Background
Stress is a natural physical, emotional, and mental reaction to a stimulus that disturbs the normal functioning of the body [
1]. It is experienced when people recognize that the demands are greater than their individual and social resources [
2]. Human beings respond to stress differently depending on their social, economic, environmental, and genetic backgrounds [
3].
Nursing is considered a demanding and stressful profession due to the excessive workloads, complexity of patient care activities, unorganized work environments, and lack of leader support [
4]. Similarly, healthcare education, including nursing education, is stressful for students, mainly due to the vast amounts and rates of knowledge and the frequent changes in needs and services [
5]. Further, healthcare education does not focus only on teaching knowledge but also on teaching skills such as problem solving, research, interpersonal interaction, psychomotor, and lifelong learning skills [
5,
6]. This requires long hours of practical and theoretical study, which increases the pressure on students [
5,
6]. Previous studies have indicated that nursing students have higher stress levels compared to students of other healthcare-related fields [
7,
8], with education-related stress levels among nursing students ranging from medium to high [
9‐
12]. While some stressors are considered motivational and may encourage achievement [
13], experiencing prolonged stress threatens the physical, mental, and psychological health of students [
6]. Furthermore, experiencing unresolved chronic stress may have adverse effects on students’ academic performance [
10,
14,
15]. Eventually, high levels of unresolved stress may discourage students from pursuing nursing education, therefore impacting the nursing workforce [
10].
Studies in the literature have highlighted several education-related stressors among nursing students, including academic, clinical, and personal/social stressors [
9,
15,
16]. Examples of academic stressors include heavy workloads, exams and assignments, the fear of failing and achieving low grades, and the lack of sufficient guidance from tutors [
11,
17‐
19]. Clinical stressors include students’ heavy responsibilities in clinical settings, students’ uncertainty regarding what is expected from them, the pressure of meeting the expectations of staff, the fear of making mistakes and harming patients, and criticism from peers, senior staff, and physicians [
11,
17,
19]. Personal and/or social stressors entail students’ health issues, family events, lack of recreation time, high parental expectations, and financial issues [
11,
17‐
19].
Previous studies have indicated a link between certain sociodemographic characteristics and increased stress levels among nursing students. For example, students from low-income families have been found to experience higher levels of stress in comparison to other students, as they may worry about not being able to meet their scholastic requirements, tuition fees, basic needs (i.e., food, accommodation, and transportation), or personal needs [
12,
18,
20]. Further, with many universities now using blended learning and/or e-learning as a result of the COVID-19 pandemic, students from low-income families may worry about the costs of purchasing appropriate electronic devices, good internet services, and information applications [
21]. Gender has also been found to impact students’ stress levels, with female nursing students frequently reporting higher levels of stress compared to male students [
12,
15,
20,
22]. Previous studies have attributed this to the fact that in comparison to female students, male students are more reluctant to talk about their stress experiences, are less aware of their stress, and have less knowledge about disease detection and health promotion behaviors [
23,
24]. Male students may be less able to express their feelings due to cultural norms which associate masculinity with indomitability and power [
15,
24]. As for the impact of academic year on students’ stress levels, studies in the literature have reported conflicting findings. For example, Aslan and Akturk [
22] and Ribeiro et al. [
12] found stress levels to be higher among senior students than students in other years, mainly due to the nature of the advanced theoretical and clinical courses that senior students must take. Meanwhile, Admi and colleagues [
14] found that junior nursing students experience the highest levels of stress, attributing this to their lack of knowledge and training experience required for future courses.
In Jordan, the wide spread of COVID-19, the strict national lockdown that was imposed by the government, and the transition to distance learning may have constituted new sources of stress for nursing students. In comparison to traditional education, distance learning is associated with higher stress levels among university students. The huge academic workload, the high frequency of examinations, and financial problems were sources of distance learning-related stress among university students in the study of Kwaah & Essilfie [
25]. Meanwhile, Moawad [
26] concluded that the main stressors affecting university students as a result of the transition to distance learning during the pandemic were uncertainty regarding exams, the semester end date, and the evaluation methods used. Further, in the study of Cao et al. [
27], financial difficulties, the changes caused to daily life, and the delays in academic activities were found to increase feelings of isolation and consequently anxiety levels among university students in China [
27].
Identifying stress levels, sources of stress, and the impacting factors is crucial for creating effective measures that help nursing students adapt and improve their educational performance. Moreover, identifying the stress levels and stressors experienced by students enables nursing faculties and administrators to resolve the causes of stress, support students, and gain the trust of students [
19,
22]. Studies which have aimed to measure stress levels and sources among nursing students in Arab countries, including Jordan, are numerous [
28‐
38]. However, all of these studies have used a single instrument which assesses clinical-related stress only and which was only recently psychometrically validated in the Arabic language [
39]. Therefore, there is a need for a wider range of validated tools in order to ensure that various aspects of academic and clinical stress and stressors among nursing students in Arab countries are considered.
The Higher Education Stress Inventory (HESI) is a tool characterized by its ability to capture various aspects of stressors related to higher education regardless of the setting or the student population. The instrument was developed by a group of psychiatry professors in Sweden to measure stress among medical students [
40]. It has previously been used to assess stress levels among medical students [
40,
41] and distance learning students [
42]. Although the language of instruction in all nursing schools in Jordan is English, the presence of a translated and validated instrument in Arabic (the official language of Jordan) would yield more accurate results and a better understanding of the context [
39]. Considering the fact that stress levels and stressors vary depending on various sociocultural aspects [
43,
44], the psychometric properties of the Arabic-HESI need to be evaluated using robust analyses like EFA and CFA. Therefore, the current study aimed to examine the psychometric properties of the Arabic-HESI, which is to be used to measure education-related stress among nursing students in Jordan, by applying EFA and CFA.
Discussion
The stress experienced by nursing students in Jordan and in other Arab countries has been examined in many studies. However, to our knowledge, all studies that have been conducted in the Arab world have used a single instrument evaluating only clinical-related stress among nursing students. Although English is the language of instruction in Jordan, there are limitations in using non-Arabic psychometrically evaluated instruments, due to language and cultural variations among students. Therefore, this study aimed to assess the psychometric properties of the Arabic version of the HESI. The translation of the HESI from English into Arabic has proved successful. This result is supported by the excellent CVI and the panel of experts’ agreement that the items of the Arabic-HESI adequately measured the sources of stress among nursing students [
54].
The EFA yielded a two-factor model with 16 items reflecting different stressors perceived by nursing students in Jordan. A total of 45% of the variance was explained by the model, compared to the 24-item and 22-item seven-factor models of the original and Korean versions, which explained 48.7 and 45.8% of the variance, respectively. The original HESI and the Korean HESI yielded seven factors, with variations in the items under the factors and in the significance of the factors to the construct of higher education [
40,
44]. As for the Arabic-HESI, the items were grouped under two factors, namely “challenges and “dissatisfaction”. The overall internal consistency of the Arabic-HESI was 0.75, compared to 0.85 for the original HESI and 0.78 for the Korean HESI. The Cronbach’s alpha values for the subscales of the Arabic-HESI were higher in comparison to the factors of the original HESI, whilst they were close to the Cronbach’s alpha values of most of the factors of the Korean HESI [
40,
44]. This may be related to the variations in the number of items under each factor in the three versions.
According to the Cronbach’s alpha results, the 13-item “challenges” factor was stronger than the 3-item “dissatisfaction” factor. The “challenges” factor items were grouped from 6 out of 7 factors of the original HESI, in addition to two other factors that were not loaded in any of the 7 factors. This may be an indication of the comprehensiveness of the “challenges” factor. Although the “financial concerns” factor in the original HESI was the weakest, the items of this factor were grouped under the “challenges” factor in the Arabic-HESI. These items were more important in the Arabic-HESI due to the financial hardship experienced by many families in Jordan, as Jordan is a developing country [
18,
55,
56]. In Jordan, about 84.9% of the population live below the poverty line [
56]. Further, the indications of financial concerns for the participating students were clear. For example, about 95% of our sample came from low- and very low-income families, and more than 84% claimed that purchasing internet services in order to keep up with the requirements of distance learning constituted an additional financial burden. Also, the limited financial and physical resources of the students were indicated by the ‘limited resources’ theme that was identified from the students’ responses to the open-ended question.
The “dissatisfaction” factor included the items of the “low commitment” factor from the original HESI and 50% of the items of the “low commitment” factor from the Korean HESI. The presence of these items emphasizes the importance of improving the educational environment in order to improve the experience and satisfaction levels of students, therefore reducing students’ stress levels [
14]. Aslan & Akturk [
22] and Hamaideh et al. [
34] found that nursing students who choose nursing willingly and/or come to like it during their time in education experience lower stress levels than students who do not. Further, the items under the “dissatisfaction” factor highlighted the stereotypes about nursing held by some Jordanians. Despite the evolution of Jordanian society’s view of nursing and nursing education over the past 70 years, some people in Jordan still do not consider nursing to be a prestigious major [
57]. To the best of our knowledge, many students in Jordan do not choose to study nursing willingly; rather, for many students, nursing is assigned to them by the unified admissions program based on their grades in the General Secondary Education Certification Examination (Tawjihi) [
58,
59].
Items which present peer relationships as being a stressor, such as “The studies have created anonymity and isolation among students”, “I feel that the studies have played a role in creating a cold and impersonal attitude among students”, “My fellow students support me” (reversed item), and “There is a competitive attitude among students”, were removed during analysis. Social support from peers has been found to decrease students’ perceived stress during education [
60], and in the context of Jordanian culture, relationships between students are characterized by strong and positive bonds [
39]. Furthermore, items related to clinical training stressors, such as “The training is characterized by an atmosphere where weakness and personal shortcomings are not accepted”, “The training demands that I join in situations that I find unethical”, and “I feel that the training is preparing me well for my future profession”, were also removed. This may be attributed to the fact that data collection took place during the period of transition to distance learning due to the COVID-19 pandemic, whereby practicum courses were taught that semester (second semester 2019/2020) using videos, computer simulations, and online quizzes and assignments. Students did not have the chance to practice in clinical settings and therefore did not experience the stressors related to actual training in clinical settings. However, the qualitative results revealed that nursing students had concerns regarding the termination of clinical training in actual clinical settings. Students were dissatisfied with the way that clinical courses were being delivered and felt that they were losing out on a golden opportunity to meet real patients and acquire psychomotor skills in real clinical settings.
Furthermore, the lack of training in clinical settings may have also reduced the students’ perceived levels of stress regarding the stressors and responsibilities of their future profession. Therefore, the items “I meet many future colleagues who seem dejected or dissatisfied with their profession”, “I worry about the long working hours and responsibilities of my future career”, and “The insight I have gained into my future profession has made me worried about the stressful workload” were removed during analysis.
Limitations
This study is not without limitations. The cross-sectional design of the study did not provide information about causal relationships among the variables. Also, the fact that this was a secondary data analysis hindered the researchers from examining the test-retest reliability, stability reliability, criterion-related validity, known-group validity, and convergent validity. Further, data were collected soon after the sudden and dramatic transition by all universities in Jordan to distance learning due to the COVID-19 pandemic. Despite the HESI being neutral to educational settings and student populations, we believe that the removal of many of the items in the Arabic-HESI during analysis may have been due to this sudden transition. Therefore, using the Arabic-HESI in normal circumstances to verify the impact of the removal or re-development of the low-loading items on the complete HESI performance is recommended.
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