez‐Zafra,
2012; Yıldırım, Karaca, Ankaralı, Açıkgöz, & Akkuş, 2016). The
stress disrupts students critical thinking and decision-making
abilities and therefore reduces academic achievement (Elias et
al., 2011; Yıldırım et al., 2016).
Nursing education, including theoretical and practice course
hours, is determined by the Council of Higher Education in
Turkey. While all nursing schools receive their education based
on certain standards, the specific models they experience
might differ. Essentially three main nursing education models
are used in Turkey.
Traditional-classical education model: The students are the
passive role in this education model. It is a teacher-centered
method because it is the teacher who determines the content
of the course and tells lessons to large groups of students
(Lewis et al., 2009; Seren & Ustun, 2008). This method is
preferred by most nursing schools in Turkey. In addition to
theoretical lectures, clinical and laboratory education is also
provided. Students attend clinical practices together with
theoretical lectures starting from the first class.
Integration model: This model is based on holistic learning.
This model groups subject areas according to a problem or
issue. Because nursing problems are interdisciplinary and
solving problems integrates many areas of knowledge, more
and more importance has been given to the integration
model in nursing education. Integration is classified as either
horizontal or vertical. Horizontal integration elucidates an
issue/problem in more than one discipline at a time, whereas
vertical integration shows the relationship between disciplines
at different stages of the education. Integrated education
programs in nursing are structured from health to disease as
related subject areas to be included basic knowledge, attitudes
and capabilities (Karagözoğlu, Özden, & Tok-Yıldız, 2013;
Sabanciogullari & Dogan, 2012; Toraman, Temel, Kalkım, &
Balyacı, 2013). The integrated method has been used in Turkish
nursing schools since 1999. In the integrated education model,
active education methods are used and nursing skills training
are given at laboratories and clinics. Besides these, students at
the third class participate in clinical practices.
Problem-based learning model: This method was first applied
in a Turkish nursing school in 1999. Problem-based learning
(PBL) is one of the student centered education approach. In
the literature it was reported that it is an effective method
to increase academic achievement and to develop critical thinking skills such as interpret knowledge, conducting a
research, creative thinking and problem solving. Also it was
reported that it was effective on increasing self-sufficient
belief and self-management. (Cónsul-Giribet & Medina-Moya,
2014; Dagistani, Al Hejaili, Binsalih, Al Jahdali, & Al Sayyari,
2016; Lewis et al., 2009; Yalcin, Karahan, Karadenizli, & Sahin,
2006; Seren & Ustun, 2008).
The effect of different nursing education models on students:
There were studies in the literature that have analyzed the
effect of different nursing education models on students.
It was reported in the literature that the conflict resolution
(Seren & Ustun, 2008), problem solving (Yalcin et al., 2006)
skills and critical thinking disposition (Dagistani et al., 2016;
Lewis et al., 2009) of students were higher in PBL education
and PBL had a stronger influence on development of students
self-perceptions regarding information literacy (Özbıçakçı,
Gezer, & Bilik, 2015).
Studies in the literature (Jiménez et al., 2010; Karagözoğlu
et al., 2013; Luo & Wong, 2009; Öner & Üstün, 2013; Pulido‐
Martos et al., 2012; Seyedfatemi et al., 2007; Watson, Deary,
Thompson, & Li, 2008) mainly focused on one method and
analyzed its effect on students academic and/or clinical stress.
There is not any study in the literature that analyzed the stress
resulting from different education models and its effect on
students academic achievements. The aim of this study was to
determine the effect of stress on nursing students academic
achievement related to three different teaching methods. The
research question for the study: What is the effect of stress
on the academic achievement of nursing students in different
The descriptive and cross-sectional study was conducted with
nursing students at three different universities, where each
used a different education method, between 15 February and
15 May 2015 in Izmir, in Turkey. Nursing students of state
universities in the city center of Izmir were accepted in the
study to take in the control stress and factors (environmental
factors, socio-economic factors etc.) that might affect academic
success. Research was conducted in three state universities
that were using different techniques on undergraduate nursing
education. Undergraduate nursing education programs were
given in four years within eight semesters. The sample size
was calculated with the known sampling universe formula at
a confidence level of 95% (Erdoğan, Nahcivan, & Esin, 2014).
630 students, who were started clinical applications, were
invited in the study with a randomly sampling method. 46 of
them didnt accept to participate in the study and 13 of them
were not accepted in the study because of missing information
on their forms. Based on this calculation, 171 students were
selected from a university with a classical traditional education,
198 students were selected from a university that used the
integrated education method and 202 students were selected
from a university that used the problem based education
method. In total, 571 students participated in the study.
Data were collected by using the Individual Identity Form that
was generated by researchers regarding the literature (Elias et
al., 2011; Jiménez et al., 2010; Karagözoğlu et al., 2013; Öner
& Üstün, 2013; Pulido‐Martos et al., 2012; Yıldırım et al., 2016)
and by using Stress in Nursing Education (SINE) Questionaire
that was developed by Rhead (Rhead, 1995). The data were
collected by face-to-face interviews conducted by researchers.
Students declared their academic achievements regarding
their grade-point average on their transcripts.
The Stress in Nursing Education Questionnaire (Rhead,
1995) is a modified version of the Nurse Stress Scale, which
incorporates academic stressors and was designed specifically
for use within nursing education. The Turkish reliability validity
of the scale was made by Karaca, Yıldırım, Ankaralı, Açıkgöz
and Akkuş (2014) and it was declared that it was a valid and
reliable tool on determining academic and practical stress of
nursing students through their undergraduate education. The
questionnaire of the four-point likert type consists of 32 items.
The points that can be taken from the questionnaire range from
0 to 96. Karaca et al. found the Cronbachs alpha for practical
stress subscale was 0.84, academic stress subscale was 0.83
and total scale was 0.90. For this study, the Cronbachs alpha
for practical stress subscale was 0.87 and academic stress
subscale was 0.86, the total scale was 0.92.
The Statistical Package for Social Science (SPSS Version 21.0)
was used for data analysis. Sociodemographic characteristics
of students were analyzed by descriptive statistics (number,
percentage and mean) and variance between groups was
analyzed by Chi-square test. ANOVA test was used to analyze
difference between SINE score and academic achievement
mean score of students regarding their different education
methods. If statistically significant difference was found,
Tukey HSD was used for further analysis. Correlation analysis
was used to look up relation between students academic
achievement mean score and SINE score.
Ethical board permission (Date: 2 February 2015; No: 22) was
given before the start of the study, and written permissions of
the universities were also given. The researchers received the
written of participants prior to the study.
The demographic data were presented in Table 1. There was
no difference regarding the gender of students in three groups
that participated in the study, but the mean age (F=33.810,
p=0.000) and year of the class (x2=13.457, p=0.001) were
statistically different for the three groups (Table 1). Also
regarding to their education type there is no statistically
meaningful difference between students on their income
level, their parents education level and employment status
The academic achievement score and SINE of the participants
in the three groups were given in Table 2. The academic
achievement score of the students in the PBL method was
higher compared to other techniques and the least score
was in integration model. The difference between them was
statistically significant (F=112, p=0.00). It was determined by
the Tukey HSD test that the difference came from the PBL
model. Academic stress subscale, practical stress subscale
and SINE total score of students in PBL model were less
compared to both integration model and traditional-classical
education model. When traditional-classical education model
and integration model compared, academic stress subscale,
practical stress subscale and SINE total score of students in
traditional-classical model were less compared to students in
integration model. Statistically significant difference between education models was found only for academic stress subscale
score (F=3.099, p=0.046). It was determined by the Tukey HSD
test that the difference came from the PBL model. There was
not any statistically significant difference between the groups
regarding either the SINE total score or the practical stress
subscale score (p>0.05) (Table 2).
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|Table 2: Academic Achievement and SINE Score Regarding the Education Methods
There was a weak negative correlation between the academic
achievement score and academic stress sub-scale score
of students in the integration model (r=-0.142, r2=0.020,
p=0.046) and the PBL model (r=-0.162, r2=0.026, p=0.021).
There wasnt relationship between the academic achievement
and the SINE total score (r=0.036, p=0.640) and the sub-scale
score of academic stress (r=-0.038, p=0.625) and practical
stress (r=0.100, p=0.192) (p>0.005) in traditional- classical
method (Table 3).
Click Here to Zoom
|Table 3: Correlation of Academic Achievement and SINE Score Regarding the Education Methods
High-level stress in nursing education might result in low
motivation in learning and low academic achievement in
students (Öner & Üstün, 2013, Seyedfatemi et al., 2007; Wolf
et al., 2015). Stress in clinical practice negatively affects the
performance and academic achievement of students (Karaca,
Yıldırım, Ankaralı, Açıkgöz, & Akkuş, 2014; Salamanson &
Andrew, 2006; Taşdelen & Zaybak, 2013). In this study, which
analyzed whether there was a difference in the stress and
academic achievement levels of nursing students educated in
three different education models, it was determined that the
academic achievement of students in the PBL model was higher
compared to those in the traditional-classical and integrated
models. It was found that the total academic achievement of
students in the PBL group was higher. Özbıçakçı, Gezer and
Bilik (2015) reported that information literacy of students
was higher in the PBL method, and Dagistani et al. (2016)
declared that the critical thinking ability of PBL students was
better. Since the academic achievement of the students in
the PBL method was found to be higher, the main affecting
factors were thought to be critical thinking, self-education,
and information literacy and combined learning capabilities.
Also its thought in the study that difference between students
university entry scores might be an affecting variable on their
academic success. But it is a constraint of this study that groups
were not homogenized regarding this variable.
Regarding the education methods, there was no difference
between the total score of the SINE and the sub-scale score
of clinical stress. In the study of Karagözoğlu, Özden and Tok
Yıldız (2013), which was conducted to measure clinical stress in
the integrated education model, it was found that the clinical
stress level of students was less, and that this was the result
of the integrated education model as because it is centered
on the student. In another study conducted by Taşdelen and
Zaybak (2013) in an integrated model nursing school, it was
found that students practice stress was at a medium level,
and the reported affecting factors that increased their stress
were the clinical nurses and lecturers. Atay and Yilmaz (2011)
conducted a study to measure practice stress in a traditionalclassical
nursing school, and they found that students stress
level was high. With three different education models in use in
Turkey, the clinical practice model is almost the same in each
model. Beside this, the factors affecting clinical stress were
the inherent elements of clinical practice, such as the clinics
environment, team, patient, new atmosphere and nursing
applications. Clinical training of students that this study was
conducted with was at the same hospitals, so clinical training
stress level was similar for all three education models as
expected. A low level of stress in practice is important, because
it can increase students academic achievement and support a
secure learning environment.
In this study, it was determined that the academic stress level
of PBL students was lower compared to the other groups.
Lewis et al. (2009) conducted a study with medical students
in UK to analyze the effect of PBL and non-PBL education models on their stress level. In this study it was found that
the PBL students were more likely to feel that they did not
know what the faculty expected from them, complain about
an unclear curriculum. Although a high level of stress was
expected because of students active participation in PBL, it
actually causes less stress and higher academic achievement
and higher motivation because it gives students the freedom
to define their own learning targets, and it requires regular
and planned study (Cónsul-Giribet & Medina-Moya, 2014;
Dagistani et al., 2016). PBL also brings out the different
capabilities of nursing students, and such capabilities might
decrease the stress level of the students. For example, it was
found that the conflict resolution (Seren & Ustun, 2008; Yalcin
et al., 2006) and problem solving (Yalcin et al., 2006) skills of
students were better with PBL
Nursing students experience stress factors that negatively
affect their academic achievement and quality of life from
the beginning of their education (Aktaş & Karabulut, 2016;
Karagözoğlu et al., 2013). In this study, it was found that the
academic achievement of students under the PBL method
and the integration model decreased as their academic stress
increased. It was found there was no relationship between
academic stress and academic achievement in the traditionalclassical
education model. Mohamed, Khletet and Al Awany
(2012) found in their study that stress negatively affects the
academic achievement of nursing students. In Goffs study
(2011) it was found that age, not stress was an important
factor affecting academic achievement. A high level of stress
disorder thinking and decision-making capabilities of students
and decreases their academic achievement.
It is important for nurses to get their professional knowledge,
capabilities and values through their nursing education.
Because of this, factors affecting their stress level in their education
have to be determined and clearly defined to minimize
the stress level. It was determined in this study that the method
used in their education was an affecting factor for their stress
level and academic achievement. Academicians should support
students in all educations models regarding clinical and
academic point of view and should determine stress causing
issues earlier. So students will be less affected by these stressing
factors and their academic achievements will increase.
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