The relationship between the academic self-efficacy and perceived stressors among nursing students in clinical settings: a cross-sectional study

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;

The mean age of the nursing students participating in the study was 21.02 ± 1.52 (min: 19, max: 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).

The mean total ANSES and NSPCSS scores of the nursing students were found as 51.50 ± 6.88 (min: 17, max: 70) and 82.98 ± 15.58 (min: 22, max: 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).

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).

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 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.