Authors: Esma Ozsaker, Zuleyha Aykut, Nihal Celikturk Doruker, Burcak Sahin Koze, Sinem Gecit
Categories: Research, Nursing education, Nursing student, Self-efficacy, Stress, Clinical, Practice
Source: BMC Nursing
Authors: Esma Ozsaker, Zuleyha Aykut, Nihal Celikturk Doruker, Burcak Sahin Koze, Sinem Gecit
Nursing students often face significant challenges in clinical settings, including high levels of stress and anxiety, which can affect their academic performance and professional development. Academic self-efficacy, defined as a student’s belief in their ability to achieve academic goals, plays an important role in managing these stressors. However, the relationship between academic self-efficacy and perceived stressors in clinical settings remains underexplored. Understanding this relationship is essential for developing strategies to support nursing students and enhance their clinical learning experiences. This study aimed to investigate the relationship between academic self-efficacy and perceived stressors in nursing students in clinical settings.
The study design was descriptive and cross-sectional. A total of 284 undergraduate nursing students practicing in surgical clinics at a university in Izmir province were recruited during the 2022–2023 academic year. A personal information form, the Academic Nurse Self-Efficacy Scale (ANSES), and the Nursing Students’ Perceptions of Clinical Stressors Scale (NSPCSS) were used to collect data. Descriptive statistics, Mann-Whitney U test, Kruskal-Wallis test, and Spearman correlation analysis were used to analyse the data.
The mean age of the students included in the study was 21.02 ± 1.52 years. The mean ANSES total score was 51.50 ± 6.88 out of 14–70 points, and the mean NSPCSS total score was 82.98 ± 15.58 out of 22–110 points. There was no statistically significant relationship between the ANSES and NSPCSS scores (r=-0.02, p = 0.711). It was found that there was a statistically significant positive weak relationship between the ANSES sociability sub-dimension score and the NSPCSS academic performance of the instructor sub-dimension score (r = 0.19, p = 0.001). A significant negative weak relationship (r=-0.16, p = 0.006) was found between the ANSES external emotion management subscale score and the NSPCSS inappropriate situations in the clinical environment subscale score.
This study found that nursing students’ perceptions of academic self-efficacy and clinical stressors were high. It is recommended that clinical practice should be emphasised as an important part of nursing education and that comprehensive studies should be conducted to reduce perceived stress in surgical clinics.
The online version contains supplementary material available at 10.1186/s12912-025-02836-0.
Nursing education is an applied and dynamic process that involves both theoretical and practical teaching methods and requires observation and interpretation [1]. The clinical education and learning environment are an integral part of the educational programme and constitutes almost half of the nursing curriculum [2, 3, 4]. During the clinical education process, students gain clinical competence by having the opportunity to put their theoretical knowledge they have learned into practice [5]. Clinical education provides students with the opportunity to put their knowledge into practice by improving their professional knowledge and skills as a result of facing practical realities that may affect their future professional practice [3, 6, 7]. Undergraduate nursing education in Türkiye is a four-year programme, and clinical practice plays an important role in nursing education. The clinical competence of undergraduate nursing students is necessary to provide quality care and high standard nursing services [8].
The primary objective of nursing education is to provide students with the knowledge and skills necessary for success in their professional lives [9, 10]. In Türkiye, nursing education includes both theoretical and clinical practice [9, 10]. At the undergraduate level, laboratory and skills simulation courses are provided to equip students with the requisite knowledge and skills necessary for clinical practice, following the completion of theoretical studies. Students are first instructed to theoretical concepts and then after which they develop their cognitive, affective, and psychomotor skills by integrating their theoretical understanding and skills related to the specific course with the practical aspects of clinical practice [9, 10]. The aim is to prepare them holistically for the professional process [9, 10]. In order to improve clinical competence, it is important to identify factors that may influence students’ clinical competence. A surgical clinic is a unit that provides perioperative nursing care to patients, including the preoperative and postoperative periods. In this context, nursing students need to develop and implement appropriate nursing care plans for patients, with the aim of ensuring optimal clinical performance [5]. During clinical practice, students may face many difficulties or threats such as how to use high technology medical equipment, how to carry out the application process in specialised units such as operating theatres, how to maintain good relationships with clinical staff and instructors, how to manage and cope with the demands of the patient’s relatives, sudden changes in the patient’s condition. These difficulties in the clinical experience process can cause students to experience stress [11]. Nursing students perceived stress in a clinical setting is defined as the gap between the students’ needs in a particular clinical situation and their resources or abilities to cope with a task or situation [12]. Studies have reported that the self-confidence, academic performance, motivation and interest in the profession of nursing students who have negative clinical experiences and are exposed to clinical stress during the clinical practice process decrease, and their physical and mental health are affected [13, 14, 15, 16, 17]. The negative effects of stress on student nurses can be mitigated by personal and environmental support [18].
The term “self-efficacy,” one of the most important concepts in the social learning theory, was fisrt introduced by Albert Bandura in 1977 [19]. Bandura defines this term as “people’s judgments of their abilities to organise and execute courses of action required to achieve certain types of performance.” [20, 21]. High levels of self-efficacy facilitate students’ ability to manage academic responsibilities effectively, whereas low levels of self-efficacy can lead to additional psychological distress [18, 22]. Self-efficacy is also reported to have a positive and moderating effect on students’ stress and ability to manage tasks and clinical responsibilities related to patient care [18, 23]. High perceived academic self-efficacy (ASE) has been found to increase motivation and the ability to cope with new or challenging tasks. On the other hand, low perceptions of self-efficacy can lead students to leave tasks unfinished and feel helpless [24].
A review of the literature showed that the high levels of stress in surgical clinics [25], and the high levels of stress experienced by nursing students in their first clinical placement [26], indicate that these processes should be carefully managed. In order to support students’ stress management skills and increase their self-efficacy, it is important to identify the stressors they experience in the clinical environment. The literature indicates that there is a significant relationship between nursing students’ the self-efficacy levels and their perceived stress and stress coping methods [27, 28], which shows that identifying perceived stressors is an important step in improving educational processes. In this case, nursing students’ self-efficacy and perceived stressors are crucial for professional development, psychological health and stress coping. Understanding the relationship between these two variables is important for developing effective educational strategies and increasing students’ academic and clinical success. This study aimed to examine the relationship between academic self-efficacy and perceived stress.
Research questions;
What is the level of academic self-efficacy of nursing students?What are the perceived stressors of nursing students in surgical clinics?What is the relationship between perceived stressors and academic self-efficacy in student nurses in surgical clinics?
The aim of this study was to determine the relationship between academic self-efficacy and perceived stressors in student nurses working in surgical clinics.
Data were collected during a specific time period, as the students were practicing surgery during this time. This descriptive and cross-sectional study was conducted at a specific time to determine nursing students’ academic self-efficacy and perceived stressors related to their professional practice in surgical clinics and to examine the relationship between these variables.
The study was conducted in a nursing faculty of a university in the province of Izmir, Western Türkiye. The research was conducted on students who were studying at the nursing faculty and practicing in surgical clinics in the 2022–2023 academic year and spring semester.
The population of the study consisted of 362 students who were studying at the Faculty of Nursing and taking the course Disease and Nursing Care I course in the year and period in which the study was conducted. The sample of the study consisted of 284 students taking this course and working in the clinics of general surgery, urology, neurosurgery, cardiovascular surgery, ophthalmology, orthopaedics and traumatology, organ transplantation, plastic surgery, thoracic surgery, otolaryngology, and emergency department. There was no sampling in the study, the aim was to include the whole population in the study. The sample size of the study was calculated at a 95% confidence level using the known universe sampling method and was found to be sufficient for the study.
Nursing education in Türkiye is devided into undergraduate and postgraduate (master’s and doctoral) levels. An undergraduate degree is the standard entry level for professional nurses. Undergraduate programmes last four years and include theoretical and practical training. Courses related to surgical nursing are usually taught in the 2nd or 3rd year.
The data collection process could not provide results for students who did not participate in the work placement or did not participate in the last day, nor for students who did not volunteer to participate. The overall participation rate is above average at 78%. It is unlikely that students who did not participate in the study would introduce any form of bias.
Inclusion criteria for the
Be a second-year student in the spring semester of the 2022–2023 academic year at the faculty where the study was conducted.Participation in the course Diseases and Nursing Care I.Willingness to participate in the study.
Exclusion
Not having filled in the data collection form.
A Personal Information Form, the Academic Nurse Self-Efficacy Scale (ANSES), and the Nursing Students’ Perceptions of Clinical Stressors Scale (NSPCSS) were used to collect data. The ANSES was chosen because of its specificity to the academic and nursing field, as well as its assessment of self-efficacy. Similarly, the NSPCSS was chosen for its focus on nursing students and its assessment of clinical stressors. These instruments were evaluated and selected by the researchers for their content and suitability for the study. To ensure the accuracy and reliability of the instruments used in the study, the homogeneity of the sample was ensured with the same surgical nursing students and students practicing in the same hospital. In addition, uniformity was ensured in the format of the questionnaires and the procedures used to administer them. A single informed consent document was prepared for all participants, and relevant information was provided verbally and in writing. The Cronbach alpha values of the scales used in the analysis of the study were also examined.
This form was developed by reviewing the literature [29, 30, 31, 32] to determine the socio-demographic and diagnostic characteristics of the students. There are a total of 13 questions, nine multiple-choice questions, and four open-ended questions, including age, gender, marital status, academic achievement grade point average, perceived academic success, the surgical clinic where practice takes place, emotions felt when going to practice, etc.
Academic Nurse Self-Efficacy Scale (ANSES): This scale was developed by Bulfone et al. [33]. The Turkish validity and reliability study was conducted by Aktay and Korkmaz, and it was suggested that it can be used validly and reliably [34]. The scale has four sub-dimensions, namely internal emotion management (items 1–3), self-control/automatically controlled behaviour (items 4–7), external emotion management (items 8–11), and sociability (items 12–14), and a total of 14 items. The scale is a 5-point Likert scale. The items in the scale are scored as ‘I do not trust myself at all’ 1 point, ‘I do not trust myself’ 2 points, ‘I neither trust myself nor resent myself’ 3 points, ‘I trust myself’ 4 points, ‘I trust myself a lot’ 5 points. The maximum score that can be obtained from the scale is 70 and the minimum score is 14. As the scores obtained from the scale increase, the students’ academic self-efficacy increases. The total Cronbach alpha value of the scale was 0.83 [34]. In this study, the Cronbach alpha value of the scale was found to be 0.81.
This scale was developed by Rafati et al. in 2021 [3]. The Turkish validity and reliability study was conducted by Aydin et al., and it was suggested that it can be used validly and reliably [13]. The scale consists of the following six sub-dimensions and a total of 22 items. The scale has six sub-dimensions and 22 items, including inappropriate situations in the clinical environment (items 7–12), inappropriate behaviour of the lecturer (items 16–19), academic performance of the lecturer (items 1–3), attitude of the lecturer towards education (items 4–6), inadequate knowledge and skills of the student (items 13–15) and concerns about nursing care (items 20–22). The scale is a 5 point Likert type and the items in the scale are ‘Never causes stress’ 1 point, ‘Rarely causes stress’ 2 points, ‘Sometimes causes stress’ 3 points, ‘Too often causes stress’ 4 points, ‘Always causes stress’ are scored as 5 points. The highest score that can be obtained from the scale is 110 and the lowest score is 22. High scores indicate that students have a high perception of clinical stressors. The total Cronbach alpha value of the scale was 0.91 [13]. In this study, the Cronbach alpha value of the scale was 0.94.
The study data were collected face-to-face from students practicing in surgical clinics as part of the Diseases and Nursing Care I course between April and June 2023. Students practice in surgical clinics three days a week on Tuesdays, Wednesdays, and Thursdays for three weeks. Data were collected on the last day of practice. Nursing students were expected to complete their surgical clinical practice in order to gain a full understanding of the relevant processes. In addition, data were collected from all students on the last day of their surgical clinical placement to ensure consistency throughout the data collection period. The study was conducted with the participation of students who volunteered to participate in the research project. There were no missing or incomplete data. It took the students approximately 10 min to complete the data collection form.
Statistical analyses were performed using IBM SPSS Statistics 25.0 (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Sociodemographic characteristics were analyzed using descriptive statistics (number, percentage, mean, standard deviation). The normality of the distribution of quantitative data was tested using the Kolmogorov-Smirnov test. (The values obtained by dividing the skewness value by its standard deviation value were found to be outside the values of -1.96 + 1.96). As the data did not show a normal distribution, continuous measurements were evaluated using nonparametric tests; the Mann-Whitney test and the Kruskal-Wallis test were used. Correlations between quantitative data were assessed using Spearman’s Rho correlation coefficient. A value of P < 0.05 was considered as the limit of statistical significance.
was obtained from the Ethics Committee for Scientific Research and Publication at Ege University (approval 23-1.1T/20, 26.01.2023). Written approval was obtained from the institution where the research was conducted. Informed written consent to participate; all of the students were informed about the aim and procedure of the research, and written approval was obtained from those who agreed to participate. All participants were informed that data would be kept confidential and that their performance would in no way affect their class grades. Before the study began, permission was obtained by e-mail from Aydin and Aktay who conducted the Turkish validity and reliability study of the scale. The forms used for data collection did not contain any identifying information about the participants. In order to ensure the confidentiality of the participants, a numbering system was used when the coding of the data.
The mean age of the nursing students participating in the study was 21.02 ± 1.52 (min: 19, 36) years and the mean academic performance score was 2.95 (out of 4.00 points). 85.6% (n: 243) of the students were female, 58.1% (n: 165) lived in a hall of residence, 82% (n: 233) of the reason for choosing nursing were the ease of the finding a job, 47.2% (n: 134) were satisfied with being a student nurse, 78.2% (n: 222) reported that they were curious, 78.5% (n: 223) reported their academic success as moderate (Table 1).
Table 1Socio-demographic and characteristic features of studentsThe mean age is 21.02 ± 1.52 (Min: 19, Max: 36)The mean academic achievement grade 2.95 (out of 4.00 points) Socio-demographic and characteristic features
n
%
Gender FemaleMale2434185.614.4 Place of residence Home (alone)Home (with friend)Home (with family)Dormitory1844571656.315.520.158.1 Reason for choosing nursing* Easy to find a jobIt is the profession of the futureI like the nursing professionMy family’s wishes and insistenceNot having enough points for another departmentGood salariesOther reasons23311585726746882.040.529.925.423.616.22.8 Satisfaction with being a student nurse SatisfiedUndecidedNot satisfied1341222847.243.09.9 Practice clinic General SurgeryNeurosurgery ClinicOrthopedics ClinicEmergencyUrology ClinicCardiovascular Surgery ClinicPlastic Surgery ClinicOtolaryngology ClinicEye Surgery ClinicThoracic Surgery ClinicOrgan Transplantation Clinic4941393227252518159417.314.413.711.39.58.88.86.35.33.21.4 Emotions experienced in clinical practice CuriosityExcitementStressAnxietyother22218312258778.264.443.020.42.5 Perceived academic success LowModerateHigh26223359.278.512.3* There was more than one answer to this question
The mean total ANSES and NSPCSS scores of the nursing students were found as 51.50 ± 6.88 (min: 17, 70) and 82.98 ± 15.58 (min: 22, 110), respectively (Table 2). When the relationship between the scores of the nursing students’ ANSES scores and the scores of the NSPCSS scores was analyzed, the results showed that there was no significant relationship between the two scales (r= -0.02, p = 0.711). It was found that there was a significant positive correlation between the sociability sub-dimension of the ANSES and the academic performance of the instructor sub-dimension of the NSPCSS (r = 0.19, p = 0.001). The findings indicated that there was a significant negative correlation between the external emotion management sub-dimension of the ANSES and the inappropriate situations in the clinical environment sub-dimension of the NSPCSS (r= -0.16, p = 0.006) (Table 3).
Table 2Total mean scores of ANSES, NSPCSS and its sub-dimensionsScalesX ± SDMedianMin-Max ANSES Internal emotion management10.63 ± 21311.003.00–15.00Self-control/automatically controlled behavior15.17 ± 2.5216.004.00–20.00External emotion management12.85 ± 3.3213.004.00–20.00Sociability12.86 ± 1.9513.003.00–15.00Total Score51.50 ± 6.8852.0017.00–70.00 NSPCSS Academic performance of the lecturer10.91 ± 2.5211.003.00–15.00Attitude of the lecturer towards education10.29 ± 2.3510.003.00–15.00Inappropriate situations in the clinical environment22.90 ± 4.8024.006.00–30.00Inadequate knowledge and skills of the student11.67 ± 2.8412.003.00–15.00Inappropriate behavior of the lecturer15.96 ± 3.4616.004.00–20.00Concerns about nursing care11.26 ± 2.7912.003.00–15.00Total Score82.98 ± 15.5885.0022.00-110.00x: Mean, SD: Standard deviation, ANSES: Academic Nurse Self-Efficacy Scale, NSPCSS: Nursing Students’ Perceptions of Clinical Stressors Scale
Table 3Relationship between ANSES and NSPCSS total score averagesANSESNSPCSSAcademic performance of the lecturerAttitude of the lecturer towards educationInappropriate situations in the clinical environmentInadequate knowledge and skills of the studentInappropriate behavior of the lecturerConcerns about nursing careTotal Score İnternal emotion management r: -0.032p: 0.589r: -0.075p: 0.208r: -0.106p: 0.074r: -0.092p: 0.123r: -0.089p: 0.132r: -0.083p: 0.162r: -0.086p: 0.148 Self-control/ automatically controlled behavior r: 0.114p: 0.055r: -0.021p: 0.727r: 0.054p: 0.360r: 0.108p: 0.069r: 0.110p: 0.065r: 0.034p: 0.572r: 0.091p: 0.128 External emotion management r: -0.040p: 0.505r: -0.002p: 0.970r: -0.163p: 0.006r: -0.128p: 0.032r: -0.113p: 0.058r: -0.126p: 0.034r: -0.123*p: 0.039 Sociability r: 0.190p: 0.001r: 0.065p: 0.278r: 0.130p: 0.028r: 0.073p: 0.220r: 0.135p: 0.023r: 0.120p: 0.044r: 0.141p: 0.017 Total Score r: 0.073p: 0.222r: -0.027p: 0.656r: -0.067p: 0.262r: -0.036p: 0.546r: -0.009p: 0.877r: -0.049p: 0.410r: -0.022p: 0.711r: Spearman Korelasyon Katsayısı, ANSES: Academic Nurse Self-Efficacy Scale, NSPCSS: Nursing Students’ Perceptions of Clinical Stressors Scale**Correlation is significant at the 0.01 level (2-tailed)*Correlation is significant at the 0.05 level (2-tailed)
The study found that the mean total score of the ANSES of male student nurses was significantly higher than that of female student nurses (p = 0,001). The results showed that the mean total scores of the ANSES of the students who were satisfied with their studies at the Faculty of Nursing were significantly higher than those of the students who were dissatisfied and undecided (p = 0,004). The research revealed that the mean total scores of the ANSES scores of students with high perceived academic success were significantly higher than those of students with low and medium academic success (p = 0,001) (Table 4). The results of the study showed that the mean total scores of female nursing students on the NSPCSS were significantly higher than those of males (p = 0,001) (Table 5).
Table 4Distribution of ANSES total score average according to independent variablesSocio-demographic and characteristic featuresANSESTotalScoreX ± SDInternal emotion management X ± SDSelf-control/ automatically controlled behavior X ± SDExternal emotion management X ± SDSociability X ± SD Gender FemaleMale50.91 ± 6.8054.98 ± 6.38U: 3262.00p:0.00110.45 ± 2.0611.68 ± 2.25U: 3128.50p:0.00115.18 ± 2.5815.07 ± 2.17U: 4632.00p:0.46612.42 ± 3.2115.32 ± 2.88U: 2307.00p:0.00112.85 ± 1.9312.90 ± 2.07U: 4837.50p:0.760 Satisfaction with being a student nurse SatisfiedNot satisfiedUndecided52.72 ± 6.5348.57 ± 8.9050.83 ± 6.48X^2^: 10.91p: 0.00410.87 ± 2.179.96 ± 2.5510.52 ± 1.94X^2^: 6.36p: 0.04215.71 ± 2.2214.04 ± 3.1014.83 ± 2.56X^2^: 14.40p: 0.00112.78 ± 3.3913.21 ± 2.9412.83 ± 3.33X^2^: 0.20p: 0.90313.35 ± 1.6311.36 ± 2.7812.66 ± 1.85X^2^: 20.44p: 0.001 Perceived academic success LowModerateHigh47.62 ± 8.7351.39 ± 6.4855.09 ± 6.26X^2^: 17.76p: 0.0019.50 ± 2.6610.61 ± 2.0611.60 ± 1.69X^2^: 13.08p: 0.00114.08 ± 3.1615.10 ± 2.4016.40 ± 2.35X^2^: 10.32p: 0.006**12.00 ± 3.8212.80 ± 3.2813.80 ± 3.03X^2^: 4.42p: 0.11012.04 ± 2.6312.89 ± 1.8713.29 ± 1.76X^2^: 4.28p: 0.118x: Mean, SD: Standard deviation, U: Mann-Whitney U test, X2: Kruskal-Wallis test, ANSES: Academic Nurse Self-Efficacy Scale, *p < 0.05, ** p < 0.01
Table 5Distribution of NSPCSS total score average according to independent variablesNSPCSSSocio-demographic and characteristic featuresTotal ScoreX ± SDAcademic performance of the lecturer X ± SDAttitude of the lecturer towards education X ± SDInappropriate situations in the clinical environment X ± SDInadequate knowledge and skills of the studentX ± SDInappropriate behavior of the lecturerX ± SDConcerns about nursing care X ± SD Gender FemaleMale84.83 ± 14.0771.98 ± 19.39U: 3043.50p: 0.00111.10 ± 2.389.83 ± 3.06U: 3863.50p: 0.020*10.48 ± 2.229.10 ± 2.75U: 3545.00p: 0.00323.37 ± 4.4620.12 ± 5.78U: 3314.50p: 0.00111.98 ± 2.609.78 ± 3.47U: 3087.00p: 0.00116.37 ± 3.1813.54 ± 4.07U: 2863.50p: 0.00111.54 ± 2.649.61 ± 3.15U: 3225.00p: 0.001 Practice clinic EmergencyGeneral SurgeryUrologyNeurosurgery Cardiovascular SurgeryEye SurgeryOrthopedicsTransplantationPlastic SurgeryThoracic SurgeryOtolaryngology80.41 ± 15.5786.35 ± 13.0685.48 ± 18.7880.44 ± 17.0784.52 ± 12.6081.80 ± 17.9983.28 ± 15.1282.25 ± 5.0684.80 ± 12.2579.67 ± 17.3277.83 ± 20.47X^2^: 6.461p: 0.77510.34 ± 2.4411.20 ± 2.05111.96 ± 2.9510.51 ± 2.7610.76 ± 1.8310.73 ± 2.8110.92 ± 2.7611.75 ± 0.5011.12 ± 2.5410.44 ± 2.0710.50 ± 296X^2^: 12.946p:0.022710.25 ± 22611.02 ± 1.8910.15 ± 3.089.71 ± 2.329.88 ± 2.339.93 ± 2.6610.33 ± 2.2410.00 ± 1.4111.12 ± 1.549.56 ± 3.549.83 ± 2.62X^2^: 14.780p:0.14022.31 ± 4.9323.78 ± 4.6623.52 ± 5.2222.24 ± 4.8323.56 ± 3.9822.13 ± 5.8923.44 ± 4.6322.75 ± 1.7122.84 ± 3.4521.89 ± 6.0721.28 ± 6.14X^2^: 5.791p:0.83211.56 ± 3.1012.24 ± 2.3711.89 ± 2.8711.44 ± 3.0312.24 ± 2.5512.13 ± 2.9011.36 ± 2.8611.50 ± 1.2911.56 ± 2.5011.33 ± 3.0810.28 ± 3.75X^2^: 6.264p:0.79315.31 ± 3.5016.59 ± 3.1716.11 ± 4.1515.49 ± 3.8816.32 ± 2.9715.20 ± 4.0416.31 ± 3.3016.25 ± 1.7116.32 ± 3.3615.89 ± 3.0215.06 ± 3.35X^2^: 6.704p:0.75310.63 ± 2.8511.51 ± 2.7211.85 ± 2.8811.05 ± 3.0011.76 ± 1.8511.67 ± 2.5310.92 ± 2.5110.00 ± 1.8311.84 ± 2.9810.56 ± 4.3310.89 ± 3.25X^2^: 9.034p:0.529 Satisfaction with being a student Nurse SatisfiedNot satisfiedUndecided82.61 ± 14.7680.32 ± 20.7083.98 ± 15.16X^2^: 0.971p: 0.61511.05 ± 2.4210.39 ± 3.1010.87 ± 2.49X^2^: 1.283p: 0.52710.26 ± 2.1110.32 ± 3.2110.30 ± 2.39X^2^: 0.439p: 0.80322.50 ± 4.7522.29 ± 6.3223.48 ± 4.42X^2^: 3.588p: 0.16611.53 ± 2.7011.21 ± 3.7211.92 ± 2.76X^2^: 1.740p: 0.41916.10 ± 3.4215.29 ± 4.0515.96 ± 3.37X^2^: 0.818p: 0.66411.17 ± 2.7410.82 ± 3.3311.47 ± 2.72X^2^: 1.145p: 0.564 Perceived academic success LowModerateHigh85.77 ± 17.9282.69 ± 15.4982.74 ± 14.56X^2^: 2.038p: 0.36111.08 ± 2.7010.81 ± 2.5311.40 ± 2.30X^2^: 1.378p: 0.50210.54 ± 2.6010.24 ± 2.3510.34 ± 2.20X^2^: 0.834p: 0.65924.19 ± 5.3122.73 ± 4.7923.03 ± 4.42X^2^: 3.034p: 0.21912.15 ± 3.5911.60 ± 2.7411.77 ± 2.90X^2^: 3.231p: 0.19916.31 ± 4.3115.96 ± 3.4315.65 ± 3.00X^2^: 2.313p: 0.31511.50 ± 3.4111.35 ± 2.6910.54 ± 2.93X^2^: 2.936p: 0.230x: Mean, SD: Standard deviation, U: Mann-Whitney U test, X2: Kruskal-Wallis test, NSPCSS: Nursing Students’ Perceptions of Clinical Stressors Scale, *p < 0.05, ** p < 0.01
The regression model predicts NSPCSS scores based on gender, stress, and emotional factors. The model fit is as R = 0.33, R²=0.11. The model is statistically significant, R²=0.11, F (6,277) = 5.65, p < 0.001, explaining 10.9% of the variance in perceived clinical stressors. Detailed results for each predictor are given. (Table 6). This regression model predicts ANSES total score averages based on gender, stress, and contextual factors. The model fit was as R = 0.33, R²=0.11. The model was statistically significant, R²=0.08, F (8,275) = 4.12, p < 0.001, explaining 8.38% of the variance in total academic self-efficacy. Detailed results for each predictor are given. (Table 6).
Table 6Regression coefficients for model 1PredictorbSEt-valuep-valueGender3.521.192.950.003Stress2.370.812.920.004Attitude of the Lecturer Towards Education0.300.221.370.173Inappropriate Situations in Clinical Environment-0.070.15-0.450.651Inadequate Knowledge and Skills of the Student-0.020.22-0.070.941Inappropriate Behavior of the Lecturer0.110.200.580.561Concerns About Nursing Care-0.260.23-1.130.258Coefficient: b, SE: Standard Error, p < 0.05
The study was conducted with second year students at a university in Türkiye. The undergraduate nursing curriculum at Turkish universities, including the basic practice courses and their content, as well as the implementation periods, are similar. In this respect, the results of the study were discussed in the context of previous studies conducted in Türkiye and other countries.
Academic self-efficacy is defined as students’ assessment of their abilities to achieve educational goals [35] and their confidence in themselves to complete academic tasks [36]. It is emphasized that special attention should be paid to the monitoring and development of the ASE in the nursing education process [24]. In this study, when the total mean scores and sub-dimension scores of ASE of nursing students were examined, it was found to be above average. Similar to the findings of this study, it was found that self-efficacy scores were above average in studies that examined self-efficacy levels in nursing students [37, 38, 39, 40]. Self-efficacy levels can increase the independence of nursing students, allowing them to exert more effort to overcome difficulties and achieve goals [8] and increase professional job satisfaction [41]. Interventions to promote self-efficacy should be structured together with the mentor and the clinical nurse during lectures and clinical practice [35].
When the total and sub-dimensional mean scores of the nursing students’ ANSES were analyzed according to the gender variable, it was found that the total and sub-dimensional mean scores of the male students’ ANSES were higher than those of the female students. The high scores of male nursing students on the ASE suggest that this group of students has a high level of confidence in their academic abilities, performance, and learning process. The high ASE scores among male nursing students indicate that they possess strong self-confidence regarding their academic skills, performance, and learning capabilities. This could be influenced by factors such as personal motivation, prior educational experiences, or a supportive learning environment. Additionally, it may reflect their ability to effectively manage academic challenges and adapt to the demands of nursing education.
In the study, it was found that the self-efficacy perceptions of the students who were satisfied with studying in the nursing department were significantly higher than those who were dissatisfied and undecided. Similarly, as a result of some studies [39, 40, 41, 42], it is highlighted that the ASE of the students who willingly chose the nursing department was higher and significantly affected their academic success. The high ASE scores of students with high satisfaction suggest that this group of students has high confidence in their abilities and belief in their success and that students with high self-efficacy also can manage their academic responsibilities positively and regularly [18, 23]. The results of the study found that students with high academic achievement perceptions had significantly higher total scores on the ANSES than students with low and medium achievement perceptions. Bulfone et al. (2022) found that high levels of self-efficacy significantly increased the likelihood of academic success [35]. This relationship is consistent with the literature, as many studies have shown that students with high levels of self-efficacy are more likely to achieve academic success [43, 44]. It can be assumed that high academic achievement perceptions may influence students’ intrinsic motivation and self-efficacy perceptions, and these students may be more likely to achieve higher levels of success by feeling confident in their abilities. In addition, it is thought that these students with high academic achievement perceptions may be more motivated because they have a positive perception of success, and with this motivation, they may put in more work and effort. This finding overlaps with the definition of ASE in the literature. It also supports the findings that students’ self-efficacy perceptions positively affect their learning speed and increase their academic success [5, 24, 35]. One of the current strategies to counteract the academic failure of nursing students is the development of students’ ASE [35].
Nurse educators need to identify areas for improvement to help students achieve high levels of clinical competence and to ensure the quality of the educational process [45]. To this end, it is important to assess students’ perceptions of the clinical learning environment [46]. In this study, nursing students’ perceptions of clinical stressors were found to be high. Karaca et al. (2017) also showed that the stress levels of Turkish nursing students in clinical practice were higher than the stress levels reached in studies conducted in other countries using the same scales [47]. The clinical learning environment can be an important source of stress for nursing students [48]. It has been stated that the most stressful factors for students in clinical practice are clinical stressors (e.g. lack of professional knowledge and skills, communication with patients and clinical staff, difficulties in hospital adaptation) and academic stressors (e.g. clinical examinations, communication with lecturers) [38]. In addition, problems may be caused by the high number of students in clinical practice, the presence of students from other faculties in the same clinical practice environment, the lack of appropriate practice areas, and the neglect of students by the existing healthcare team [49]. Students’ inadequate knowledge and skills for practice, mistakes, unclear expectations from the instructor, thoughts such as encountering negative reactions, and low self-confidence may be the cause of clinical stress [38]. Negative clinical education experiences may lead to a decrease in students’ self-confidence, academic performance, motivation, and interest in the profession, which may affect their physical and mental health [13]. The stress experienced by students in clinical education is an important factor that reduces the effectiveness of education [38]. Nursing students with high-stress levels have been found to have low academic performance and clinical competence [18, 50]. Therefore, clinical stressors should be effectively managed, and the clinical practice environment should be considered as the best learning environment opportunity [3, 51]. Identifying students’ sources of clinical stress and providing them with adequate support to cope with it can reduce students’ exposure to the negative effects of stress and improve the quality of professional care.
The study found that the mean total score of the NSPCSS was significantly higher in female nursing students than in male nursing students. Gender may affect an individual’s perception of stress. This may suggest that female students experience more stress during the nursing education process. It is thought that the higher perceptions of clinical stress in female nursing students compared to male nursing students may be due to occupational stressors, for example, gender role expectations or gender-related difficulties within the profession may influence these differences. In the literature, no relationship was found between gender and perceived stress [52, 53, 54]. It is postulated that the discrepancy in the findings of this study may be attributable to the fact that the pertinent research was conducted with patients or nurses. Although this study result does not support the literature in this regard, in another study that investigated the relationship between educational stress and professional self-esteem among nursing students, the mean scores of female students were higher than male students, which is similar to our study result [55]. Therefore, it can be interpreted that being a nursing student in hospitals may cause stress in female individuals to a greater extent than in male individuals, compared to being a nurse, a patient, or a patient’s relative.
Evaluating students’ views and self-efficacy perceptions about clinical practice will contribute to the development of effective clinical teaching strategies by assessing the effectiveness of strategies adopted in nursing education for clinical teaching [56]. In this study, which aimed to examine the relationship between ASE and perceptions of clinical stressors among nursing students who were practicing in surgical clinics for the first time, no significant relationship was found between nursing students’ ASE and perceptions of clinical stressors (p > 0.05). In accordance with Bandura’s self-efficacy theory, it was assumed that stress levels could affect self-efficacy. There was no relationship between clinical stress levels and academic self-efficacy among second year students undertaking their first surgical clinical placement. This may be due to the students’ different previous clinical experiences, the support provided by mentors at all stages of the placement, and the students’ individual and life differences. In the study conducted by Aciksoz et al. (2016) on nursing students, in which they investigated the relationship between self-efficacy perception and anxiety and stress toward clinical practice, it was found that the level of anxiety toward clinical skills decreased with the increase in students’ self-efficacy perception; however, no significant relationship was found between self-efficacy perception and perceived stress toward clinical skills [38]. Ozvurmaz and Mandıracıoglu (2018) found a moderately significant relationship between ASE perception and clinical teaching perception in nursing students [57]. Goger and Cevirme (2018) found that the level of self-efficacy of nursing students was affected by educational stress [39]. Yu et al. (2021) found that self-efficacy mediated the relationship between clinical learning environment and clinical competence [8]. The lack of a significant relationship between academic self-efficacy and clinical stress factors in nursing students suggests that these two concepts may have independent effects on students’ experiences. While academic self-efficacy refers to students’ success in the courses and their self-confidence in achieving academic goals, clinical stress factors are thought to arise more from real patient care, the dynamics of the hospital environment and applied education processes. This may suggest that students’ perceptions of academic competence do not directly affect clinical stress or that they use different mechanisms to cope with stress. This finding suggests that strategies for coping with clinical stress should be further investigated and indirect links between self-efficacy and stress management in nursing education should be examined.
In another study, it was reported that students who came to the nursing department willingly were more determined to cope with the problems they encountered and that individuals with high levels of self-efficacy were more determined to succeed [58]. Understanding students’ perceptions of self-efficacy and the factors that may affect their learning, such as stress in the clinical environment, has been reported to enable the planning of activities to improve the effectiveness of nursing education and have important implications for the future of education [38]. It was found that there was a significant positive correlation between the ANSES sociability sub-dimension of nursing students and the NSPCSS academic performance of the instructor sub-dimension. This indicates that as nursing students’ social skills (sociability sub-dimension) increase, so do their perceptions of the academic performance of the instructor. It is thought that students with high social skills will be able to communicate more effectively with instructors in the field and this may contribute to their academic self-efficacy by improving their clinical skills in the field. It can be interpreted that increased interaction with instructors may positively affect students’ success in practice and their perceptions of academic performance. It is assumed that educational programs and social support services that focus on improving nursing students’ social skills may have a positive effect on students’ perceptions of academic performance.
The significant negative correlation between nursing students’ ANSES external emotion management sub-dimension and the NSPCSS inappropriate situations in the clinical environment sub-dimension suggests that as nursing students’ external emotion management skills increase (i.e. how they respond to stress and emotional reactions), their perception of inappropriate situations in the clinical environment decreases. Increased external emotion management skills may help student nurses cope more effectively with clinical stressors and reduce the tendency to perceive these stressors negatively. Contrary to the findings of this study, the literature indicates that nursing students who are exposed to clinical stressors or who have negative clinical experiences are less interested in the profession, their self-confidence, motivation, and academic performance decrease, and their physical and mental health is negatively affected [13, 14, 15, 16, 17], and students with high-stress levels have lower academic and clinical competencies [18,50]. As more effective management of clinical stressors by student nurses can have a positive impact on both their emotional well-being and academic performance, there is a need to increase the number of training and activities that can help student nurses cope with stress and improve their emotional management skills [3, 47, 59].
It is recommended that the specific stressors identified (e.g., inappropriate clinical situations) be translated into strategies for educators and health institutions. It is recommended that situations that may be inappropriate for students to encounter during the clinical practice process be evaluated in advance. Furthermore, it is advised that the clinical area be created with simulation before the practices commence. A realistic clinical setting should be constructed and students’ responses, behaviors, and stress levels should be assessed in potential scenarios. It is recommended that students be provided with the opportunity to develop effective coping mechanisms through simulation practices prior to engaging in clinical practice. It is also advised that students be observed in situations that may elicit stress responses in clinical settings and that they be encouraged to maintain open communication with instructors and health institution staff. In instances where students require additional support, referrals to psychological services, individual counseling, and the evaluation and improvement of clinical practice conditions may be recommended.
The study was conducted with second-year students from a single university in a specific province during a limited time frame and employed a cross-sectional design. The data collection process yielded incomplete results due to the non-participation of certain students, namely those who did not complete the internship or did not participate on the last day. Additionally, the data were based on self-reported data from the students, which introduces a potential limitation to the study.
In addition to these limitations, the study also has strengths. Having a sufficient sample size in the study increases the reliability of statistical analyses. The findings may provide concrete suggestions for improving nursing education and clinical practices. The study may also be instructive for other health professionals interested in academic self-efficacy and stress outside of nursing. Consequently, the results of the study can be generalized to nursing students at other Turkish universities. Furthermore, the findings can be extended to nursing students in other countries with comparable educational systems.
The study found that nursing students’ ASE and perceptions of clinical stress were high, and there was no significant relationship between nursing students’ ASE and perceptions of clinical stress. It is recommended that future studies examine this relationship.
In order to improve the ASE of nursing students, it is recommended to integrate theoretical education with practical education, to prioritize clinical experience as an important aspect of nursing education, and to conduct comprehensive research to assess the stress levels of students in surgical settings by instructors. In addition, comprehensive studies should be conducted to reduce the perceived stress in surgical clinics. Simultaneously, pre and post-clinical ASE and stress levels of nursing students can be evaluated and their fluctuations over time can be examined. It may be advisable to conduct qualitative studies through student interviews to gain insight into ASE and stress levels. This study underscores the significance of addressing academic self-efficacy and stressors among nursing students, particularly those preparing for surgical practice. As nurses play crucial roles in surgical teams, their self-efficacy and stress management directly impact patient care outcomes. Therefore, nursing education should include interventions to boost students’ self-efficacy and equip them with stress coping strategies for surgical settings. Prior to engaging in surgical clinic training, students may benefit from structured guidance on how to respond to potential scenarios they may encounter. This could be achieved through the creation of a simulated surgical environment, incorporating laboratory and simulation applications. Such a training approach could be integrated into the curriculum before students are expected to apply these skills in actual clinical settings. In the event of a challenging situation, related to their self-efficacy and stress management, students should be closely monitored by their mentors and provided with the necessary support to navigate these challenges effectively. By investing in students’ self-efficacy and stress management, healthcare systems can improve surgical care quality and patient safety.
Table 7Regression coefficients for model 2PredictorbSEt-valuep-valueGender-11.172.67-4.18< 0.001Stress-1.911.84-1.040.298Internal Emotion Management-0.450.49-0.910.364Self-Control-0.060.39-0.160.876External Emotion Management-0.310.32-0.970.335Sociability0.990.492.020.045Coefficient: b, SE: Standard Error, p < 0.05
Below is the link to the electronic supplementary material.
Supplementary Material 1