Academic stress factors and associated symptoms in nursing students

Tiffanny Solansh Pezo-Fasanando

doi:10.56294/shp2026375

Abstract

Introduction: Academic stress is a recurring phenomenon among university students, especially in demanding programs such as Nursing. It can trigger a range of physical, psychological, and behavioral symptoms that affect students' academic performance and mental health. Objective: To determine the relationship between academic stress factors and associated symptoms in nursing students at the National University of San Martín during the 2022-I academic semester. Methods: A basic, quantitative, descriptive-correlational study with a non-experimental cross-sectional design was conducted. The population consisted of 355 students, from which a sample of 183 was selected using simple random sampling. Two previously validated questionnaires were administered: the Academic Stressors Scale (ECEA) and the Questionnaire on Reactions to Stressful Stimuli. Results: The main stress factors identified were methodological deficiencies of the teaching staff, exams, and student overload. At the symptom level, average levels predominated for physical symptoms (43.2%) and psychological symptoms (53.5%), while low levels predominated for behavioral symptoms (55.2%). A significant correlation was found between academic stress factors and physical (r = 0.513), psychological (r = 0.584), and behavioral (r = 0.514) symptoms. Conclusions: There is a direct and significant relationship between academic stress factors and associated symptoms, highlighting the need to implement institutional strategies to prevent stress and promote student well-being.

Keywords

academic anxiety, physiological reactions, coping behaviors, university demands, student mental health

INTRODUCTION

A healthy university life is one in which the pressure on students is balanced by their ability to respond, the resources available for their academic training, the degree of control over their activities, and the support they receive from important people in their environment.(1,2) However, physical, psychological, and social well-being throughout a degree course can be disrupted by changes and demands such as meeting academic requirements, requirements for adequate performance,(3) and even abandoning behaviours related to healthy habits such as eating.(4)

Furthermore, in response to the COVID-19 pandemic, the world has shifted to virtual education, moving from face-to-face classes to remote learning. Eighty per cent of university students report that this modality has hurt their mental health,(5) with academic stress related to their ability to succeed being a particular area of concern.(6) This lack of experience is exacerbated by difficult home conditions, including loss of access to academic resources (computers and internet connectivity) and distractions in the learning environment (interruptions from other family members and additional responsibilities).(7)

The activities or tasks carried out at university involve different situations that can be perceived as stressful, to a greater or lesser extent, depending on the cognitive and emotional resources of the students to cope with them, especially in nursing students.(8) Studies have found that nursing students experience higher levels of stress than the general population and students in other disciplines, as they are naturally involved in direct contact with life and human finitude, with the possibility of suffering, delicate situations, and complex decisions that involve the whole human being.(9)

Applied research on postgraduate nursing students at a university in Jamaica showed that the development of programmes generates stress due to excessive workloads, time constraints, late publication of grades, and lack of timely feedback from research supervisors and the ethics committee. For this reason, the authors call on nursing faculty to explore creative strategies to reduce sources of academic stress.(10)

In Brazil, the Federal Public University of the State of Bahia demonstrated the prevalence of higher stress levels among final-year students compared to first-year students about practical activities (they are more exposed to clinical activities), professional communication (they spend more time in professional practice), environment (complications regarding the distance between the university and the places of practice and their homes) and professional training (they are going through a stage in which there is greater concern about their future entry into the labour market).(11)

In the Peruvian context, it was found that academic stress among nursing students at a university in the city of Arequipa was moderate in most of the interviewees (56 out of 126 students), with a tendency to increase with the number of years of study, which would indicate an accumulation of stress as they progress in their professional career. They also found a negative relationship between academic stress and self-esteem, showing that the higher the level of academic stress, the lower the self-esteem.(12)

Within the Professional School of Nursing of the National University of San Martín, it was identified in 2021 that the stress level perceived by students was predominantly moderate, at 73,7 %.(13) Similarly, another study conducted at the Professional Schools of Nursing and Obstetrics determined that academic stress was evident at a medium level of 66,1 % and 12,9 % at a low level, highlighting that environmental demands and physical, psychological, and behavioural reactions directly and indirectly influence academic stress.(14)

In this context, stress can affect students positively or negatively depending on its severity. Minimal levels generate positive results, such as motivation and improved academic performance, while the prevalence of stress hurts academic performance and physical and psychological well-being. Symptoms of stress include loss of energy, increased blood pressure, depression, difficulty concentrating, impatience, and nervousness.(15) This study aimed to determine the relationship between academic stress factors and associated symptoms in nursing students at the National University of San Martín during the 2022-I academic semester.

METHODS

The study was basic, with a quantitative approach, as numerical data were collected and analysed to establish relationships between the variables. It was developed at a descriptive-correlational level, as it allowed the characteristics of academic stress factors and associated symptoms to be described and the relationship between the two to be evaluated. The design was non-experimental and cross-sectional, given that the variables were not manipulated and the information was collected simultaneously, preserving the phenomena as they presented themselves in their natural context.

The research considered two main variables. The independent variable was academic stress factors, divided into eight dimensions: teachers' methodological deficiencies, student overload, beliefs about academic performance, public interventions, hostile social climate, exams, lack of value of content, and difficulties in participation. The dependent variable was symptoms associated with academic stress, composed of three dimensions: physical symptoms, psychological symptoms, and behavioural symptoms.

The unit of analysis consisted of students enrolled in the Professional School of Nursing at the National University of San Martín (UNSM) during the 2022-I academic semester. The total population was 355 students, and a sample of 183 students was obtained, selected by simple random probability sampling, using the formula for finite populations, with a confidence level of 95 % and a margin of error of 5 %.

The survey technique was used, applying two previously validated instruments. To measure academic stress factors, the ‘Academic Stressors Scale of the Academic Stress Questionnaire (ECEA)’,(16) which consists of 54 items distributed across eight dimensions, with a five-level Likert ordinal scale: 1 (never), 2 (sometimes), 3 (quite often), 4 (almost always), and 5 (always). The ‘Questionnaire on Reactions to Stressful Stimuli’(17) was used to identify associated symptoms, consisting of 15 items grouped into three dimensions (physical, psychological, and behavioural), with the same measurement scale.

The data obtained were tabulated in Microsoft Excel 2019 spreadsheets and then exported to SPSS version 26 statistical software for analysis. Descriptive statistical techniques (frequencies and percentages) were applied to characterise stress levels and associated symptoms. Inferential statistics were also used, employing Spearman's correlation coefficient, appropriate for ordinal data, to determine the existence and strength of the relationship between the main variables. A significance level of 5 % (p < 0,05) and % confidence level of 95 % were established for statistical decision-making.

Formal authorisation was obtained from the UNSM Professional School of Nursing, and coordination was carried out with teachers to ensure an appropriate environment during the application of the instruments. Student participation was voluntary, and informed consent was signed, ensuring confidentiality, anonymity, and the exclusive use of information for academic purposes. Likewise, scientific integrity was guaranteed in data treatment, avoiding any form of manipulation or distortion of the results.

RESULTS AND DISCUSSION

Academic stress factors

According to table 1, the factors that generate high levels of academic stress in nursing students at the UNSM during the 2022-I academic semester were methodological deficiencies of the teaching staff (30,0 %), followed by exams (23,5 %), student overload (15,3 %), lack of value of the content (14,8 %), difficulties in participation (13,1 %), beliefs about academic performance (10,9 %), hostile social climate (8,7 %), and in last place, public interventions (6,0 %). It was also found that regular levels of academic stress are usually caused by student overload (60,1 %), followed by beliefs about academic performance (59,6 %) and methodological deficiencies of teachers (58,5 %). Likewise, public speaking, hostile social climate, and exams are factors of academic stress in 43,7 %, 47,0 %, and 44,3 % of nursing students, respectively.

Table 1. Academic stress factors in nursing students

Stress level	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors	Academic stressors
Stress level	DMP	DMP	SE	SE	CRA	CRA	IP	IP	CSN	CSN	EXA	EXA	EXA	CVC	CVC	CVC	DP	DP
Stress level	Fi	%	Fi	%	Fi	%	Fi	%	Fi	%	Fi	%	Fi	Fi	%	Fi	Fi	%
Low	21	11,5	45	24,6	54	29,5	92	50,3	81	44,3	59	32,2	93	93	50,8	92	92	50,3
Regular	107	58,5	110	60,1	109	59,6	80	43,7	86	47,0	81	44,3	63	63	34,4	67	67	36,6
High	55	30,0	28	15,3	20	10,9	11	6,0	16	8,7	43	23,5	27	27	14,8	24	24	13,1
Total	183	100,0	183	100,0	183	100,0	183	100,0	183	100,0	183	100,0	183	183	100,0	183	183	100,0

Note. TMP: Teacher methodological deficiencies; SOW: Student overload; ABI: Academic belief; PI: Public speaking; NSC: Negative social climate; EXA: Exams; CVC: Lack of value of content; PD: Participation difficulties.

Although most students reported regular and high levels of academic stress, some students did not experience any negative stress factors during the 2022-I academic semester. This can be seen in the low scores for the aspects of lack of value of the content (50,8 %), public speaking (50,3 %), and hostile atmosphere (44,3 %). Therefore, more than 50 % of students perceive good academic value in the content taught in the nursing programme, have public speaking skills, and, above all, have a favorable academic climate with teachers and fellow students.

Research reporting values similar to those found in this study was conducted by Teque et al.(18), who stated that nursing students at the Señor de Sipán University in Chiclayo perceive a moderate level of stress related to competition with their classmates (36,1 %); the personality and character of the teacher (40 %) are other factors that increase academic stress, as do not understanding the teaching content in class (48,8 %) and speaking in public (35,1 %).

On the other hand, Chávez et al.(12) showed that nursing students at the National University of San Agustín in Arequipa had a medium level of academic stress (44,4 %), followed by high (31 %) and low (24,6 %); where the trend in academic stressors falls within a regular level, except for the dimensions of lack of value of the content (34,4 %) and difficulties in participation (36,6 %). These authors assert that high levels of stress in nursing students originate from the association with the academic workload and the accumulated pressure that students are subjected to as they progress through the cycles, and this is due to the nature of the nursing degree programme.

At the UNSM, Rengifo et al.(13) reported during the COVID-19 pandemic 2021 that academic stress in 73,7 % of nursing students was moderate, followed by high in 15,6 % and low in 10,7 %. These findings were predominant in the 2022-I academic semester, a post-pandemic period, where academic stress was mainly at a regular level due to factors related to student overload (60,1 %) and beliefs about academic performance (59,6 %). In general, research on the presence of academic stress in nursing students confirms that it is an issue that requires timely attention to ensure mental health and academic performance.

Associated symptoms of academic stress

According to table 2, nursing students at UNSM during the 2022-I academic semester presented physical symptoms of stress at a regular level (43,2 %), followed by low (37,2 %) and high (19,6 %).

They also had psychological stress symptoms at a regular level (53,5 %), followed by low (36,1 %) and high (10,4 %). In terms of behavioural symptoms, they had low stress levels (55,2 %), followed by regular (36,1 %) and low (8,7 %).

Table 2. Symptoms associated with academic stress

Table 1.

Level	Symptoms of stress	Symptoms of stress	Symptoms of stress	Symptoms of stress	Symptoms of stress	Symptoms of stress
Level	Physicists	Physicists	Psychological	Psychological	Behavioural	Behavioural
Level	Fi	%	Fi	%	Fi	%
Low	68	37,2	66	36,1	101	55,2
Regular	79	43,2	98	53,5	66	36,1
High	36	19,6	19	10,4	16	8,7
Total	183	100,0	183	100,0	183	100,0

The symptoms of academic stress most frequently perceived by nursing students at a high level were physical (19,6 %), at a regular level, psychological (53,5 %), and at a low level, behavioural (55,2 %). Lower results than those reported by Castillo et al.(19) were found in 587 nursing students from three Colombian universities, with physical symptoms in 35,5 %, psychological symptoms in 34,6 %, and behavioural symptoms in 21,6 %.

At the UNSM during the 2021-I semester, Vela et al.(14) reported that physical symptoms in nursing students as responses to academic stress were predominantly moderate in 58,4 % of 190 students, as were psychological symptoms (56,8 %) and behavioural symptoms (61,1 %). Unlike the present study, behavioural reactions predominated low (55,2 %), although physical and psychological symptoms persisted in the 2022-I academic semester. It is important to emphasise that symptoms associated with stress are predictors of poor performance among nursing students at the UNSM, increasing the possibility of dropouts and mental health complications.

Relationship between academic stress factors and associated symptoms

The results in table 3 confirm the hypothesis that academic stress factors are significantly related to physical, psychological, and behavioural symptoms. The positive correlations found show that stress perceived in the academic environment not only affects the emotional state but also the physical and behavioural functioning of students.

Table 3. Relationship between academic stress factors and physical symptoms

Table 1.

		Academic stress factors
Physical symptoms	Spearman's correlation	0,513**
Physical symptoms	Mr. (bilateral)	0,000
Physical symptoms	N	183
Psychological symptoms	Spearman's correlation	0,584**
Psychological symptoms	Mr. (bilateral)	0,000
Psychological symptoms	N	183
Behavioural symptoms	Spearman's correlation	0,514**
Behavioural symptoms	Mr. (bilateral)	0,000
Behavioural symptoms	N	183

Note: **. Correlation is significant at the 0,01 level (two-tailed).

The correlation between academic stress factors and physical symptoms was positive and significant, with a Spearman coefficient of 0,513 and a bilateral significance value of 0,000. This result indicates that as academic stress factors increase, so do physical symptoms in students, such as fatigue, sleep disorders, headaches, and digestive problems.

The strength of the correlation is moderate to high, which shows a consistent relationship between academic demands and the manifestation of somatic responses. Regarding the relationship between academic stress factors and psychological symptoms, the highest correlation coefficient was found among the three dimensions, with a value of 0,584, which was also significant at the 0,01 level.

This strong positive correlation suggests that increased academic stress is strongly associated with symptoms such as anxiety, sadness, irritability, and difficulty concentrating. These findings are relevant, as the psychological dimension represents a key component of student well-being, especially in highly demanding educational contexts such as nursing studies.

The correlation obtained for behavioural symptoms was 0,514, with equally high statistical significance (p = 0,000). This relationship is also positive and moderately firm, reflecting how academic stress can influence behaviours such as procrastination, absenteeism, disorganisation, or negative changes in study habits. Such symptoms are warning signs of possible effects on students' academic performance and adaptation to university life.

The results are consistent with those reported by Pozos et al.(20), who stated that behavioural symptoms have a moderate correlation with academic overload (r = 0,357) and compulsory work (r = 0,384). However, these authors also indicated that taking an exam is not correlated with behavioural symptoms (r = 0,095). This value differs from that found in the present study, where academic stress factors in nursing students at the UNSM show a strong association with behavioural symptoms.

Behavioural changes are generally an indicator of stress among university students, who often deal with it through unfavourable and unhealthy behaviours such as organisational problems, increased tardiness to class, failure to complete assignments, unjustified absences, changes in class participation, sleeping in class, interpersonal issues, among others.(21) These factors are reported by nursing students at UNSM due to their relationship with academic stressors often arising from indicators linked to university academic status. Therefore, it is essential to understand mechanisms that can reduce stress factors and behavioural symptoms.

Asenjo et al.(18) found a prevalence of psychological symptoms in nursing students at the National Autonomous University of Chota, where 39,3 % reported that they almost always or always could not relax or be calm, 36,1 % reported feelings of depression and sadness, 42,6 % reported anxiety, distress or despair, and 41,8 % reported difficulty concentrating. These are similar symptoms that affect the psychological state of nursing students at UNSM, and are therefore indicative of poor academic performance and mental health problems.

On the other hand, Pozos et al.(20) reported that psychological symptoms have a moderate correlation with compulsory work (r = 0,406), followed by class participation (r = 0,388), group work (r = 0,350) and other academic stressors linked to academic tasks; These are related to factors such as methodological deficiencies among teachers, student overload, exams, etc., which affect the psychological conditions of nursing students at the UNSM. This picture shows that anxiety, feelings of depression, distress, aggression, or irritability are alarming symptoms of academic stress in nursing students; it is therefore considered a problem that affects educational performance and limits adequate professional training.

Likewise, the results reveal that sleep disorders, chronic fatigue, headaches or migraines, digestive problems, nail biting or scratching, and drowsiness are symptoms associated with academic stressors experienced by nursing students throughout the 2022-I academic semester, a finding similar to that described by Asenjo et al.(18), who, when evaluating 122 nursing students from the first to tenth cycle at the National Autonomous University of Chota in the 202-I semester, recognised that symptoms of sleep disorders, permanent fatigue, headaches, stomach pain, nail biting and drowsiness are indicators that are almost always or always present in 34,4 %, 37,7 %, 45,1 %, 13,9 %, 22,1 % and 36,9 %, respectively, are associated with perceived academic stress at university.

CONCLUSIONS

Academic stress factors, such as methodological deficiencies in teaching, exams, and student overload, were positively and significantly related to physical, psychological, and behavioural symptoms in nursing students. These findings show that continuous exposure to stressful academic situations directly influences students' overall well-being, affecting their performance, mental health, and adaptation to university life. The strongest correlation was observed in psychological symptoms, indicating high emotional vulnerability to the educational demands of the degree programme.

From a practical perspective, the results support the need to implement institutional psycho-emotional support programmes and more empathetic teaching strategies to minimise stressors within the academic environment. Likewise, it is suggested that teacher training in active methodologies and fair assessment be strengthened, and workshops on stress management, self-care, and coping skills development be promoted among students. These actions could contribute to reducing academic stress levels, improving the quality of the teaching-learning process, and promoting retention and academic success in demanding degree programmes such as nursing.

References

1 Jeong EJ, Ferguson CJ, Lee SJ. Pathological Gaming in Young Adolescents: A Longitudinal Study Focused on Academic Stress and Self-Control in South Korea. J Youth Adolesc. diciembre de 2019;48(12):2333-42.
2 Cohen S, Kamarck T, Mermelstein R. A Global Measure of Perceived Stress. J Health Soc Behav [Internet]. diciembre de 1983;24(4):385. Disponible en: http://www.jstor.org/stable/2136404?origin=crossref
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13 Rengifo Cabanillas RI, Lozano García JD. Estrés percibido durante la pandemia de la COVID 19 en estudiantes de la Escuela Profesional de Enfermería. Universidad Nacional de San Martín Tarapoto. Periodo mayo - octubre 2021. Universidad Nacional de San Martín; 2022.
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Declarations

Funding

The author did not receive funding for the development of this research.

Conflict of interest

The author declares that there is no conflict of interest.

Authorship contributions

Conceptualisation: Tiffanny Solansh Pezo-Fasanando.

Data curation: Tiffanny Solansh Pezo-Fasanando.

Formal analysis: Tiffanny Solansh Pezo-Fasanando.

Research: Tiffanny Solansh Pezo-Fasanando.

Methodology: Tiffanny Solansh Pezo-Fasanando.

Project management: Tiffanny Solansh Pezo-Fasanando.

Validation: Tiffanny Solansh Pezo-Fasanando.

Visualisation: Tiffanny Solansh Pezo-Fasanando.

Writing – original draft: Tiffanny Solansh Pezo-Fasanando.

Writing – revision and editing: Tiffanny Solansh Pezo-Fasanando.

[ref1] 1 Jeong EJ, Ferguson CJ, Lee SJ. Pathological Gaming in Young Adolescents: A Longitudinal Study Focused on Academic Stress and Self-Control in South Korea. J Youth Adolesc. diciembre de 2019;48(12):2333-42.

[ref2] 2 Cohen S, Kamarck T, Mermelstein R. A Global Measure of Perceived Stress. J Health Soc Behav [Internet]. diciembre de 1983;24(4):385. Disponible en: http://www.jstor.org/stable/2136404?origin=crossref

[ref3] 3 Freire C, Ferradás M, Núñez J, Valle A, Vallejo G. Eudaimonic Well-Being and Coping with Stress in University Students: The Mediating/Moderating Role of Self-Efficacy. Int J Environ Res Public Health. diciembre de 2018;16(1):48.

[ref4] 4 Trigueros R, Padilla AM, Aguilar-Parra JM, Rocamora P, Morales-Gázquez MJ, López-Liria R. The Influence of Emotional Intelligence on Resilience, Test Anxiety, Academic Stress and the Mediterranean Diet. A Study with University Students. Int J Environ Res Public Health. marzo de 2020;17(6):2071.

[ref5] 5 López-Castro T, Brandt L, Anthonipillai NJ, Espinosa A, Melara R. Experiences, impacts and mental health functioning during a COVID-19 outbreak and lockdown: Data from a diverse New York City sample of college students. Sirois FM, editor. PLoS One. abril de 2021;16(4):e0249768.

[ref6] 6 Clabaugh A, Duque JF, Fields LJ. Academic Stress and Emotional Well-Being in United States College Students Following Onset of the COVID-19 Pandemic. Front Psychol [Internet]. 17 de marzo de 2021;12. Disponible en: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.628787/full

[ref7] 7 Son C, Hegde S, Smith A, Wang X, Sasangohar F. Effects of COVID-19 on College Students’ Mental Health in the United States: Interview Survey Study. J Med Internet Res. septiembre de 2020;22(9):e21279.

[ref8] 8 Ribeiro FMS e S, Mussi FC, Pires CG da S, Silva RM da, Macedo TTS de, Santos CA de ST. Stress level among undergraduate nursing students related to the training phase and sociodemographic factors. Rev Lat Am Enfermagem. 2020;28.

[ref9] 9 Labrague LJ, McEnroe–Petitte DM, De Los Santos JAA, Edet OB. Examining stress perceptions and coping strategies among Saudi nursing students: A systematic review. Nurse Educ Today. junio de 2018;65:192-200.

[ref10] 10 Leslie K, Brown K, Aiken J. Perceived academic-related sources of stress among graduate nursing students in a Jamaican University. Nurse Educ Pract. mayo de 2021;53:103088.

[ref11] 11 Mussi FC, Pires CG da S, Carneiro LS, Costa ALS, Ribeiro FMS e S, Santos AF dos. Comparison of stress in freshman and senior nursing students. Rev da Esc Enferm da USP. 2019;53.

[ref12] 12 Chávez Parillo JR, Peralta Gómez RY. Estrés académico y autoestima en estudiantes de enfermería, Arequipa-Perú. Rev Ciencias Soc. 2019;25(1):384-99.

[ref13] 13 Rengifo Cabanillas RI, Lozano García JD. Estrés percibido durante la pandemia de la COVID 19 en estudiantes de la Escuela Profesional de Enfermería. Universidad Nacional de San Martín Tarapoto. Periodo mayo - octubre 2021. Universidad Nacional de San Martín; 2022.

[ref14] 14 Vela Sangama WS, Meza Acuña SA. Estrés académico en el uso de aulas virtuales en estudiantes de las Escuelas Profesionales de Enfermería y Obstetricia. Universidad Nacional de San Martín. Tarapoto mayo - octubre 2021 [Internet]. Universidad Nacional de San Martín; 2021. Disponible en: https://repositorio.unsm.edu.pe/handle/11458/4198

[ref15] 15 Aihie ON, Ohanaka BI. Perceived Academic Stress among Undergraduate Students in a Nigerian University. J Educ Soc Res. mayo de 2019;9(2):56-66.

[ref16] 16 Cabanach RG, Souto-Gestal A, Franco V. Escala de Estresores Académicos para la evaluación de los estresores académicos en estudiantes universitarios. Rev Iberoam Psicol y Salud [Internet]. julio de 2016;7(2):41-50. Disponible en: http://linkinghub.elsevier.com/retrieve/pii/S2171206916300138

[ref17] 17 Castillo Ávila I, Barrios Cantillo A, Alvis Estrada L. Estrés académico en estudiantes de enfermería de Cartagena, Colombia. Investig en Enfermería Imagen y Desarro. 2018;20(2).

[ref18] 18 Asenjo-Alarcón JA, Linares-Vásquez O, Díaz-Dávila YY. Nivel de estrés académico en estudiantes de enfermería durante la pandemia de COVID-19. Rev Peru Investig en Salud [Internet]. 7 de abril de 2021;5(2):59-66. Disponible en: http://revistas.unheval.edu.pe/index.php/repis/article/view/867

[ref19] 19 Castillo Ávila IY, Barrios Cantillo A, Alvis Estrada LR. Estrés académico en estudiantes de enfermería de Cartagena, Colombia. Investig en Enfermería Imagen y Desarro. 2018;20(2).

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