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Aim. The aim of this study was to investigate how differences in life events and stress contribute to psychological distress in
nurses and nursing students.
Background. Stress is an issue for nursing students and qualified nurses leading to psychological distress and attrition.
Design. A longitudinal study using four time waves was conducted between 19941997.
Methods. Measures were taken of stress, life events and psychological distress in addition to a range of demographic data. Data
were analysed using descriptive statistics, linear modelling and mixed-effects modelling. The study was set in Scotland, UK and
used newly qualified nurses and nursing students from four university departments of nursing over four years. The study was
initiated with 359 participants (147 nurses and 212 nursing students) and complete data were obtained for 192 participants.
Results. Stress levels, psychological distress and life events are all associated within time and across time. At baseline, life events
and stress contributed significantly to psychological distress. The pattern of psychological distress differed between the nursing
students and the newly qualified nurses with a high level in the nurses after qualifying and starting their career.
Conclusion. Stress, individual traits, adverse life events and psychological distress are all interrelated. Future lines of enquiry
should focus on the transition between being a nursing student and becoming a nurse.
Relevance to clinical practice. Stress and psychological distress may have negative outcomes for the retention of nursing students
in programmes of study and newly qualified nurses in the nursing workforce.
Key words: nurses, nursing students, psychological upset, psychology, quantitative approaches, stress
Accepted for publication: 20 June 2008
Introduction
Stress in nurses, studied extensively in recent decades, is an
international phenomenon (Chang et al. 2005). There has
also been an increasing amount of research on stress in
student nurses (Jones & Johnson 1997, 1999, 2000). Nursing
is an occupation with a constellation of circumstances leading
to stress. The relevant literature was reviewed recently by
Chang et al. (2005) and the factors leading to stress include a
Authors: Roger Watson, PhD, RN, FAAN, School of Nursing and
Midwifery, The University of Sheffield, Sheffield, UK; Eric Gardiner,
BSc, MSc, PhD, Hull York Medical School, The University of Hull,
Hull, UK; Richard Hogston, BA, MSc, RGN, PGDipEd, Faculty of
Health, Leeds Metropolitan University, Leeds, UK; Helen Gibson,
BA, MA, Faculty of Health and Social Care, University of Hull, Hull,
UK; Anne Stimpson, BA, RGN, Faculty of Health and Social Care,
University of Hull, Hull, UK; Robert Wrate, MBBS, DPM,
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2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278
doi: 10.1111/j.1365-2702.2008.02555.x
The study
The aim of the present study was to examine how a range of
demographic, personal, circumstantial/environmental factors
and stress contribute to differences in psychological distress
in newly qualified nurses and nursing students.
Stress is a process. Studies which examine stress in a crosssectional manner, with a limited number of relevant variables, only reveal part of the process, and at worse, simply
report correlations among scales with overlapping content
(Deary et al. 1996). In addition to the inclusion of the
appropriate variables, studies capture the process of stress
better if they are longitudinal because the outcomes of the
stress process can then be assessed. The transactional model
of work-related stress (Deary et al. 1996) recognises that
there are various factors that act as antecedents to stress.
There are personal factors such as demographics, personality
traits and environmental life events. These can have an
influence on the amount of stress reported at work, which
should also be measured. But this work-related stress is not
the outcome of the process. In fact, there might be more
than one outcome, such as psychological distress. Following
this process model, the present study includes most of the
above-mentioned elements, and is longitudinal. The antecedent variables collected included demographic and social
Design
The design was a longitudinal cohort study with an existing
dataset, which came from a three-year longitudinal study by
Working Minds (see Acknowledgements), with four waves of
data collection (Baldwin 1999). The subjects were newly
qualified nurses and nursing students in Scotland. Participants entering the study as students were recruited in the
classroom at the beginning of their programme of study and
participants entering the study as newly qualified nurses were
recruited in the classroom at the end of their programme of
study. Written consent was obtained from the students to be
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278
271
R Watson et al.
Sample
Initially, 220 nurses were approached and 67% were
recruited (n = 147); 285 students were approached and
74% (n = 212) were recruited. The study was, therefore,
initiated with 359 participants and there were complete data
for 192 (depending upon which outcome is studied). Eighteen
nurses were men (129 women) and 38 students were men
(174 women). The median age of the nurses was 26 (range
2052) and of the students 22 (range 1744).
Questionnaires
Demographic and circumstantial factors Information was
available on sex, age, marital status, having a close friend or
not (at each of the four waves), status (staff or student) and
having a dependent child or not (at each of the four waves).
The brief life events inventory measures stressful life events
in the last year. It is an eight item questionnaire which asks
respondents to answer yes or no to a series of life events
such as financial problems or job applications. It then asks the
subjects to respond, using a five point Likert scale, to how
much this has affected them with possible responses ranging
from Not at all stressful (0)Extremely stressful (4) through
Slightly stressful, Moderately stressful and Very stressful.
The total score was used here. It was administered four times,
in all four waves: in 1994, 1995, 1996 and 1997. The internal
consistency of the brief life events inventory measured at first
use in the study using Cronbachs alpha was 053.
The work-stress inventory (Firth-Cozens 1992) used in the
Working Minds project was a 15-item work-related stress
questionnaire which enquired about both frequency and level
of stress with items such as Difficult relations with senior
nurses and Making decisions. Frequency of stressors was
responded to on a three point Likert scale from Never (0)
through Occasionally (1)Frequently (2). The level of
stress for each stressor was responded to on a five point Likert
scale from Not at all stressful (0)Extremely stressful (4)
through Slightly stressful, Moderately stressful and Very
stressful. Total stress frequency and level were used here. It
was administered once, at wave 4 in 1997. The internal
consistency of the work-stress inventory frequency scale was
068 and for the level of stress was 076 measured using
Cronbachs alpha.
272
Analysis
Descriptive statistics and linear modelling
Distributions (means and standard deviations) are described
for the principal variables. Malefemale and staffstudent
differences are examined (unpaired t-tests). Differences over
the four waves of testing are examined (paired t-tests).
Pearsons correlations (pairwise and listwise) are examined
between variables and within variables across time waves.
The GHQ scores are modelled as a function of life
events, sex, stress and other demographic variables (general
linear modelling: ANCOVA ). These analyses were run on SPSS
version 14.
Mixed-effects modelling
The principal novel analysis used mixed-effects models: statistical models with both fixed and random effects. Because
the data were longitudinal, they allow an understanding of
both the mean levels of stress and the changes in stress over
time in these groups of nurses and student nurses. The GHQ
and the life events scales were administered on four occasions. There are missing data, with not every subject
continuing until the end of the study. We were also able to
use, in the mixed-effects modelling, information on whether
or not the person was present at each wave. Therefore,
dropout from each wave was used as information, actually
part of the statistical modelling. Demographic and circumstantial/environmental factors may be modelled using fixed
effects. Further, individual variation may be modelled using
random effects, in particular, random individual intercepts
and random individual slopes over time. Life events can also
be introduced as a random effect because they were measured
repeatedly over time. These analyses were conducted using
R 220 for Windows (R Development Core Team 2005).
Because mixed-effects modelling is still used and understood by relatively few health researchers, and because it is
especially well suited to the data we are examining here, a
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278
Results
Descriptive statistics
Mean (SD) values and numbers are shown for stress
frequency and level (1997), GHQ (from 19941997) and
life events (from 19941997) (Tables 1 and 2). These are
shown for all subjects and according to sex-specific and
status-specific (student or newly qualified nurses) subgroups.
Table 1 shows the pairwise values and Table 2 shows the
Correlations
Pearsons correlations are shown between stress frequency
and level (1997), GHQ (from 19941997) and life events
(from 19941997) (Table 3). Because of the large numbers of
participants in this study, r-values equal to or greater than 02
are significant at p < 001. Listwise correlations are shown
above the diagonal and pairwise below, and they are very
similar. Self-esteem, tested in 1994, is associated significantly
with GHQ across all four waves (r-values from 045 to
021) but correlates progressively lower as the GHQ is more
distant in time.
General health questionnaire shows moderate stability
across the four waves with coefficients between 027048 (all
p < 0001). Life events show similar across-wave stability
with coefficients ranging from 021055 (all p < 0001). The
correlations between GHQ and life events were also examined and four of the GHQ-life events correlations are based
on GHQ and life events measures taken contemporaneously;
the mean of these is 031 and the range is 026039. Twelve
Table 1 Descriptive statistics (pairwise) for the variables used in the Working Minds study
Stress frequency*
Stress level*
GHQ 1994*
GHQ 1995
GHQ 1996
GHQ 1997
Life events 1994*
Life events 1995*
Life events 1996*
Life events 1997
All subjects
Male students
Female students
Male staff
Female staff
122
186
196
213
221
172
72
57
50
72
114
164
169
220
224
169
70
49
54
86
108
168
177
221
226
172
66
35
39
86
119
156
184
171
191
142
70
54
41
51
138
215
230
206
219
176
79
87
64
58
(38) 237
(80) 232
(101) 359
(118) 318
(131) 289
(108) 291
(49) 357
(54) 306
(43) 282
(48) 266
(45) 22
(84) 22
(96) 38
(130) 30
(146) 30
(97) 26
(47) 36
(55) 27
(45) 30
(57) 24
(33) 103
(70) 101
(85) 174
(109) 154
(122) 130
(109) 134
(46) 174
(39) 146
(38) 127
(49) 114
(29) 13
(57) 13
(97) 18
(85) 16
(118) 15
(66) 15
(33) 18
(41) 16
(38) 14
(38) 15
(36) 99
(85) 96
(114) 129
(129) 118
(140) 114
(115) 116
(54) 129
(58) 117
(44) 111
(43) 113
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278
273
R Watson et al.
Table 2 Descriptive statistics (listwise) for the variables used in the Working Minds study
Stress frequency
Stress level
GHQ 1994*
GHQ 1995*
GHQ 1996*
GHQ 1997*
Life events 1994
Life events 1995
Life events 1996
Life events 1997
All subjects
(n = 192)
Male
students
(n = 18)
Female
students
(n = 85)
Male
staff
(n = 12)
Female
staff
(n = 77)
122
188
190
192
207
167
72
56
48
73
113
161
179
228
213
161
66
45
54
92
108
167
164
194
215
166
66
33
37
85
120
158
158
157
177
128
70
58
30
49
138
221
223
187
202
176
80
83
61
60
(38)
(83)
(105)
(99)
(119)
(105)
(50)
(52)
(40)
(50)
(47)
(87)
(109)
(153)
(138)
(96)
(53)
(49)
(49)
(62)
(33)
(73)
(82)
(80)
(108)
(96)
(44)
(34)
(36)
(50)
(30)
(59)
(80)
(61)
(119)
(43)
(27)
(45)
(25)
(42)
(37)
(85)
(121)
(105)
(127)
(121)
(57)
(58)
(41)
(44)
Table 3 Correlations pairwise (below the diagonal) and listwise (above the diagonal; n = 192)
Stress frequency
Stress level
GHQ 1994
GHQ 1995
GHQ 1996
GHQ 1997
Life events 1994
Life events 1995
Life events 1996
Life events 1997
Stress
frequency
Stress
level
GHQ
1994
GHQ
1995
GHQ
1996
GHQ
1997
Life
events
1994
Life
events
1995
Life
events
1996
Life
events
1997
076 (231)
034 (237)
022 (227)
019 (222)
031 (237)
016* (237)
035 (219)
036 (217)
022 (232)
079
033
021
028
037
021
032
033
028
036
036
041
049
034
035
046
034
020
024
023
038
055
029
024
028
031
026
018*
030
048
044
041 (253)
035 (287)
026 (269)
034 (282)
030 (247)
034
039
035
027
039
018 (291)
025 (261)
016* (247)
032 (266)
014
021
033
017*
030
022
039 (304)
033 (280)
025 (266)
032
034
056
027
030
030
043
054 (263)
016* (245)
034
032
036
020
026
013
029
055
027 (242)
021
029
027
019*
030
039
028
021
029
(232)
(222)
(218)
(232)
(232)
(214)
(214)
(227)
(318)
(289)
(291)
(357)
(305)
(282)
(266)
(279)
(271)
(317)
(304)
(272)
(254)
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278
Life events
GHQ
GHQ
GHQ
GHQ
GHQ
Stress
1994
1995
1996
1997
1997*
level
372,
154,
256,
265,
165,
155,
<0001,
<0001,
<0001,
<0001,
<0001,
<0001,
Sex
009
005
009
009
007
007
40,
01,
02,
09,
01,
60,
Stress level
0047, 001
072, 000
067, 000
033, 000
071, 000
0015, 003
Mixed-effects analyses
Data were grouped into the following dropout time categories
for GHQ scores: Missing at all time points (n = 74; not used
in the analysis), Dropout after first time point (n = 19),
Dropout after second time point (n = 13), Dropout after
third time point (n = 34) and Completer or intermittent
responder (n = 293). Marital status was recoded into two
categories (Married/living with someone vs. Single/divorced/
separated/widowed).
First stage of analysis
The purpose of this stage of the analysis was to determine
what factors were associated with dropout from the study as
a necessary prelude to the next stage of the analysis. This
stage was carried out on SPSS 13 for Windows. Multinomial
regression of four dropout time categories (not assuming any
ordering) was used to determine whether status (newly
qualified nurses or nursing student), age, life event score,
marital status and sex were associated with missingness category. Only status was statistically significant (likelihood
ratio v2 = 10285, df = 3, p = 0016): newly qualified nurses
were more likely to be completers or intermittent responders
than nursing students. Ordinal regression, taking into
account the natural ordering in the dropout categories, gave
similar results; only status was statistically significant.
Second stage of analysis
The purpose of this stage of the analysis was to determine
what was associated with, or predicted, GHQ scores and
change in GHQ scores. This stage of the analysis was carried
out on R version 220. Linear mixed models were fitted
assuming missing at random data. In this missing at random
analysis, the following were examined:
1 A random slope for time of GHQ measurement (year,
treated as continuous) and a random slope for life events
(treated as continuous);
2 A variety of correlation structures for the repeated GHQ
scores;
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278
275
R Watson et al.
Parameter
Estimate
Intercept
Age
Life events
Married (married/living
with someone)*
Sex (female)*
Status (staff)
Time
Status (staff) time
SE
t-Value
p-Value
95% CI
(5543,
(0086,
(0172,
( 2048,
9560
0211
0294
0533
2047
0063
0062
0772
467
333
473
069
<0001
0001
<0001
049
1940
4036
0089
1234
1162
1263
0288
0426
167
320
031
290
0095
0001
076
0004
1358)
0335)
0415)
0981)
( 0340, 4221)
(1558, 6513)
( 0477, 0654)
( 2069, 0398)
increases, GHQ score is predicted to increase. Other covariates, although not statistically significant, point in the
expected directions. The details of a validity check on the
data are appended (Appendix 1).
Discussion
Previous work by the present investigators (Deary et al. 2003)
and others has demonstrated that stress and psychological
distress are related in nurses and nursing students. This has
implications for work-related illness and attrition in both
groups. The present study, using longitudinal data and
advanced statistical analysis, has added significantly to this
knowledge base by demonstrating that, in addition to stress,
there is an effect on psychological distress of life events and
the trait of self-esteem. In addition, there is a combined effect
of age and life events on psychological distress. Measured
over the same time, from start of nursing education and start
of nursing career, this study has shown that psychological
distress is higher initially in newly qualified nurses but that
this falls to the same level as nursing students over four years.
Possible limitations of this study include the use of a nonstandard measure of stress making direct comparisons with
other studies difficult; the lack of a comprehensive measure of
personality traits at baseline which could have provided
insight into subsequent individual differences and the fact
that the transition from nursing student to newly qualified
nurses nurse was not followed through in individuals.
Despite limitations, in terms of the transactional model
of stress which was the theoretical underpinning for
the present study the longitudinal design with repeated
276
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278
Acknowledgements
Working Minds was established by Robert Wrate and the late
Pamela Baldwin who was Chief Investigator for the present
project which was funded by the Chief Scientist Office for
Scotland. Data were collected and initially entered onto SPSS
by Marjory Dodd. Funding from the Chief Scientist Office for
Scotland for this present study is acknowledged. Ian Deary is
the recipient of a Royal Society-Wolfson Research Merit
Award.
Contributions
Study design: RWr, ID, RWa; data collection and analysis:
RWr, AS, HG, RW, ID, EG and manuscript preparation:
RWa, ID, RH.
References
Baldwin PJ (1999) Nursing. In Stress in Health Professionals (FirthCozens J & Payne RL eds). John Wiley & Sons Ltd, London, pp.
93104.
Chang EM & Hancock K (2003) Role stress and role ambiguity in
new nursing graduates in Australia. Nursing Health Science 5,
155163.
Chang EM, Hancock KM, Johnson A, Daly J & Jackson D (2005)
Role stress in nurses: review of related factors and strategies for
moving forward. Nursing and Health Sciences 7, 5765.
Appendix 1
The purpose of this third stage of analysis is mainly as a
statistical validity check. Stage 2 attempts to answer
primary research questions but assumes that the probability
of dropout does not depend on the missing GHQ scores
that would have been observed. As mentioned, stage 2
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278
277
R Watson et al.
makes what is known as the missing at random assumption. Stage 3 attempts to see whether the findings from
stage 2 change when this assumption is not made. This
stage of the analysis was also carried out on R version
2.2.0. We proceeded with the mixed model containing the
fixed main effects of age, life event score, sex, status, time
and marital status, the fixed status time interaction, no
random effects and a general covariance structure (no
constraints on correlations or variances of the repeated
GHQ scores). Sensitivity analyses were performed by
adding interaction terms involving the dropout times and
covariates as additional terms to this linear mixed model to
obtain pattern mixture models (Fitzmaurice et al. 2001). In
these models, missing data are no longer assumed to be
missing at random: the possibility that the likelihood of
data being missing is dependent on the unobserved GHQ
scores is permitted. Fitzmaurice et al. (2001) indicate that
the dropout time may be treated as a factor, and this
was performed here. However, the standard errors reported
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2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 270278