Systematic Review and Meta-Analysis Medicine ®

Stress levels of nursing students

A systematic review and meta-analysis
Yan-xue Zheng, MSNa , Jia-Ru Jiaoa, Wen-Nv Hao, MB, RNb,*
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Abstract
Context: Nursing students experience psychosocial stress in their workplace. Available statistics are at variance, and hence, the
need to know the overall prevalence of psychosocial stress among nursing students.
Aims: This study aimed to determine the prevalence of psychosocial stress among nursing students through meta-analysis.
Materials and methods: PubMed, Cochrane, Web of Science, CNKI, and China Biomedical Literature Service System were
searched for articles. Search terms include “psychosocial stress,” “nursing students.” Articles were included if they used validated
psychosocial stress assessment instruments. Of the 15 articles with data on stress prevalence, 8 met all inclusion criteria. Each
article was independently reviewed by the authors and relevant data were abstracted. Statistical analysis was done using Revman
4.1.
Results: Overall, the average score for stress among nursing students was 3.70 (95% confidence interval [CI]: [3.33, 4.06])
based on the analyzed 15 articles with a sample size of 9202.
Conclusion: This study showed that the stress level of intern nursing students was mainly moderate.
Abbreviations: AHRQ = the Agency for Healthcare Quality and Research, ASNS = Assessment of Stress in Nursing Students,
CNKI = China National Knowledge Infrastructure, PSS = the perceived stress scale.
Keywords: meta-analysis, nursing students, stress prevalence

1. Introduction
Nursing is a profession that requires nursing students to
have comprehensive theoretical knowledge and proficiency in
clinical operations.[1] The purpose of clinical education is to
improve the professional knowledge and skill level of nursing
students and to provide opportunities to translate their theory
into practice.[2] Some studies have shown that positive clinical
experiences improve nursing students’ critical thinking skills,
and problem-solving abilities, and develop a sense of profes-
sional identity and belonging.[3] On the contrary, negative clin-
ical experiences can reduce nursing students’ self-confidence,
professional satisfaction, and sense of professional benefit.[4]
Clinical placements are an important part of nursing educa-
tion, but nursing students are often under greater stress during
clinical placements due to their dynamic and challenging
nature.[5–7]
In the latest study, according to Brianna Chu[8], any physi-
cal or psychological stimuli that disrupt homeostasis result in a
stress response. The stimuli are called stressors and physiologi-
cal and behavioral changes in response to exposure to stressors
constitute the stress response. The stress response is adaptive,
to begin with, that prepares the body to handle the challenges
presented by an internal or external environmental challenge
(stressor), for example, the body’s physiologic responses to
trauma and invasive surgery serve to attenuate further tissue
damage. But if the exposure to a stressor is actually or per-
ceived as intense, repetitive (repeated acute stress), or prolonged
(chronic stress), the stress response becomes maladaptive and
detrimental to physiology, for example, exposure to chronic
stressors can cause maladaptive reactions including depression,
anxiety, cognitive impairment, and heart disease.[9] More white
matter abnormalities have been reported in children and ado-
lescents with bipolar disease than in those with unipolar dis-
ease. Importantly, more abnormalities have been documented
in the brains of adolescents with bipolar depression than uni-
polar depression.[10] In addition, there is a close relationship
between stress and suicide which is frequently underreported.
Unfortunately, above 2% of traffic accidents (especially among
young adolescents) are suicide behaviors. This phenomenon
may be underreported considering that suicides by car acci-
dents are reported as accidental in the national statistics. [11]
Related studies have found that medical professionals have
higher levels of workplace stress and burnout compared to other

Y-XZ and J-RJ contributed equally to this work.
The authors report no funding or conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request. Additional
unpublished data is only available to authors.
The corresponding author has full access to all data in the study and is ultimately
responsible for the decision to submit for publication.
a
Affiliated Hospital of Inner Mongolia Medical University Hohhot, Inner Mongolia,
China, b Inner Mongolia Medical University, Hohhot, China.
* Correspondence: Wen-Nv Hao, Department of Emergency, Affiliated Hospital
of Inner Mongolia Medical University, No. 1 Tongdao North Road, Huimin District,
Hohhot 010050, Inner Mongolia, China (e-mail: haowennv@163.com).
Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is
permissible to download, share, remix, transform, and buildup the work provided
it is properly cited. The work cannot be used commercially without permission
from the journal.
How to cite this article: Zheng Y-X, Jiao JR, Hao W-N. Stress levels
of nursing students: A systematic review and meta-analysis. Medicine
2022;101:36(e30547).
Received: 8 July 2022 / Received in final form: 8 August 2022 / Accepted:
10 August 2022
http://dx.doi.org/10.1097/MD.0000000000030547

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 Zheng et al • Medicine (2022) 101:36Medicine
jobs or occupations.[12] Nursing students can have higher levels
of stress compared to students in other healthcare-related profes-
sions.[13] In many countries, nursing students also tend to report
higher stress outcomes than other student groups,[14,15] and the
clinical component of nursing education is more stressful than the
theoretical component.[16] Studies have also shown that almost
all nursing students experience moderate to high levels of stress
while working in the clinical setting[17] but there is a lack of data
on the stress levels of nursing students. Accurate and compre-
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hensive assessment and analysis of intern nursing students’ stress
levels is important to promote the physical and mental health of
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intern nursing students, improve the quality of their practice, and
enhance clinical teaching. The purpose of this study was to pro-
vide a study to explore the issue of stress among nursing students.
2. Materials and Methods
This work has followed the systematic review, meta-analy-
sis, and meta-regression methods. To identify relevant studies
from literature PubMed, Cochrane, Web of Science, CNKI,
and China Biomedical Literature Service System databases
were searched. The keywords of prevalence, stress, nursing stu-
dents, and all possible combinations of these words were used
in the search strategy and for each of the above-mentioned
databases. No lower time limit was considered in the search
process. Once all related studies were identified, the identifying
information about the selected sources was transferred into the
EndNote bibliography management software. To maximize the
comprehensiveness of the search, the reference lists within all
selected articles were manually reviewed. Taking PubMed as
an example, the specific search strategy is shown in Figure 1.
2.1. Inclusion criteria
Cross-sectional study; the study population was intern nursing
students; the results of the study were expressed as mean±stan-
dard deviation of stress levels.
2.2. Exclusion criteria
Criteria for excluding a study were: research works without
sufficient data, duplicate papers, and studies with unclear meth-
ods (diagnostic methods other than those listed in the inclusion
criteria).
2.3. Study selection
Initially, studies that were repeated in various databases were
removed from the list. Subsequently, a list of the titles of all
#1"Students, Nursing"[Mesh]) OR (((((((Pupil Nurses[Title/Abstract]) OR (Student,
Nursing[Title/Abstract])) OR (Nurses, Pupil[Title/Abstract])) OR
Pupil[Title/Abstract])) OR (Pupil Nurse[Title/Abstract])) OR
Student[Title/Abstract])) OR (Nursing Students[Title/Abstract]))
#2("Stress, Psychological"[Mesh]) OR (((((((((((((Psychological Stresses[Title/Abstract])
OR (Stresses, Psychological[Title/Abstract])) OR (Life Stress[Title/Abstract])) OR (Life
Stresses[Title/Abstract])) OR (Stress, Life[Title/Abstract])) OR (Stresses,
Life[Title/Abstract])) OR (Stress, Psychologic[Title/Abstract])) OR (Psychologic
Stress[Title/Abstract])) OR (Stressor, Psychological[Title/Abstract])) OR (Psychological
Stressor[Title/Abstract])) OR (Psychological Stressors[Title/Abstract])) OR (Stressors,
Psychological[Title/Abstract])) OR (Psychological Stress[Title/Abstract]))
Total retrieval formula˖#1AND#2
Figure 1. Search strategy of PubMed.
the remaining articles was prepared, so that the quality of arti-
cles could be evaluated. For the systematic review, the PRISMA
guidelines were followed; in the first stage, screening, the title,
and abstract of the remaining articles were carefully examined
and several irrelevant articles were excluded, considering the
inclusion and exclusion criteria. In the second stage, that is, eli-
gibility evaluation, the full text of the possible related articles
remaining from the screening stage were examined, and simi-
larly, at this stage, several other irrelevant studies were removed.
To prevent bias, all stages of resource review and data extraction
were performed by 2 reviewers independently. If an article was
not included, the reason for the exclusion was mentioned. In
cases where there was a disagreement between the 2 reviewers,
the third person reviewed the article.
2.4. Quality evaluation of articles
To evaluate the quality of articles (i.e., with respect to the meth-
odological validity and results), a checklist appropriate to the
type of study was used. Descriptive cross-sectional studies are
usually used to describe the prevalence and incidence of dis-
ease. Hence, the Agency for Healthcare Quality and Research
(AHRQ)[18] evaluates cross-sectional studies/prevalence studies.
AHRQ consists of 11 items. If the answer is “no” or “unclear,”
the item score is “0”; If the answer is “yes,” the item score is “1”.
A score of 8–11 is considered high quality, 4–7 moderate qual-
ity, and below 4 poor quality. After the independent evaluation,
2 researchers will discuss and reach a consensus. If there is any
disagreement, the third researcher will arbitrate, or the research
group will discuss and decide.
2.5. Statistical analysis
Endnote X9 was used to summarize the literature. Excel soft-
ware was used for data extraction management, statistics, and
descriptive analysis of outcome indicators. Revman 4.1 software
was used to merge the prevalence of stress levels in each study.
The chi-square test and I2 index were used to determine whether
there was heterogeneity among studies, and the heterogeneity of
effect sizes was analyzed. The fixed-effect model was adopted
if there was no heterogeneity among studies (P > .1, I2 < 50%).
The random-effects model was used to combine effect sizes with
heterogeneity among studies (P < .1, I2 ≥ 50%).
2.6. Ethical consideration
Based on the use of already published secondary data and the
meta-analysis nature, ethical approval was not required.
3. Results
3.1. Literature screening process and results
As mentioned earlier, the Preferred Reporting Items for
(Nurse, Systematic Reviews and Meta-Analysis (PRISMA guidelines)
(Nursing were used to conduct the systematic review, meta-analysis,
and meta-regression. At the identification stage, 1235 possible
related articles were identified and transferred into the EndNote
bibliography management software. Of the total 1235 studies
identified, 265 were duplicates and were therefore excluded. In
the screening stage, of the 970 remaining studies, 745 articles
were omitted by studying their title and abstract and based on
the inclusion and exclusion criteria. In the evaluation eligibility
stage, out of 225 remaining articles, 210 ineligible articles were
removed following the examination of their full text, and sim-
ilarly according to the inclusion and exclusion criteria. In the
quality evaluation stage, by reading the full text of the article
and based on the score obtained from AHRQ checklist, 15[19–33]
articles were entered into the final analysis (Fig. 2).
2
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3.2. Basic characteristics of included studies

Preliminary search of relevant literature at databases (n=1235): PubMed
(n=111); Cochrane (n=42); Web of science (n=220); Embase (n=63);
In total, 15 articles were included in this review. The included
China Knowledge Network (n=485); China Biomedical Literature literature was published from 2011 to 2021. The sample size
Service (SinoMed) (n=314) of the study subjects was 2999 at most and 121 at least, and
the findings of these studies are based on a total of 9202 par-
Endnote software to remove ticipants. The 15 articles all used cross-sectional studies, and
literature (n=265) all quantitative studies used validated scales for data collec-
tion. Among the 15 articles, there are 6 articles in English and
Literature obtained after removing
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Exclusion (n=745) 10 articles in Chinese. The most popular scales for measuring
duplicates (n=970) ①Review or meta-analysis stress levels were the perceived stress scale (PSS), the stress in
(n=38)
nursing students questionnaire (SINS), the student nurse stress
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②Qualitative study (n=50)

③Unrelated to the topic
(n=654)
④Non-English or Chinese
(n=4)
⑤Conference abstracts,
After reading the title and abstract, the
guidelines, index (n=3)
initial screening obtained literature
Exclusion (n=210)
ķ full text not available (n=6)
ĸDuplicate content or
incomplete data (n=29)
Ĺthose with non-conforming
study subjects (n=15)
ĺThe non-cross-sectional
study (n=88)
ĻThe study content does not
match (n=72)
After reading the full text, the literature
was obtained after re-screening (n=15)
After the quality evaluation, there
were 15 articles with intermediate
quality grade of literature
index scale (SNSI-CHI), nursing student stressors scale (Zhang
Guixia), etc. The basic characteristics of the included studies are
shown in Table 1
3.3. Basic risk assessment results of included studies
The bias risk assessment results of the included studies are
shown in Table 2. Among the 15 articles, the quality assessment
grade of 1 literature was high, and 14 kinds of literature were
medium.
3.4. Meta-analysis results
Fifteen studies[19–33]were included, including 9202 patients. The
results of the meta-analysis showed that the average score for
stress among nursing students was 3.70 (95% confidence inter-
val [CI]:[3.33, 4.06]). The results showed great heterogeneity (P
< .00001, I2=71%), so the random effects model was used for
analysis, as shown in Figure 3.

Inclusion of meta-integrated
literature (n=15) 4. Discussion
Figure 2. Literature screening process and result. The purpose of this study was to conduct a systematic review,
and meta-analysis to determine the prevalence of stress among

Table 1
Basic characteristics of included studies.
Reference Study design Date of data collection Country Instruments Sample Score (M±SD)

María Dolore cross-sectional 2017 Spain Perceived Stress Scale (PSS) 190 22.78 ± 8.54
Onieva-Zafra (2020)
Ewa Kupcewicz (2020) cross-sectional May 2018 to April 2019 Poland Perceived Stress Scale (PSS) 1002 18.60 ± 6.95,
18.55 ± 6.07,
18.66 ± 4.70,
Yanyan Zhao (2021) cross-sectional Not reported China Psychological Stress 2999 2.11 ± 0.73
Questionnaire for College Students (PSQCS)
Wafaa Aljohani (2021) cross-sectional April to June 2017 Saudi Arabia Stress in Nursing Students (SINS) 500 118.25 ± 24.29
questionnaire.
Yiru Zhu (2020) cross-sectional August 2017 to January 2018 China The Student Nurse Stress Index Scale 1076 85.37 ± 18.73
(SNSI-CHI)
Perceived Stress Scale (PSS) 25.83 ± 5.95
the Chinese Perceived Stress Scale (CPSS) 58.37 ± 13.66
Zhiqing Zhou (2015) cross-sectional June to September 2019 China Nursing Student Stressors Scale (Zhang Guixia) 590 84.42 ± 21.53
Luping Ding (2016) cross-sectional February to April 2015 China Nursing Student Internship Pressure Scale (Xiao Meilian) 460 1.34 ± 0.36
Lifeng Yang (2020) cross-sectional March to April 2019 China Stress Sources and Stress Level Evaluation 306 78.15 ± 15.93
Scale for Nursing Students in Practice (Chu Yanxiang)
Rujun Hu (2019) cross-sectional Not reported China Nursing student practice Stress scale(Lazarus) 121 1.43 ± 0.43
Yin Lin (2021) cross-sectional Not reported China Nursing Student Stressors Scale (Zhang Guixia) 422 59.41 ± 12.00
Zuqing Zhong (2011) cross-sectional 2009 China Nursing Student Stress Scale (self - made) 235 1.21 ± 0.51
Li Luo (2015) cross-sectional 2013–2014 China Nursing Student Stressors Scale (Zhang Guixia) 145 3.55 ± 0.87
Dengxin He (2021) cross-sectional February to May 2019 China Perceived Stress Scale(PSS) 252 21.6 ± 4.9
Feng Li (2021) cross-sectional December 2018 China College Student Stress Coping Personality Inventory 836 183.1 ± 28.7
Younkyung Lee (2014) cross-sectional 9th to 24th 2013 Korea The Korean version of Perceived 518 15.47 ± 5.49
Stress Scale (PSS)

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Table 2
Bias risk assessment results of included studies.
① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ ⑪ Score grade

María Dolore Y Y Y N N Y Y UN Y Y N 7 Medium

Onieva-Zafra (2020)
Ewa Kupcewicz (2020) Y Y Y Y N N Y Y Y Y UN 8 High
Yanyan Zhao (2021) Y Y Y Y N N Y N Y Y N 7 Medium
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Wafaa Aljohani (2021) Y Y Y Y N Y N UN N Y UN 6 Medium

Yiru Zhu (2020) Y Y Y Y N N Y UN Y Y N 7 Medium
Luping Ding (2016) Y Y Y N N N N Y Y Y UN 6 Medium
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Lifeng Yang (2020) Y Y Y Y N N N N N Y N 5 Medium

Rujun Hu (2019) Y Y Y Y N N N UN UN Y UN 5 Medium
Yin Lin (2021) Y Y Y N N Y Y UN UN Y UN 6 Medium
Zuqing Zhong (2011) Y Y Y Y N N N Y Y N N 6 Medium
Li Luo (2015) Y Y Y Y N N N Y N Y UN 6 Medium
Dengxin He (2021) Y Y Y Y UN N N N N Y N 5 Medium
Feng Li (2021) Y Y Y Y UN UN N N N Y N 5 Medium
Younkyung Lee (2014) Y N Y Y N N N N N Y N 4 Medium
① Whether the source of the data is clear (investigation, literature review); ② Are the inclusion and exclusion criteria for exposure and no exposure groups (cases and controls) listed or referred to previous
publications? ③ Is a time period given for identifying patients? ④ If not from the population, are the subjects continuous? ⑤ Does the subjective factor of the evaluator cover up other aspects of the
research object? ⑥ Describe any assessment for quality assurance (e.g. testing/ retesting of primary outcome indicators); ⑦ The reasons for excluding any patients from the analysis were explained; ⑧
It describes how to evaluate and/ or control the confounding factors⑨ If possible, the explanation is that how to deal with the loss of data; ⑩ The response rate and data collection were summarized the
integrity of the system; ⑪ If there is a follow-up, identify the percentage of expected incomplete data or follow-up results.

Figure 3. Meta-analysis results.

nursing students in their internship. In this meta-analysis, the
prevalence of stress among practicing nursing students was
estimated to be 61.97% (CI 95%: 41.013–80.823) using a ran-
dom effects model. Thus, the results suggest a high prevalence
of psychological stress among practicing nursing students,
which is very concerning. This is similar to the findings of Lin
Bingchun, Cheng Qiuhong et al[34,35]. The reasons for this may
be analyzed as follows: first, nursing students enter an unfa-
miliar clinical environment from the campus, a wide variety of
nursing operations, and the gap between the theoretical knowl-
edge learned in school and clinical practice, which can bring
some psychological stress to the students.[36] Secondly, nursing
students have less social experience and relatively less ability to
communicate with people, and poor communication with their
supervising teachers, patients and families as well as complex
interpersonal relationships can bring corresponding stress.[37]
Mild stress can stimulate the organism to be in a state of ten-
sion and stimulate students to study, while high levels of stress
or stress lasting too long can cause an imbalance in the organism
4
and lead to physical and mental illness,[38] affecting nursing
students’ ability to work in the clinic and even shaking their
determination to pursue nursing. If nursing students lack appro-
priate strategies to cope with stress and the negative effects of
their work life, it will not only affect their personal physical and
psychological health, but also affect their clinical professional
competence, affect the quality of care, and lead to burnout.[39]
Therefore, the results obtained through this study suggest that
attention should be focused on the stress level of intern nursing
students and bring it down to an appropriate level.
Nursing students face multiple psychological stressors during
their internship, and studies by Zhiqing Zhou,[25] Luping
Ding,[26] and Yanyan Zhao[21] have all shown that among the
stressors of internship nursing students, employment stress is
the first stressor of nursing students during their internship. It
is said that this may be related to the fact that the number of
nursing students graduating has been increasing year by year
in recent years, while the number of jobs offered by major hos-
pitals is becoming less and less, the employment situation is
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becoming increasingly severe, and the gap between nursing stu-
dents’ career expectations and employment reality causes them
greater stress.[40,41]
Yin Lin,[29] Zuqing Zhong,[30] and Li Luo et al[31] reported that
internship nursing students’ stressors to their knowledge and
skills are the main stressors of nursing students’ internship. The
reason for this is that nursing students end their familiar campus
life and step into clinical practice, which brings them different
degrees of stress due to the change of identity, learning environ-
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ment, and employment pressure.
Dengxin He’s study[32] showed that intern nursing stu-
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dents’ professional identity and psychological resilience were
influential factors of psychological stress. This is similar to
Yanyan Zhao’s study[21]: stress was negatively correlated with
nursing students’ professional identity, and the higher the
professional identity and the stronger the psychological resil-
ience of intern nursing students, the lower their psychological
stress levels.
5. Limitations of this review
This review has important limitations. The most relevant short-
comings of this paper need to be extensively reported. We
extracted data from cross-sectional studies to summarize asso-
ciated factors; therefore, we must note that this type of study
design is not suitable for making causal infer. Due to the char-
acteristics of single rate meta-analysis, the included studies had
high heterogeneity. Objective factors such as the source of liter-
ature and the amount of information provided have a certain
impact on the research results. Therefore, it is necessary to carry
out higher-quality case-control studies and cohort studies to
provide evidence for clinical practice.
6. Conclusion
This study showed that the stress level of intern nursing students
was mainly moderate, this result shows that the mental health
of nursing students deserves our attention, and the intervention
research of nursing students should be strengthened in future
related research. In addition, in future studies, the stress level
of intern nursing students should be accurately and comprehen-
sively assessed and analyzed, and different specific interventions
should be given for different stressors, which is important to
promote the physical and mental health of intern nursing stu-
dents, improve the quality of internship and improve clinical
teaching.
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