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journal-of-nursing-sciences/2352-0132

Original Article

Perceived stress among Macao nursing students in

the clinical learning environment

Ming Liu a, Ken Gu a,*, Thomas K.S. Wong b, Min Z. Luo a, Men Y. Chan a
a
School of Health Sciences, Macao Polytechnic Institute, Rua De Luis Gonzaga Gomes, Macao
b
Knowledge Transfer and Consultancy Company Limited, Hong Kong

article info abstract

Article history: Objective: This study aimed at investigation of the stress perceived by Macao nursing stu-
Received 29 December 2014 dents in the clinical learning environment.
Received in revised form Methods: A cross-sectional research was designed and 203 nursing students in a public
21 April 2015 higher education institute were recruited. The Stressors in Nursing Students Scale-Chinese
Accepted 24 April 2015 Version (SINS-CN) was used to measure nursing students' stress. Data analysis includes
Available online 14 May 2015 descriptive analysis and analysis of variance.
Results: The overall SINS-CN mean score was 3.33 (SD 0.49), while the scores for different
dimensions were: clinical, 3.44 (SD 0.54), education, 3.35 (SD 0.62), finance and time,
3.31 (SD 0.72), confidence, 3.21 (SD 0.60), and personal problems, 3.03 (SD 0.68).
Among 10 most common stressors, four belong to the clinical dimension, four to the ed-
ucation dimension, one to the confidence dimension, and one to the finance & time
dimension. Analysis for factors associated with stress indicated that no statistical signifi-
cance was found in most demographic variables, except year two students' stress scores
were significantly lower than those of students in other years (p values were between 0.000
and 0.026).
Conclusions: Macao nursing students, to some extent, experienced stress in clinical learning
environment and the stress level was higher than that of Hong Kong nursing students. The
most common stressors were related to clinical and educational dimensions. The study
suggests that teaching and learning modalities and the workload of nursing students
should be reviewed.
Copyright 2015, Chinese Nursing Association. Production and hosting by Elsevier
(Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

*
Corresponding author.
E-mail address: kengu@ipm.edu.mo (K. Gu).
Peer review under responsibility of Chinese Nursing Association.
http://dx.doi.org/10.1016/j.ijnss.2015.04.013
2352-0132/Copyright 2015, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 1 2 8 e1 3 3
1. Introduction
Stress refers to a dynamic interaction between the individual
and the environment [1]. This interaction may lead to cogni-
tive, emotional and behavioral alteration [2]. Nursing as a
caring profession has been known to be a stressful occupation
[3]. Nursing students who engage in a wide range of clinical
duties during their learning in clinical settings share similar
stressors as professional nurses experience. In addition,
nursing students also have stress related to their educational
studies and personal/social experience [4]. Stress can be
deleterious to individuals and lead to physical and psycho-
logical distress [5]. This psychological distress may hamper
students' academic performance and hence impede their
pursuit of the nursing career temporarily or permanently [6].
What is more, stress and psychological distress may have
negative effects on nursing graduates in the workforce [7].
Existing evidence indicates that nursing students have
higher levels of stress than students in other disciplines [8,9],
but stress varies at different education levels of nursing stu-
dents and different nursing programs [7,10,11]. Common
sources of stress in nursing students basically include: a)
academic-related concerns such as workload, lack of knowl-
edge, examination, teaching style; b) clinical practice for
example, lack of competence, taking care of death and dying,
shifting, supervision, assessment; c) relationships with others
(clients, peers, teachers or other health professionals) [12]; and
d) personal factors such as gender, age, new surroundings
away from home, family structure, financial burdens and job
roles [4,7,13].
Study on nursing student stress in the Macao Special
Administrative Region of Republic of China (Macao SAR) is
very limited. Vong and colleagues used a convenience sam-
pling method to recruit 77 nursing students to complete a self-
developed scale of nursing student stress [14]. The psycho-
metric properties of the scale were not presented. The results
indicated that the average level of stress was moderate and
the clinical practice and academic workload were the first and
second ranked stress factors. Another unpublished study was
conducted by Li [15]. Its main purpose was to explore the effect
of personal characteristics of nursing students on stress and
coping strategies [15].
There are two nursing education agencies in Macao, a
charity agency which was founded in 1923 and a government-
funded agency, founded in 1964 [16]. Together with Macao's
political system, the Macao nursing education system has
experienced remarkable changes in the past 15 years since the
return of Macao's sovereignty from Portugal to the People's
Republic of China (PR China) in 1999. Nursing education has
been transformed from hospital-based training to tertiary
education based, from a three-year diploma program to
the3 1 supplementary bachelor degree (three-year
diploma plus one-year of supplementary study), and then to
the current four-year baccalaureate degree program [16].
Simultaneously, clinical practice has been reformed from
supervision and assessment of students by clinical nurses to
one that typifies the cooperative work of the nursing faculty
and clinical nurses [16]. The advantage of doing this is
ensuring the quality of students' learning in clinical practice.
129
However, it may cause more stress to students. In an Annual
School-Student Dialog in one of the public universities in
Macao, some nursing students reported that they are over-
loaded with work because assignments and assessment usu-
ally come from both nursing faculty and clinical supervision
nurses. Another unpublished report from the Student Affairs
Office indicated that among 18 different disciplinary pro-
grams, the nursing program students ranked the highest in
Level of Academic Challenge [17].
In addition, students may be overwhelmed by and feel
stressed in Macao's complex multicultural clinical environ-
ment. Although about 95% of the population is Chinese [18],
Macao was a Portuguese colony for more than 400 years,
resulting in a very multicultural society. The original multi-
culturalism has been compounded in recent years by a dra-
matic increase of immigration and tourism, making the
healthcare services situation even more complicated and
challenging [19]. A simple example is the increasingly multi-
lingual environment, where three languages (Chinese, Portu-
guese and English) consisting of four dialects (Cantonese,
Mandarin, Portuguese and English) are in daily use in clinical
settings. Nursing students often report experiencing difficulty
in such a multilingual working environment. Therefore, it is
important for us to understand the stress perceived and
stressors experienced by our nursing students so that we can
prevent the undesirable impacts incurred in the current sit-
uation of healthcare provision in Macao. The general aim of
this study was to investigate the stress perceived by Macao
nursing students in the clinical learning environment. The
specific objectives of the study were: a) to measure the level of
stress perceived by nursing students; b) to identify the sources
of nursing student stress in the clinical learning environment;
and c) to analyze the factors that are associated with stress
experienced by nursing students.
2. Methods
2.1. Study design
The study was a cross-sectional descriptive design using self-
administered questionnaires for data collection.
2.2. Setting and sample
The study took place in a public higher education institution
in Macao SAR. All students studying in the nursing program
were recruited to minimize sampling error. The total number
of nursing students was 231. Excluding 20 students who
participated in the instrument test-retest reliability study,
there were 211 participants in the main study.
2.3. Ethical consideration
Approval was sought from the Research Ethics Committee of
the study setting before conducting the study. Permission for
using the questionnaire was granted by the original corre-
sponding author. All participants were assured of anonymity
and confidentiality. A signed consent form was obtained from
130 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 1 2 8 e1 3 3

those who were willing to participate in the study before data

Table 1 e Demographic data (n 203).
collection.
Demographic characteristics No. %

2.4. Measurements/instruments Gender

Male 45 22.2
Female 158 77.8
Data collection instruments included the demographic profile
and the Stressors in Nursing Students Scale-Chinese Version Age
(SINS-CN). The validity of the SINS-CN has been established in Mean 20.8 (SD 2.9)

a previous study and the internal consistency with Cronbach's Year of students
a is >0.7 [20]. The original SINS-CN is a 43-item, self- Year 1 54 26.6
administered questionnaire covering clinical, confidence, ed- Year 2 53 26.1
Year 3 53 26.1
ucation and financial sources of stress [20]. The questionnaire
Year 4 43 21.2
uses a five-point Likert scale from 1 being not at all stressful to
5 being extremely stressful [20]. The validated version among Religions
No religion 173 85.3
Macao nursing students consists of 43-item with five di-
Christians 14 6.9
mensions with Cronbach's a 0.96 for overall scale and
Catholics 8 3.9
0.67e0.94 for sub-dimensions [21]. A test-retest reliability with Buddhists 8 3.9
2-week interval was 0.82 for the overall instrument and
Parents' marriage status
0.70e0.88 for the sub-dimensions [21].
Married 173 85.2
Single 11 5.4
2.5. Data collection/procedure Divorced 19 9.4

Family household monthly income (MOP)a

The researchers delivered the questionnaire to all 211 partic- <10,000 3 1.5
ipants at the end of a single semester at the point in time 10,000e20,000 21 10.3
when each level of students finished their clinical placement. 20,000e30,000 95 46.8
The completed questionnaires were collected from the 30,000e40,000 68 33.5
>50,000 MOP 16 7.9
returning boxes after two weeks. These questionnaires and
a
data sheets were stored in a locked cabinet. MOP: Macao Pataca (1 US $ 8.00MOP).

2.6. Data analysis

The Statistical Package for the Social Sciences (SPSS version
20) was used in performing data analysis. Descriptive statis-
tics were used to analyze the socio-demographic data and
stress level as well as the common stressors of students. Post
hoc was used to compare the mean scores of the five factors
among the four years of students.
3. Results
3.1. Demographic characteristics of participants
3.3. Factors associated with stress
The researchers further explored the demographic variables
which might affect the students' stress. However, no statisti-
cal significance was found in most variables except year of
study. The p-values were found significant in the statistic re-
sults between year of study and total mean score and each of
the five dimensions. In further analysis for multi-group com-
parison, we found year two students' stress scores (including
the five dimensions) were significantly lower than those of
students in other years (with p values between 0.000 and
0.026), as shown in Table 3.

Totally, 203 valid responses were obtained with a 96% valid

return rate. Demographic characteristics of participants were
presented in Table 1.
3.2. Level of stress and common stressors
The overall SINS-CN mean score was 3.33 (SD 0.49), while
the scores for different dimensions were: clinical, 3.44
(SD 0.54), education, 3.35 (SD 0.62), finance and time, 3.31
(SD 0.72), confidence, 3.21 (SD 0.60), and personal prob-
lems, 3.03 (SD 0.68). The ten most highly scoring common
stressors perceived by students are presented in Table 2.
Among them, four stressors belonged to the clinical dimen-
sion (items 3, 9, 24, 39), four to the education dimension (items
1, 4, 7, 18), one to the confidence dimension (item 33), and one
to the finance and time dimension (item 22).
4. Discussion
4.1. Level of stress and common stressors
The results revealed that Macao nursing students, to some
extent, experienced stress in the clinical learning environ-
ment and the stress level was higher than that of Hong Kong
nursing students [22]. Macao and Hong Kong have a lot of
similarities in terms of nationality, political system, social
structure and economy; however, nursing education is, to
some extent, different. Nursing in higher education in Hong
Kong is quite mature, while in Macao it is still in its transition
period to a four-year tertiary education degree with an
extensive clinical practice component [19]. Moreover, the
arrangement and management of clinical placement might
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 1 2 8 e1 3 3 131

Table 2 e Common stressors perceived by nursing students (N 203).

Item No Stressors Rank Mean (SD)
9 Fear of making a mistake in clinical placements 1 4.00 (0.93)
3 Having too much clinical responsibility 2 3.86 (0.71)
22 The lack of free time 3 3.79 (0.98)
33 Fear of failing in the course 4 3.77 (0.94)
1 The amount of classwork material to be learned 5 3.75 (0.73)
7 Examinations and placement gradings 6 3.67 (0.94)
24 Criticism from peers or senior staff 7 3.66 (0.94)
18 Having too much to learn 8 3.65 (0.89)
39 Feeling responsible for what happens to patients 9 3.63 (0.88)
4 The difficulty of the classwork material to be learned 10 3.50 (0.73)

have attributed to the level of stress reported in the results.
The multicultural and complex clinical environment certainly
had an impact on the students' stress. As mentioned in the
introduction, students could have felt challenged and stressed
by the multi-language clinical environment. Leong stated that
even the students majoring in languages in Macao, e.g.
Translation and Interpretation majors, have to cope with
three formidable languages and several dialects [23]. It sug-
gests that school should help students build up their language
ability by employing more strategies, e.g. adding Portuguese
leaning in the curriculum, facilitating mandarin leaning and
practicing opportunities.
Among the top ten common stressors ranked by Macao
nursing students, most of them were clinical and education
related stressors. Particularly, the first and second most
common stressors encountered by students were due to stress
from the clinical dimension, such as Fear of making a mistake
in clinical placement (M 4.00, SD 0.93) and Having too
much clinical responsibility (M 3.86, SD 0.71). These
findings are consistent with the previous findings by Wilson
and by Mahat [24,25]. The high stress scores could be a result
of inadequate preparation and lack of confidence. Students
often worry that any mistake they make will affect their grade
and even their status. According to the currently implemented
clinical placement regulations in the studied school, a student
who makes any mistake in invasive procedures, adminis-
tering oral medications, or procedures causing any injury to
clients, would be suspended from his/her clinical placement.
The student is then asked back to the school laboratory to
practice the skills until judged satisfactory by the School
Pedagogical Committee, whereupon the student is allowed to
resume his/her clinical practice. Besides, the students' fear
could have been exaggerated by the preceptors' high
expectations of the students' performance, particularly on the
part of clinical preceptors [25,26]. A special training program is
needed to equip clinical preceptors' knowledge and skills in
precepting students in clinical environment.
The other most common stressors were related to the
heavy workload. The findings supported those from the
studies in Hong Kong and Taiwan [27,28]. This might be a
result of the heavy curriculum with too many clinical place-
ment hours compared to those in western countries. Ac-
cording to the California Board of Registered Nursing, nursing
students in the United States are only required to complete
about 1000 hours of clinical practice before graduation [29];
the University of Notre Dame in Australia requires 1240 hours
of clinical placement [30]. The 4-year Bachelor of Nursing
program in Macao was designed with 160 learning credits,
among which 46 credits (1840 hours) are clinical placement
[31]. In each clinical unit, students are required to submit at
least three assignments including a clinical learning plan,
clinical reflections and case study reports. In addition, both
clinical supervision nurses and academic teachers are
required to assess the performance of each student, which
might have caused additional stress to students. Considering
the present study findings, the researchers suggest that the
teaching and learning modalities and the workload of nursing
students should be reviewed.
4.2. Factors associated with stress
Among all demographic variables, only year of study was
found to have a significant effect on students' stress. Post-hoc
analysis demonstrated that the second year students claimed
to experience less stress than their peers in the other three
class groups both for the overall stress scale and sub-

Table 3 e Comparison between year groups with overall SINS-CN and sub-dimensions.
Scale and sub-dimensions Year 1 (n 54) Year 2 (n 53) Year 3 (n 53) Year 4 (n 43) F p
Mean score (SD)
Overall scale 3.57 (0.54) 2.98a (0.51) 3.46 (0.37) 3.37 (0.44) 5.63 0.021
Clinical 3.58 (0.62) 2.99a (0.54) 3.57 (0.42) 3.48 (0.43) 9.33 0.000
Confidence 3.39 (0.63) 2.98a (0.62) 3.24 (.46) 3.21 (0.60) 7.74 0.000
Finance and time 3.31 (0.74) 2.97a (0.72) 3.36 (0.62) 3.59 (0.75) 3.27 0.022
Education 3.34 (0.52) 3.02a (0.71) 3.34 (0.52) 3.40 (0.60) 4.80 0.003
Personal problem 3.25 (0.78) 2.78a (0.65) 3.03 (0.56) 3.04 (0.67) 3.14 0.026
a
p < 0.05.
132 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 1 2 8 e1 3 3
dimensions (p < 0.05, Table 3). This result is inconsistent with
the findings of the previous studies reported from other
countries. A study conducted by Rajesh Kumar in Iran found
that the first year students had the highest level of stress
compared with other senior year students [32]. She explained
that the higher stress level experienced by first year students
could be a result of being placed in an unfamiliar environ-
ment, separation from the families and the demand of form-
ing new social groups apart from academic pressures and
clinical training. Interestingly, a study conducted in Malaysia
found that second year students in fact claimed to be more
stressed than other year groups [33]. It is therefore appropriate
to postulate year of study as an independent factor that may
affect the nursing students' experience and perception of
stress, though the effect is very much dependent on curricular
context. Reviewing the curriculum design and organization of
clinical placement in the studied school, the researchers
noted that no special feature was found in year two study
except more extra-curricular activities than in other years of
the program. These activities might have helped students
enhance their adaptation to and management of the stress
induced in the clinical environment. In view of this uncertain
association, we recommend a longitudinal cohort study be
conducted to assess the possible changes of stress perception
of Macao nursing students and the associated factors. To
further understand the student's experience and perception, a
qualitative study including, but not limited to the use of in-
depth interview and story-telling should be carried out
either together with the longitudinal study or on its own.
5. Limitations
This study used cross-sectional design, so the data were
collected at a single time point. The pattern, consistency and
intensity of stress over time were not assessed. Future study
should incorporate a longitudinal cohort design to improve
the present research methodology. In addition, as previously
mentioned, Macao SAR has two higher nursing education in-
stitutions, one charity-funded and another government-
funded. This study setting was confined only to the
government-funded institution. Therefore, generalization of
the results should be cautioned. Dimensions of SINS-CN
questionnaire does not address local issues such as multi-
culturalism and language issue, a modification and validation
of scale study may be needed.
6. Conclusions
Macao nursing students, to some extent, experienced stress in
clinical learning environment and the stress level was higher
than that of Hong Kong nursing students. The most common
stressors were related to clinical and educational dimensions.
Except for the variable year of study, all other demographic
variables did not show any statistically significant effect on
students' stress. Comparative results analysis indicated that
year two students experienced less stress than other peer
groups. To further understand the student's experience of
stress in learning, the researchers consider it necessary in the
future to conduct a longitudinal study on a cohort of students,
and if possible, complementary work with a qualitative
procedure.
Acknowledgment
The authors gratefully acknowledge the valuable contribu-
tions of Dr. Joanna Radwanska-Williams in the preparation of
this manuscript. The project was sponsored by the Macao
Polytechnic Institute Research Fund (Code: RP/ESS-03/2012).
Conflict of interest
The authors declare no conflict of interest regarding this
research and paper.
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