sample case study psychiatric nursing

Case Study 1: Psych Patient in ED

Aaron Smith, age 20, is a psychiatric patient with bipolar disorder. At the request of his father, he is brought by police to the Emergency Department. This is his third visit to the ED for psychiatric treatment this year.

Personal History and Recent Events

Last month, Aaron was expelled from his college dorm due to aggressive behavior and substance abuse. He has moved back into his parents' home. Today, in an outburst, he put his fist through a wall and then turned his rage toward his father. His parents suspect he has stopped taking his medication for bipolar disorder.

Aaron's Demeanor upon Arrival

Aaron displays classic signs of potential to become violent. These include:

• disheveled appearance
• clenched fists

Cues from Hospital Records

A quick look at Aaron's hospital records reveals a history of violent behavior:

• Aaron is being treated for bipolar disorder with prescribed medications.
• He has had two other recent ED visits before this one: once for disruptive, violent behavior, and once for a drug overdose.
• He rated "high" for dangerousness on assessment from a previous visit.

Triage Reveals Suicidal Thoughts

The triage nurse questions Aaron to help determine the extent of present danger. After several prompts to get beyond surface answers, the nurse learns that besides his violent outburst at home, Aaron had planned to kill himself by crashing his car, which increases his risk of danger to others.

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Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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Patient Case Navigator: Major Depressive Disorder

Welcome to the Patient Case Navigator, an interactive learning experience for Nurse Practitioners. Please use the Next or Previous buttons at the bottom of the page to move forward or backwards.

Recommended on NP Psych Navigator

Disease Primer

Major depressive disorder (MDD) is one of the most recognized mental disorders in the United States. Learn more about the prevalence, pathophysiology, diagnosis, and management of MDD here.

Clinical Article

State-Dependent Differences in Emotion Regulation Between Unmedicated Bipolar Disorder and Major Depressive Disorder

Rive et al use functional MRI to look at some of the differences between patients with bipolar depression and major depressive disorder.

Unrecognized Bipolar Disorder in Patients With Depression Managed in Primary Care: A Systematic Review and Meta-Analysis

Daveney et al explore the characteristics of patients with mixed symptoms, as compared to those without mixed symptoms, in both bipolar disorder and major depressive disorder.

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• Section One: Introduction
• Section Two: Learning and Teaching Resources to Support Integration of Mental Health and Addiction in Curricula
• Section Three: Faculty Teaching Modalities and Reflective Practice
• Section Four: Student Reflective Practice and Self-Care in Mental Health and Addiction Nursing Education
• Section Five: Foundational Concepts and Mental Health Skills in Mental Health and Addiction Nursing
• Section Six: Legislation, Ethics and Advocacy in Mental Health and Addiction Nursing Practice
• Section Seven: Clinical Placements and Simulations in Mental Health and Addiction Nursing Education
• Section Eight: Reference and Bibliography
• Section Nine: Appendices and Case Studies

Section Nine

Case studies, also in this section.

• Alignment between CASN/ CFMHN Entry-to-Practice Mental Health and Addiction Competencies and Sections in the Nurse Educator Mental Health and Addiction Resource
• Process Recording
• Criteria for Validation: Process Recording
• Criteria for Phase of Relationship: Process Recording
• Journaling Activity
• Safety and Comfort Plan Template
• Advocacy Groups for Mental Health in Canada
• Tips for Engaging Lived Experience
• Glossary of Terms
• Case Study 1
• Case Study 2
• Case Study 3
• Case Study 4
• Case Study 5
• Case Study 6
• Case Study 7
• Case Study 8
• Case Study 9

The case study is an effective teaching strategy that is used to facilitate learning, improve critical thinking, and enhance decision-making Sprang, (2010). Below are nine case studies that educators may employ when working with students on mental illness and addiction. The case studies provided cover major concepts contained in the RNAO Nurse Educator Mental Health and Addiction Resource.

While not exhaustive, the case studies were developed and informed by the expert panel. It is recommended that educators use the case studies and tweak or add questions as necessary to impart essential information to students. Also, educators are encouraged to modify them to suit the learning objective and mirror the region in which the studies are taking place. Potential modifications include:

• demographics (age, gender, ethnicity);
• illness and addiction, dual diagnosis or additional co-morbidities such as cardiovascular disease; and
• setting (clinical, community).

Suggested “Student questions” explore areas of learning, while “Educator elaborations” recommend ways to modify the case study. Discussion topics are a limited list of suggested themes.

When using these case studies, it is essential that this resource is referenced.

See Engaging Clients Who Use Substances BPG appendices for examples

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Case Studies

Case 5: denise.

Denise, a 19-year-old woman, has been admitted informally to an acute mental health ward; this is Denise's first admission. Denise was being treated for depression by her GP; prior to her admission Denise attempted to kill herself by cutting her wrists. Subsequently a short admission was arranged with the aim of devising a comprehensive care package.

After speaking about the circumstances leading up to her suicide attempt Denise became increasingly tearful and distressed, and started demanding to see a doctor. After being told that the doctor was on their way and would arrive in about 10 minutes, Denise became angry demanding medication to calm her down; she then proceeded to run towards the ward's doors shouting that she wanted to go home. At that moment the doctor arrived on the ward and Denise also immediately calmed down.

During the assessment process Denise disclosed that being angry if she did not get her way was not unusual for her. She also mentioned that she felt awful after these bouts of anger. She described herself as a "terrible person who was out of control" and she just wanted to die. After assessing Denise the nurse started to formulate a plan of care.

(a) What type of psychological interventions would the nurse consider implementing?

Show Answer

• Build a collaborative and therapeutic relationship based on a person-centred approach.
• Normalise an individual's experiences of mental distress.
• Take a "strengths approach".
• Maintain safety and effectively manage challenging behaviours.
• Explore the individual's capacity to change.
• Modify thought processes – identify, challenge and replace negative thoughts.
• Focus on the individual controlling and regulating their behaviour – promoting and enhancing healthy ways of coping.
• Prevent social isolation and promote social functioning.
• Focus on relapse prevention – early warning signs and self-monitoring of symptoms.
• Signpost to self-help and relevant support groups.
• Therapeutically support recovery.

(b) Currently Denise has been admitted informally to the ward. Due to Denise's impulse control difficulties this may change. On this basis what does the nurse professionally need to know when managing Denise's legal status?

• Understand and apply current legislation in a way that protects Denise.
• Act in accordance with the law, relevant ethical and regulatory frameworks, and also take into account local protocols/policies.
• Respect and uphold Denise's rights
• Know when to actively share personal information with others when the interests of safety and protection override the need for confidentiality.

(c) Denise is subsequently diagnosed with a "borderline personality disorder". What other types of personality disorders are there?

• Cluster A – paranoid, schizoid and schizotypal.
• Cluster B – antisocial (type: dissocial), borderline (type: emotionally unstable), histrionic, and narcissistic (not included in types).
• Cluster C – avoidant (type: anxious), dependent, obsessive-compulsive (type: anankastic).
• paranoid – suspicious and excessively sensitive;
• schizoid – emotional coldness, little interest in other people;
• schizotypal – odd beliefs and unusual appearance;
• borderline – instability of mood, impulsive;
• histrionic – excessive attention seeking;
• narcissistic – grandiose and arrogant;
• antisocial – disregard of self and others;
• avoidant – feelings of inadequacy;
• dependent – submissive behaviour;
• 0bsessive-compulsive – a preoccupation with orderliness.

(d) What specific psychological interventions would the nurse deliver?

• boundary setting;
• promoting healthy ways of coping;
• motivational interviewing and pre-therapy work;
• delivering specific therapeutic approaches/therapies.

(e) How could the nurse learn from their experiences of working with Denise?

• identifying and describing the experiences;
• examining the experiences in depth and teasing out the key issues;
• critically processing the issues;
• learning from the experiences by implementing future actions that improve the nurse's practice.

Denise has now been on the ward for over 6 months. Each time discharge has been arranged Denise self-harms or threatens suicide. Denise has now agreed to go to a therapeutic community, a place has been secured and Denise is now engaging in pre-therapy work.

(a) What other treatments besides a therapeutic community are recommended for individuals diagnosed with a borderline personality disorder?

• cognitive behaviour therapy – group and individual;
• behavioural approaches;
• mentalisation-based approaches;
• dialectic behaviour therapy.

(b) While working with Denise the primary nurse has found the relationship at times to be quite stressful. What are the signs of stress?

• sleep problems;
• loss of appetite;
• difficulty concentrating;
• constantly feeling anxious;
• feeling irritable and/or angry;
• having repeating thoughts;
• avoiding certain situations and/or people;
• an increased use of alcohol;
• muscle tension.

(c) What strategies could the nurse use to manage their stress?

• engage in physical activity;
• engage in something that makes them laugh;
• learn relaxation and/or deep breathing techniques;
• take control of the situation;
• seek support and talk;
• problem solve;
• eat a healthily diet;
• drink plenty of water;
• be mindful.

(d) What process should be utilised as a way to support the primary nurse to improve their practice?

Correct answer: A common method of systematically reflecting on practice is through the clinical supervision, which is a formal activity where a clinical supervisor facilitates the nurse to reflect upon their practice and identify strategies that focus on improving their practice.

Consider Chapters 20, 34 and 37.

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Sample Case Presentation in Psychiatric Nursing Case Analysis

Because the pros and cons for the use of medicine in psychiatry are not absolutely clear or agreed upon, strong arguments have risen on all sides. The objective of this paper is not to create a division in the clinical practice. Rather, to present an example of how to use a model in the analysis of understanding the patient behavior.

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The purpose of this project was to develop a repository of NextGen NCLEX case studies that can be accessed by all faculty members in Maryland.

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The case studies are in a Word document and can be modified by faculty members as they determine. 

NOTE: The answers to the questions found in the NextGen NCLEX Test Bank  are only available in these faculty case studies. When students take the Test Bank questions, they will not get feedback on correct answers. Students and faculty should review test results and correct answers together.

The case studies are contained in 4 categories: Family (13 case studies), Fundamentals and Mental Health (14 case studies) and Medical Surgical (20 case studies). In addition the folder labeled minireviews contains PowerPoint sessions with combinations of case studies and standalone items. 

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Effective nurse–patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance

Samantha hartley.

a Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester M139PL, United Kingdom

b Pennine Care NHS Foundation Trust, Ashton-under-Lyne OL6 7SR, United Kingdom

Jessica Raphael

Karina lovell.

c Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M139PL, United Kingdom

Katherine Berry

Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships.

We aimed to collate and critique papers reporting on interventions targeted at improving the nurse–patient therapeutic alliance in mental health care settings.

Systematic literature review.

Data sources

The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted.

Review methods

Original journal articles in English language were included where they reported on interventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment.

Relatively few eligible papers ( n  = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality.

Conclusions

The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.

What is already known about the topic?

• • The therapeutic relationship between nursing staff and patients in mental health care is key to positive outcomes.
• • Therapeutic alliance is a multi-faceted concept that is valued by patients while being difficult for staff to develop.

What this paper adds

• • Interventions targeting the therapeutic alliance were identified; including training, psychological formulation, reflective groups, consultation and shared activity.
• • The review showed that none of these is as yet confirmed effective and that the methodological quality of the evidence base at present is predominantly poor.

1. Introduction

Nursing staff are the core of the caring profession and central to their role is the development of effective relationships with the individuals they support ( Hoeve et al., 2014 ; Zugai et al., 2015 ). In the United Kingdom, engaging meaningfully with patients (rather than ‘doing to’) runs through the principles of the nursing profession ( Royal College of Nursing, 2010 ); while in the United States, the interpersonal relationship is seen as foundational to a person-centred, recovery-oriented approach within mental health nursing ( Kane, 2015 ). Internationally, the alliance features heavily in the remit of European and Australasian nursing associations, who highlight the need for human connection and the ability to demonstrate effective therapeutic relationships ( Australian College of Mental Health Nurses, 2018 ; World Health Organisation, 2003 ).

The nursing relationship has been conceptualised as ‘a significant therapeutic interpersonal process [that] functions co‐operatively with other human processes that make health possible for individuals and communities’ ( Peplau, 1988 , p. 16). This therapeutic alliance—the relationship connecting professional and service user—is between one human and another, with a uniqueness of each dyad ( Forchuk, 1995 ), which therefore requires renewed efforts at each new pairing. Nurses see the development of the alliance as requiring a convergence of interpersonal professional skills with personal life experience ( Scanlon, 2006 ) and clients view it as life-sustaining in its ability to foster collaboration and a sense of being understood ( O'Brien, 2001 ). The concept has recently enjoyed a renewed focus, with an emphasis on consumer-models that encourage personal recovery assisted by therapeutic alliance ( Zugai et al., 2015 ).

Therapeutic alliance has the greatest impact on treatment outcomes for those with mental health difficulties, over and above the specific mode or model of intervention that is provided ( Duncan et al., 2010 ; Martin et al., 2000 ; Messer and Wampold, 2002 ; Priebe and McCabe, 2006 ; Wampold, 2001 ). Emerging initially within the psychoanalytic discipline and later generalised to multiple therapeutic contexts, the concept of alliance has been defined as an agreement on goals, tasks and a therapeutic bond between therapist and client ( Bordin, 1979 ). The phenomena can be measured using various tools from both the perspective of the professional and service user, with important differences between the two ( Bachelor and Salamé, 2000 ; Fitzpatrick et al., 2005 ). In an age of increasingly remote therapeutic interactions, the alliance and concomitants of it are still seen as intrinsic to change, whether therapy is facilitated by phone ( Mulligan et al., 2014 ), online dialogue ( Cook and Doyle, 2002 ) or even fully-automated chat-bot ( Fitzpatrick et al., 2017 ).

Traditionally, research has focused on understanding and improving the alliance between therapist and client; as part of one-to-one, psychotherapeutic interventions ( Lambert and Barley, 2001 ; Martin et al., 2000 ). In contrast to these direct therapy roles, there are also staff members who adopt a care coordination role or act as a key worker; assessing, engaging and organising care with individuals ( Burns, 2004 ; Simpson, 2005 ; Thurston, 2003 ). All of these roles inevitably involve the building and maintenance of an effective alliance and therefore research has shifted to include definitions and exploration of the relationship as built within these guises ( Farrelly et al., 2014 ; Kirsh and Tate, 2006 ), where it remains correlated with outcomes ( Cruz and Pincus, 2002 ; Howgego et al., 2003 ) and is developed in a range of settings.

As part of secondary care community services, nursing staff coordinate care and deliver brief therapies, which despite (or possibly because of) their short-term nature require the adept building of alliance. People supported by secondary care services are those experiencing severe mental health difficulties, often in the context of challenging relational and social circumstances. Here, nurses strive to develop mutuality, reciprocity, synchrony, and sense of belonging with their clients ( Spiers and Wood, 2010 ) and clients value being known and related to as a person rather than service-recipient ( Shattell et al., 2007 ), requiring a skilful use of the self ( O'Brien, 2000 ). Service users value therapeutic relationships with care coordinators in community settings, and view these as central to recovery; over and above the role of specific care plans ( Simpson et al., 2016 ). These complex processes are rendered difficult for staff members by burnout, struggles building engagement with patients and ineffective team-working ( Koekkoek et al., 2011 ; Singh, 2000 ), with the nature of organisational structures and roles limiting the care that nurses can provide ( Simpson, 2005 ).

The therapeutic role of nursing staff in mental health care is especially pertinent in settings such as inpatient wards, where patients interact with nurses for the largest proportion of time and the relationship with them is cited as key to therapeutic progression ( Hopkins et al., 2009 ; McAndrew et al., 2014 ), with a perceived interplay between therapeutic relationships and the quality of care ( Coffey et al., 2019 ) . Engagement in these challenging contexts requires a balance of approaches, the development of personalised understanding and use of the self to facilitate recovery-oriented growth of the patient ( McAllister et al., 2019 ). However, how these specific competencies can be developed is not fully elucidated in the literature or supported by service structures. The alliance can be impeded by individual and organisational factors that leave it unseen and stifled in practice ( Pazargadi et al., 2015 ), with nurses left to negotiate contradictory and challenging relational minefields ( Cleary et al., 2012 ).

Despite the potential value and best efforts, attempts to develop strong nursing alliance in mental health care can be hampered by challenging settings where its development is impeded ( McAndrew et al., 2014 ). Moreover, interactions between nursing staff and patients are often not supported or guided by the psychological theory of relationships; there is a substantial theory-practice gap ( Cameron et al., 2005 ) that might leave both staff and service users vulnerable to relational difficulties and the consequent impact on wellbeing and outcomes. It seems that services, patients and staff place value on the therapeutic alliance, its core attributes have been explored and conceptualised, and yet theoretically-driven, evidenced systems that support its development and maintenance are lacking. With this deficiency in targeted support, staff members increasingly report feeling burnt-out as a result of managing complex and emotionally difficult relationships ( Holmqvist, and Jeanneau, 2006 ; Nathan et al., 2007 ). This could lead to compassion sometimes waning when it is needed most ( Lombardo, and Eyre, 2011 ; Ray et al., 2013 ) and staff retention proving extremely difficult, with subsequent strategic priorities to improve this in both the United Kingdom and internationally ( Andrews, and Wan, 2009 ; European Commission, 2014 ; NHS, 2019 ; Parliament of Australia, 2002 ).

There has been some tentative progress in supporting effective relationships, with indications that clinical supervision can protect against staff burnout ( Edwards et al., 2006 ) and psychologically-informed case discussions can enhance positive feelings towards service users and reduce staff self-blame ( Berry et al., 2009 ). Team-based training to develop staff skills using psychological models can even improve patient engagement with the service ( Caruso et al., 2013 ). However, there is no comprehensive, critical summary of interventions that have specifically targeted the element of treatment that we know is essential; the therapeutic alliance, for the group who potentially has the capacity and context to deliver compassionate, caring relationships; nurses.

In conducting this review, we systematically collated and critiqued studies reporting on interventions targeting the therapeutic relationship between nursing staff and service users in mental health settings. We aimed to answer some key questions; what intervention methods have been tested, in what clinical contexts and with which groups, what outcome measures were utilised, what effects were demonstrated and what was the quality of the methods used.

3.1. Protocol and registration

The review protocol was pre-registered and is available online within the international prospective register of systematic reviews (PROSPERO) under the registration number CRD42018111022.

3.2. Criteria for inclusion

Papers were considered eligible for inclusion if they: were published as an original, peer-reviewed journal article; written in English; included an intervention aimed to improve the therapeutic relationship between nursing staff and user/s of psychiatric or mental health services; included analysis of the impact of the intervention utilising a standardised measure of alliance. The review includes studies from any mental health service context (such as community, inpatient), client groups of any age, with any mental health diagnosis or need and interventions targeted at the relationship with either qualified or non-qualified nursing staff. Where the staff group incorporated other disciplines, these findings were still eligible if that included nurses in the overall sample.

3.3. Search methods

The current review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( Moher et al., 2009 ). Search terms were generated through review of empirical and opinion pieces regarding alliance and systematic review papers of alliance (for example, Elvins, and Green, 2008 ; Flückiger et al., 2012 ; Horvath, and Luborsky, 1993 ; Priebe, and McCabe, 2006 ; Zaitsoff et al., 2015 ), scoping literature searches and consultation with experts in the field. A systematic search of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases was conducted on 05/07/18 and then updated on 04/04/19 using the following search strings: (nurse* OR nursing OR staff) AND (alliance OR relationship*) AND (mental OR psychiatry*) AND (improve* OR interven* OR change OR support). The reference lists of eligible papers were also consulted for any additional studies and a forward citation search undertaken.

3.4. Data collection and analysis

All potentially eligible records were imported into Endnote reference management software package (Version 8) and duplicate references identified and deleted. One reviewer screened titles and abstracts for relevance, using the inclusion criteria set out above and alongside regular discussion with the research team. Another independent reviewer blindly assessed 50% (randomly selected) of the full texts against the inclusion criteria demonstrating 88% agreement, with any remaining disagreements resolved through discussion with the project team, resulting in full agreement. Data extraction was guided by a pre-specified data extraction sheet detailing key features of the study: sample, setting, design, intervention, outcome measure, analysis, effect size, limitations. Authors were contacted where effect size data was not available in the original paper. The review used a narrative synthesis approach, whereby an attempt was made to go beyond a description of the studies to explore relationships within and between them ( Popay et al., 2006 ).

3.5. Assessment of methodological quality

In order to evaluate the methodological rigour of the studies included and therefore to inform the critical synthesis of the findings produced and subsequent recommendations, the papers were assessed using a standardised quality tool. There is a distinct lack of assessment tools that fulfil both the need to be demonstrably reliable and valid and also appropriate for use with a range of study designs. Based on a previous review of quality assessment tools ( Deeks et al., 2003 ), the Effective Public Health Practice Project tool ( Effective Public Health Practice Project, 1998 ) was selected as one that could offer valid ( Thomas et al., 2004 ), reliable ( Armijo-Olivo et al., 2012 ) and flexible appraisal of varying study designs. All of the eligible papers were assessed for quality by the first author and blind second-rated, with 86% agreement demonstrated. Initial ratings from the first author were reviewed collaboratively with the second rater and a decision was made to retain these scores.

4.1. Flow of records

The flow of records through the review process can be seen in Fig. 1 , in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines ( Moher et al., 2009 ). The search resulted in a total of eight papers which met inclusion criteria. These are summarised in Table 1 .

Flow of records

Summary of papers and quality ratings.

4.2. Methodological quality

Table 1 provides the overall quality rating for each paper, based on the constituent ratings of the Effective Public Health Practice Project tool and its guideline procedure. Full details of the ratings are available from the first author. As is evident, six of the eight studies were rated as weak methodologically. Berry et al. (2016) was the only study that met ‘strong’ design criteria, while Moreno-Poyato et al. (2018) was deemed moderate. The studies were predominantly down-rated due to lack of randomised designs, blinding, confounder control and full reporting of retention information.

4.3. Participant and settings

The eligible papers included interventions delivered in a range of settings (inpatient and community services, acute, rehabilitation), in a number of different countries (United Kingdom, Australia, Sweden, Spain, Netherlands) for individuals with a range of conditions under the umbrella of severe mental health problems, including psychosis and difficulties associated with a diagnosis of personality disorder. As per the inclusion criteria, all studies targeted the relationship between mental health nursing staff and service users, although there were a range of additional criteria. The range of settings and participants is reflective of the variety of roles and services within which the therapeutic alliance is fostered.

4.4. Interventions

The interventions varied in scope, focus and theoretical underpinning. Berry et al. (2012 , 2016 ) drew on psychological formulation (allied mainly to a cognitive behavioural model) to foster understanding of drivers for patients’ behaviour and clinical presentation within staff group workshops. Carpenter et al. (2007) offered group training in psycho-social interventions that included focus on specific models and also core values of therapeutic engagement. Kellett et al. (2019) utilised a consultancy model provided to pairs of staff members and service users, with cognitive analytic therapy as the underlying approach. Molin et al. (2018) focused on the structure of ward timetables, creating space for time spent together between nursing staff and patients, providing opportunity for joint activities and meaningful engagement. The authors involved staff on each ward in the precise implementation structure to provide a good fit to routine ward activities and preferences. Moreno-Poyato et al. (2018) utilised a participatory action research approach whereby the nurses involved in the study generated intervention elements in a bid to reach best practice, which ultimately involved daily interactions with individual patients, reflective groups for staff and study of scientific texts as selected by staff. Stringer et al. (2015) adopted a broad-based collaborative care programme that consisted of elements including understanding (via timeline work), structural changes (teams, treatment plans), specific interventions (problem solving) and psycho-education. The primary focus of Byrne and Deane's (2011) intervention was to improve medication adherence, with the alliance targeted as a mediating variable, involving modifying clinician beliefs about non-adherent patients that can pose barriers to the relationship and support for adherence.

4.5. Outcome measurement

The majority of the studies ( Berry et al., 2012 , 2016 ; Byrne and Deane, 2011 ; Kellett et al., 2019 ; Moreno-Poyato et al., 2018 ) utilised the Working Alliance Inventory (WAI; Horvath and Greenberg, 1989 ) as the primary alliance outcome, reflecting its prominence in the literature, although only Berry et al. (2016) and Kellett et al. (2019) used both the patient- and clinician-rated version, with the rest opting for the latter only. Others ( Molin et al., 2018 ; Stringer et al., 2015 ) used the Caring Professional Scale ( Swanson, 2000 ), as rated by service users and the scale to asses therapeutic relationships (STAR; McGuire-Snieckus et al., 2007 ), respectively. Carpenter et al. (2007) relied on a non-validated but user-defined outcome scale ( Barnes et al., 2000 ), which included numerous items relevant to the alliance; including involvement, listening and understanding.

Four of the eight included studies reported no statistically significant difference as a result of the intervention in terms of assessed therapeutic alliance ( Berry et al., 2012 , 2016 ; Molin et al., 2018 ; Stringer et al., 2015 ). Molin et al. (2018) did not provide data to facilitate a more nuanced interpretation. Berry et al. (2016) findings are intriguing as staff-rated alliance was better for the control than intervention group (similar to Berry et al., 2012 ), whereas client-rated alliance delivered a large effect size in favour of the intervention, which was presumably then diluted by a more rigorous analysis method in their strongly rated study. Stringer et al. (2015) showed a small effect in favour of the intervention group at nine months, although crucially, both groups declined in reported alliance through the course of the intervention period, leaving the findings difficult to interpret and confounded by a weak study design.

Carpenter et al. (2007) did not report longitudinal statistical improvement but did find a difference between the intervention and control groups in terms of user-rated involvement with staff, although sufficient data was not available to comment on the size of this effect and the weak study quality rating detracts from the significance. Byrne and Deane (2011) reported a statistically significant change in Working Alliance Inventory scores between baseline and six months following the alliance intervention with a medium effect size, although no improvement at 12 month follow-up and concerns raised by the weak study quality rating. Moreno-Poyato et al. (2018) demonstrated a significant difference in post-intervention alliance scores between the active and comparison group, with a median difference of 7 scale points, and large effect size. This study was one of only two in the review to score better than a weak rating in terms of quality assessment, placing more weight on the potential effectiveness of their collaboratively developed intervention. Kellett et al. (2019) demonstrated statistically significant change and a large effect size improvement for client-rated alliance in their case series study, but not for staff-rated alliance or for their larger ( n  = 12 staff-client pairings) pre-post service evaluation. The weak study rating also means that these findings should be interpreted with caution, despite the encouraging ratings from service-user perspectives.

5. Discussion

We set out to collate and synthesise information pertaining to interventions that aim to support effective therapeutic alliance between nursing staff and users of mental health services, which has been shown to be central to positive outcomes in both psychotherapy and broader engagement contexts ( Cruz and Pincus, 2002 ; Duncan et al., 2010 ; Howgego et al., 2003 ; Martin et al., 2000 ; Messer and Wampold, 2002 ; Priebe and McCabe, 2006 ). The central finding of note, in the authors’ view, is the dearth of studies in this area. It seems surprising that an element of care that is so intrinsic to both patient progress and clinician role does not have a robust evidence base on which to draw in order to provide effective foundations for its development and maintenance. It might be that this has emerged from an assumption of alliance building and maintenance as an implicit ability rather than a skill to be honed and scaffolded, or of the difficulty in addressing a complex issue with a readily-evaluated design.

The evaluated interventions adopted a range of methods, including psychosocial approaches ( Berry et al., 2012 , 2016 ; Carpenter et al., 2007 ; Kellett et al., 2019 ), those targeting specific clinician attitudes ( Byrne and Deane, 2011 ) and those derived from action research, where the intervention content was collaboratively developed with staff in an attempt to bridge the gap between current and best practice ( Moreno-Poyato et al., 2018 ). The lack of a coherent, shared theoretical underpinning might contribute to the deficiency of robust research and consistent evidence base. The interventions largely consisted of group-based programmes, whereas the relationship that is predominantly measured is a dyadic one between one nurse and one service user; this discrepancy might be contributing to lack of consistent positive change. Kellett et al. (2019) did demonstrate change when the dyadic relationship was specifically targeted and measured as such in the context of a dynamic consultation approach rather than workshop-based training. It is also not entirely clear what level of public (staff and/ or service user) involvement there was in the development of the intervention packages, which might have enhanced the feasibility, acceptability and ultimately, impact ( Brett et al., 2014 ).

Data gathered by the current review do not permit recommendations in terms of effective interventions and their theoretical underpinnings. The evolution of the concept of the therapeutic alliance, from one of dyadic and confined psychotherapeutic engagement to one that often spans relationships within complex team structures, with multiple professionals at once and in varying roles outside of the narrow remit of formal therapy no doubt contribute to the difficulty in developing interventions that are sufficiently targeted yet appropriately flexible. Given the nuanced conceptualisation of the core elements of therapeutic relationships between different settings ( Cleary et al., 2012 ; McAllister et al., 2019 ; O'Brien, 2000 ; Pazargadi et al., 2015 ; Shattell et al., 2007 ; Spiers and Wood, 2010 ), it might be that the development of an alliance intervention needs to draw from both theoretical understanding, alongside setting-based contextual needs, which will need to be explored and supported in situ.

As the methodological quality assessment indicates, the studies were predominantly under-controlled, with a lack of randomised designs and matched comparison groups or controls. This limits conclusions that can be drawn even from those studies where positive outcomes were identified. The relatively small samples sizes might also have limited statistical power to detect differences, and those studies that showed promise in terms of effect sizes will need to be replicated with more adequate samples and appropriate statistical control. Few studies checked the validity of their intervention with any kind of fidelity tool ( Santacroce et al., 2004 ). It is therefore also possible that negative outcomes were due to a dilution of or divergence from the intervention protocol, rather than necessarily an intrinsic limitation of the active elements. The lack of statistical control also highlights difficulties central to the issue of intervention design and evaluation in this field. As the alliance is conceptualised as a reciprocally developed, genuine human connection, then how can this be reliably supported and measured between different pairs of individuals, where the goals, needs and definition of the relationship will be inherently idiosyncratic? The current review therefore also points to the need for a range of evaluation methods, alongside the development of controlled trials, which can adequately capture the key elements of the alliance both in terms of supporting its development and evaluating its progress.

Most studies chose to measure outcome using the working alliance inventory. Although fairly ubiquitous, this might be somewhat problematic. The Working Alliance Inventory is a tool designed for use in the context of therapy that does not fully converge with the nature of a nurse–patient relationship, which might often be more accurately conceptualised as a therapeutic key worker role, where therapeutic conversations might be had in the context of a broader care-coordination or care-planning role ( Burns, 2004 ; Simpson, 2005 ; Thurston, 2003 ). Thus, the relationship of interest and its quality might not be accurately evaluated by the use of Working Alliance Inventory. In terms of the source of the ratings, two studies that reported mixed findings ( Kellett et al., 2019 ; Berry et al., 2016 ) demonstrated larger effect sizes for the client perspective as compared to the staff member. This underscores the importance of considering multiple sources but also the need to elaborate on the best method for determining good relational outcomes, especially since client-rated alliance is the better predictor of therapeutic progress ( Bachelor, 1991 ; Fitzpatrick et al., 2005 )

5.1. Strengths and limitations of the review

We aimed to provide a comprehensive and critical summary of current evidence pertaining to intervention to support nursing staff in their therapeutic relationships with people utilising mental health services. The systematic, thorough nature of the review offers a contribution to an important area of literature hitherto unreported. The small sample of studies is reflective of the field as it stands while also limiting the utility of the review and it will be important to repeat the process as the evidence based develops, incorporating more nuanced analysis of the findings and methods and robust meta-analysis or meta-synthesis, where the nature of the interventions delivered and their qualitative impact could be more fully explored. Our decision to include both qualified and non-qualified staff interventions, and to include studies whose sample include nurses alongside other staff groups was pragmatic in nature to ensure any relevant intervention was highlighted, particularly in a limited evidence base. However, future work might wish to consider how to delineate samples more precisely and thus provide evidence best-suited to the target discipline. This review has focused on interventions that specifically target the therapeutic alliance as a core aspect of effective mental health care. It is acknowledged that the alliance is part of the approach of other modality-specific therapies, such as cognitive behavioural therapy, dialectical behaviour therapy or cognitive analytic therapy ( Bennettet al., 2006 ; Bedics et al., 2015 ; Gilbert, and Leahy, 2007 ). Therefore, synthesising findings from modality-specific intervention research, where the alliance might be evaluated as a mechanism of change, with the current, more focused conceptualisation might be warranted.

5.2. Clinical implications and recommendations for future work

The nature of the evidence base as it stands renders it difficult to make clear clinical recommendations in terms of how nursing staff should be best supported to develop and maintain effective therapeutic relationships with the individuals they work with in the settings they operate. There is some indication that interventions targeting clinician attitudes and reflective capacity, relational understanding and dynamic interactions might be helpful, although further work is needed. There is also a relative absence of service user and clinical staff involvement in the development of the reported interventions, which might limit their acceptability and feasibility. This paper, therefore, should serve as an impetus to develop a clear trajectory of research endeavours that build on the current findings and creates a more robust body of work incorporating the following key elements: i) intervention based on strong theoretical underpinnings and service user and clinician involvement; ii) methodologically sound studies; iii) assessment of fidelity to the intervention model; iv) targeting and evaluation of the alliance aligned with its conceptualisation as a dyadic, mutual, professional relationship outside the specific bounds of psychotherapy.

Conflict of interest

Dr Samantha Hartley is funded by a National Institute for Health Research (NIHR) Integrated Clinical Academic Clinical Lectureship for this research project. This paper presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Mental Health and Psychiatric Nursing NCLEX Practice Questions Nursing Test Bank (700+ Questions)

Welcome to your ultimate NCLEX practice questions and nursing test bank for mental health and psychiatric nursing. For this nursing test bank, test your knowledge on the concepts of mental health and psychiatric disorders. This quiz aims to help students and registered nurses grasp and master mental health and psychiatric nursing concepts.

Mental Health and Psychiatric Nursing Test Banks

In this section, you’ll find the NCLEX practice questions and quizzes for mental health and psychiatric nursing. This nursing test bank set includes 700+ practice questions divided into comprehensive quizzes for mental health and psychiatric nursing and a special set of questions for common psychiatric disorders. Use these nursing test banks to augment or as an alternative to ATI and Quizlet.

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Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

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Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study

• Rawhia Salah Dogham 1 ,
• Heba Fakieh Mansy Ali 1 ,
• Asmaa Saber Ghaly 3 ,
• Nermine M. Elcokany 2 ,
• Mohamed Mahmoud Seweid 4 &
• Ayman Mohamed El-Ashry   ORCID: orcid.org/0000-0001-7718-4942 5  

BMC Nursing volume  23 , Article number:  249 ( 2024 ) Cite this article

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Nursing education presents unique challenges, including high levels of academic stress and varied learning approaches among students. Understanding the relationship between academic stress and learning approaches is crucial for enhancing nursing education effectiveness and student well-being.

This study aimed to investigate the prevalence of academic stress and its correlation with learning approaches among nursing students.

Design and Method

A cross-sectional descriptive correlation research design was employed. A convenient sample of 1010 nursing students participated, completing socio-demographic data, the Perceived Stress Scale (PSS), and the Revised Study Process Questionnaire (R-SPQ-2 F).

Most nursing students experienced moderate academic stress (56.3%) and exhibited moderate levels of deep learning approaches (55.0%). Stress from a lack of professional knowledge and skills negatively correlates with deep learning approaches (r = -0.392) and positively correlates with surface learning approaches (r = 0.365). Female students showed higher deep learning approach scores, while male students exhibited higher surface learning approach scores. Age, gender, educational level, and academic stress significantly influenced learning approaches.

Academic stress significantly impacts learning approaches among nursing students. Strategies addressing stressors and promoting healthy learning approaches are essential for enhancing nursing education and student well-being.

Nursing implication

Understanding academic stress’s impact on nursing students’ learning approaches enables tailored interventions. Recognizing stressors informs strategies for promoting adaptive coping, fostering deep learning, and creating supportive environments. Integrating stress management, mentorship, and counseling enhances student well-being and nursing education quality.

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Introduction

Nursing education is a demanding field that requires students to acquire extensive knowledge and skills to provide competent and compassionate care. Nursing education curriculum involves high-stress environments that can significantly impact students’ learning approaches and academic performance [ 1 , 2 ]. Numerous studies have investigated learning approaches in nursing education, highlighting the importance of identifying individual students’ preferred approaches. The most studied learning approaches include deep, surface, and strategic approaches. Deep learning approaches involve students actively seeking meaning, making connections, and critically analyzing information. Surface learning approaches focus on memorization and reproducing information without a more profound understanding. Strategic learning approaches aim to achieve high grades by adopting specific strategies, such as memorization techniques or time management skills [ 3 , 4 , 5 ].

Nursing education stands out due to its focus on practical training, where the blend of academic and clinical coursework becomes a significant stressor for students, despite academic stress being shared among all university students [ 6 , 7 , 8 ]. Consequently, nursing students are recognized as prone to high-stress levels. Stress is the physiological and psychological response that occurs when a biological control system identifies a deviation between the desired (target) state and the actual state of a fitness-critical variable, whether that discrepancy arises internally or externally to the human [ 9 ]. Stress levels can vary from objective threats to subjective appraisals, making it a highly personalized response to circumstances. Failure to manage these demands leads to stress imbalance [ 10 ].

Nursing students face three primary stressors during their education: academic, clinical, and personal/social stress. Academic stress is caused by the fear of failure in exams, assessments, and training, as well as workload concerns [ 11 ]. Clinical stress, on the other hand, arises from work-related difficulties such as coping with death, fear of failure, and interpersonal dynamics within the organization. Personal and social stressors are caused by an imbalance between home and school, financial hardships, and other factors. Throughout their education, nursing students have to deal with heavy workloads, time constraints, clinical placements, and high academic expectations. Multiple studies have shown that nursing students experience higher stress levels compared to students in other fields [ 12 , 13 , 14 ].

Research has examined the relationship between academic stress and coping strategies among nursing students, but no studies focus specifically on the learning approach and academic stress. However, existing literature suggests that students interested in nursing tend to experience lower levels of academic stress [ 7 ]. Therefore, interest in nursing can lead to deep learning approaches, which promote a comprehensive understanding of the subject matter, allowing students to feel more confident and less overwhelmed by coursework and exams. Conversely, students employing surface learning approaches may experience higher stress levels due to the reliance on memorization [ 3 ].

Understanding the interplay between academic stress and learning approaches among nursing students is essential for designing effective educational interventions. Nursing educators can foster deep learning approaches by incorporating active learning strategies, critical thinking exercises, and reflection activities into the curriculum [ 15 ]. Creating supportive learning environments encouraging collaboration, self-care, and stress management techniques can help alleviate academic stress. Additionally, providing mentorship and counselling services tailored to nursing students’ unique challenges can contribute to their overall well-being and academic success [ 16 , 17 , 18 ].

Despite the scarcity of research focusing on the link between academic stress and learning methods in nursing students, it’s crucial to identify the unique stressors they encounter. The intensity of these stressors can be connected to the learning strategies employed by these students. Academic stress and learning approach are intertwined aspects of the student experience. While academic stress can influence learning approaches, the choice of learning approach can also impact the level of academic stress experienced. By understanding this relationship and implementing strategies to promote healthy learning approaches and manage academic stress, educators and institutions can foster an environment conducive to deep learning and student well-being.

Hence, this study aims to investigate the correlation between academic stress and learning approaches experienced by nursing students.

Study objectives

Assess the levels of academic stress among nursing students.

Assess the learning approaches among nursing students.

Identify the relationship between academic stress and learning approach among nursing students.

Identify the effect of academic stress and related factors on learning approach and among nursing students.

Materials and methods

Research design.

A cross-sectional descriptive correlation research design adhering to the STROBE guidelines was used for this study.

A research project was conducted at Alexandria Nursing College, situated in Egypt. The college adheres to the national standards for nursing education and functions under the jurisdiction of the Egyptian Ministry of Higher Education. Alexandria Nursing College comprises nine specialized nursing departments that offer various nursing specializations. These departments include Nursing Administration, Community Health Nursing, Gerontological Nursing, Medical-Surgical Nursing, Critical Care Nursing, Pediatric Nursing, Obstetric and Gynecological Nursing, Nursing Education, and Psychiatric Nursing and Mental Health. The credit hour system is the fundamental basis of both undergraduate and graduate programs. This framework guarantees a thorough evaluation of academic outcomes by providing an organized structure for tracking academic progress and conducting analyses.

Participants and sample size calculation

The researchers used the Epi Info 7 program to calculate the sample size. The calculations were based on specific parameters such as a population size of 9886 students for the academic year 2022–2023, an expected frequency of 50%, a maximum margin of error of 5%, and a confidence coefficient of 99.9%. Based on these parameters, the program indicated that a minimum sample size of 976 students was required. As a result, the researchers recruited a convenient sample of 1010 nursing students from different academic levels during the 2022–2023 academic year [ 19 ]. This sample size was larger than the minimum required, which could help to increase the accuracy and reliability of the study results. Participation in the study required enrollment in a nursing program and voluntary agreement to take part. The exclusion criteria included individuals with mental illnesses based on their response and those who failed to complete the questionnaires.

socio-demographic data that include students’ age, sex, educational level, hours of sleep at night, hours spent studying, and GPA from the previous semester.

Tool two: the perceived stress scale (PSS)

It was initially created by Sheu et al. (1997) to gauge the level and nature of stress perceived by nursing students attending Taiwanese universities [ 20 ]. It comprises 29 items rated on a 5-point Likert scale, where (0 = never, 1 = rarely, 2 = sometimes, 3 = reasonably often, and 4 = very often), with a total score ranging from 0 to 116. The cut-off points of levels of perceived stress scale according to score percentage were low < 33.33%, moderate 33.33–66.66%, and high more than 66.66%. Higher scores indicate higher stress levels. The items are categorized into six subscales reflecting different sources of stress. The first subscale assesses “stress stemming from lack of professional knowledge and skills” and includes 3 items. The second subscale evaluates “stress from caring for patients” with 8 items. The third subscale measures “stress from assignments and workload” with 5 items. The fourth subscale focuses on “stress from interactions with teachers and nursing staff” with 6 items. The fifth subscale gauges “stress from the clinical environment” with 3 items. The sixth subscale addresses “stress from peers and daily life” with 4 items. El-Ashry et al. (2022) reported an excellent internal consistency reliability of 0.83 [ 21 ]. Two bilingual translators translated the English version of the scale into Arabic and then back-translated it into English by two other independent translators to verify its accuracy. The suitability of the translated version was confirmed through a confirmatory factor analysis (CFA), which yielded goodness-of-fit indices such as a comparative fit index (CFI) of 0.712, a Tucker-Lewis index (TLI) of 0.812, and a root mean square error of approximation (RMSEA) of 0.100.

Tool three: revised study process questionnaire (R-SPQ-2 F)

It was developed by Biggs et al. (2001). It examines deep and surface learning approaches using only 20 questions; each subscale contains 10 questions [ 22 ]. On a 5-point Likert scale ranging from 0 (never or only rarely true of me) to 4 (always or almost always accurate of me). The total score ranged from 0 to 80, with a higher score reflecting more deep or surface learning approaches. The cut-off points of levels of revised study process questionnaire according to score percentage were low < 33%, moderate 33–66%, and high more than 66%. Biggs et al. (2001) found that Cronbach alpha value was 0.73 for deep learning approach and 0.64 for the surface learning approach, which was considered acceptable. Two translators fluent in English and Arabic initially translated a scale from English to Arabic. To ensure the accuracy of the translation, they translated it back into English. The translated version’s appropriateness was evaluated using a confirmatory factor analysis (CFA). The CFA produced several goodness-of-fit indices, including a Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100. Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100.

Ethical considerations

The Alexandria University College of Nursing’s Research Ethics Committee provided ethical permission before the study’s implementation. Furthermore, pertinent authorities acquired ethical approval at participating nursing institutions. The vice deans of the participating institutions provided written informed consent attesting to institutional support and authority. By giving written informed consent, participants confirmed they were taking part voluntarily. Strict protocols were followed to protect participants’ privacy during the whole investigation. The obtained personal data was kept private and available only to the study team. Ensuring participants’ privacy and anonymity was of utmost importance.

Tools validity

The researchers created tool one after reviewing pertinent literature. Two bilingual translators independently translated the English version into Arabic to evaluate the applicability of the academic stress and learning approach tools for Arabic-speaking populations. To assure accuracy, two additional impartial translators back-translated the translation into English. They were also assessed by a five-person jury of professionals from the education and psychiatric nursing departments. The scales were found to have sufficiently evaluated the intended structures by the jury.

Pilot study

A preliminary investigation involved 100 nursing student applicants, distinct from the final sample, to gauge the efficacy, clarity, and potential obstacles in utilizing the research instruments. The pilot findings indicated that the instruments were accurate, comprehensible, and suitable for the target demographic. Additionally, Cronbach’s Alpha was utilized to further assess the instruments’ reliability, demonstrating internal solid consistency for both the learning approaches and academic stress tools, with values of 0.91 and 0.85, respectively.

Data collection

The researchers convened with each qualified student in a relaxed, unoccupied classroom in their respective college settings. Following a briefing on the study’s objectives, the students filled out the datasheet. The interviews typically lasted 15 to 20 min.

Data analysis

The data collected were analyzed using IBM SPSS software version 26.0. Following data entry, a thorough examination and verification were undertaken to ensure accuracy. The normality of quantitative data distributions was assessed using Kolmogorov-Smirnov tests. Cronbach’s Alpha was employed to evaluate the reliability and internal consistency of the study instruments. Descriptive statistics, including means (M), standard deviations (SD), and frequencies/percentages, were computed to summarize academic stress and learning approaches for categorical data. Student’s t-tests compared scores between two groups for normally distributed variables, while One-way ANOVA compared scores across more than two categories of a categorical variable. Pearson’s correlation coefficient determined the strength and direction of associations between customarily distributed quantitative variables. Hierarchical regression analysis identified the primary independent factors influencing learning approaches. Statistical significance was determined at the 5% (p < 0.05).

Table  1 presents socio-demographic data for a group of 1010 nursing students. The age distribution shows that 38.8% of the students were between 18 and 21 years old, 32.9% were between 21 and 24 years old, and 28.3% were between 24 and 28 years old, with an average age of approximately 22.79. Regarding gender, most of the students were female (77%), while 23% were male. The students were distributed across different educational years, a majority of 34.4% in the second year, followed by 29.4% in the fourth year. The students’ hours spent studying were found to be approximately two-thirds (67%) of the students who studied between 3 and 6 h. Similarly, sleep patterns differ among the students; more than three-quarters (77.3%) of students sleep between 5- to more than 7 h, and only 2.4% sleep less than 2 h per night. Finally, the student’s Grade Point Average (GPA) from the previous semester was also provided. 21% of the students had a GPA between 2 and 2.5, 40.9% had a GPA between 2.5 and 3, and 38.1% had a GPA between 3 and 3.5.

Figure  1 provides the learning approach level among nursing students. In terms of learning approach, most students (55.0%) exhibited a moderate level of deep learning approach, followed by 25.9% with a high level and 19.1% with a low level. The surface learning approach was more prevalent, with 47.8% of students showing a moderate level, 41.7% showing a low level, and only 10.5% exhibiting a high level.

Nursing students? levels of learning approach (N=1010)

Figure  2 provides the types of academic stress levels among nursing students. Among nursing students, various stressors significantly impact their academic experiences. Foremost among these stressors are the pressure and demands associated with academic assignments and workload, with 30.8% of students attributing their high stress levels to these factors. Challenges within the clinical environment are closely behind, contributing significantly to high stress levels among 25.7% of nursing students. Interactions with peers and daily life stressors also weigh heavily on students, ranking third among sources of high stress, with 21.5% of students citing this as a significant factor. Similarly, interaction with teachers and nursing staff closely follow, contributing to high-stress levels for 20.3% of nursing students. While still significant, stress from taking care of patients ranks slightly lower, with 16.7% of students reporting it as a significant factor contributing to their academic stress. At the lowest end of the ranking, but still notable, is stress from a perceived lack of professional knowledge and skills, with 15.9% of students experiencing high stress in this area.

Nursing students? levels of academic stress subtypes (N=1010)

Figure  3 provides the total levels of academic stress among nursing students. The majority of students experienced moderate academic stress (56.3%), followed by those experiencing low academic stress (29.9%), and a minority experienced high academic stress (13.8%).

Nursing students? levels of total academic stress (N=1010)

Table  2 displays the correlation between academic stress subscales and deep and surface learning approaches among 1010 nursing students. All stress subscales exhibited a negative correlation regarding the deep learning approach, indicating that the inclination toward deep learning decreases with increasing stress levels. The most significant negative correlation was observed with stress stemming from the lack of professional knowledge and skills (r=-0.392, p < 0.001), followed by stress from the clinical environment (r=-0.109, p = 0.001), stress from assignments and workload (r=-0.103, p = 0.001), stress from peers and daily life (r=-0.095, p = 0.002), and stress from patient care responsibilities (r=-0.093, p = 0.003). The weakest negative correlation was found with stress from interactions with teachers and nursing staff (r=-0.083, p = 0.009). Conversely, concerning the surface learning approach, all stress subscales displayed a positive correlation, indicating that heightened stress levels corresponded with an increased tendency toward superficial learning. The most substantial positive correlation was observed with stress related to the lack of professional knowledge and skills (r = 0.365, p < 0.001), followed by stress from patient care responsibilities (r = 0.334, p < 0.001), overall stress (r = 0.355, p < 0.001), stress from interactions with teachers and nursing staff (r = 0.262, p < 0.001), stress from assignments and workload (r = 0.262, p < 0.001), and stress from the clinical environment (r = 0.254, p < 0.001). The weakest positive correlation was noted with stress stemming from peers and daily life (r = 0.186, p < 0.001).

Table  3 outlines the association between the socio-demographic characteristics of nursing students and their deep and surface learning approaches. Concerning age, statistically significant differences were observed in deep and surface learning approaches (F = 3.661, p = 0.003 and F = 7.983, p < 0.001, respectively). Gender also demonstrated significant differences in deep and surface learning approaches (t = 3.290, p = 0.001 and t = 8.638, p < 0.001, respectively). Female students exhibited higher scores in the deep learning approach (31.59 ± 8.28) compared to male students (29.59 ± 7.73), while male students had higher scores in the surface learning approach (29.97 ± 7.36) compared to female students (24.90 ± 7.97). Educational level exhibited statistically significant differences in deep and surface learning approaches (F = 5.599, p = 0.001 and F = 17.284, p < 0.001, respectively). Both deep and surface learning approach scores increased with higher educational levels. The duration of study hours demonstrated significant differences only in the surface learning approach (F = 3.550, p = 0.014), with scores increasing as study hours increased. However, no significant difference was observed in the deep learning approach (F = 0.861, p = 0.461). Hours of sleep per night and GPA from the previous semester did not exhibit statistically significant differences in deep or surface learning approaches.

Table  4 presents a multivariate linear regression analysis examining the factors influencing the learning approach among 1110 nursing students. The deep learning approach was positively influenced by age, gender (being female), educational year level, and stress from teachers and nursing staff, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by stress from a lack of professional knowledge and skills. The other factors do not significantly influence the deep learning approach. On the other hand, the surface learning approach was positively influenced by gender (being female), educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by gender (being male). The other factors do not significantly influence the surface learning approach. The adjusted R-squared values indicated that the variables in the model explain 17.8% of the variance in the deep learning approach and 25.5% in the surface learning approach. Both models were statistically significant (p < 0.001).

Nursing students’ academic stress and learning approaches are essential to planning for effective and efficient learning. Nursing education also aims to develop knowledgeable and competent students with problem-solving and critical-thinking skills.

The study’s findings highlight the significant presence of stress among nursing students, with a majority experiencing moderate to severe levels of academic stress. This aligns with previous research indicating that academic stress is prevalent among nursing students. For instance, Zheng et al. (2022) observed moderated stress levels in nursing students during clinical placements [ 23 ], while El-Ashry et al. (2022) found that nearly all first-year nursing students in Egypt experienced severe academic stress [ 21 ]. Conversely, Ali and El-Sherbini (2018) reported that over three-quarters of nursing students faced high academic stress. The complexity of the nursing program likely contributes to these stress levels [ 24 ].

The current study revealed that nursing students identified the highest sources of academic stress as workload from assignments and the stress of caring for patients. This aligns with Banu et al.‘s (2015) findings, where academic demands, assignments, examinations, high workload, and combining clinical work with patient interaction were cited as everyday stressors [ 25 ]. Additionally, Anaman-Torgbor et al. (2021) identified lectures, assignments, and examinations as predictors of academic stress through logistic regression analysis. These stressors may stem from nursing programs emphasizing the development of highly qualified graduates who acquire knowledge, values, and skills through classroom and clinical experiences [ 26 ].

The results regarding learning approaches indicate that most nursing students predominantly employed the deep learning approach. Despite acknowledging a surface learning approach among the participants in the present study, the prevalence of deep learning was higher. This inclination toward the deep learning approach is anticipated in nursing students due to their engagement with advanced courses, requiring retention, integration, and transfer of information at elevated levels. The deep learning approach correlates with a gratifying learning experience and contributes to higher academic achievements [ 3 ]. Moreover, the nursing program’s emphasis on active learning strategies fosters critical thinking, problem-solving, and decision-making skills. These findings align with Mahmoud et al.‘s (2019) study, reporting a significant presence (83.31%) of the deep learning approach among undergraduate nursing students at King Khalid University’s Faculty of Nursing [ 27 ]. Additionally, Mohamed &Morsi (2019) found that most nursing students at Benha University’s Faculty of Nursing embraced the deep learning approach (65.4%) compared to the surface learning approach [ 28 ].

The study observed a negative correlation between the deep learning approach and the overall mean stress score, contrasting with a positive correlation between surface learning approaches and overall stress levels. Elevated academic stress levels may diminish motivation and engagement in the learning process, potentially leading students to feel overwhelmed, disinterested, or burned out, prompting a shift toward a surface learning approach. This finding resonates with previous research indicating that nursing students who actively seek positive academic support strategies during academic stress have better prospects for success than those who do not [ 29 ]. Nebhinani et al. (2020) identified interface concerns and academic workload as significant stress-related factors. Notably, only an interest in nursing demonstrated a significant association with stress levels, with participants interested in nursing primarily employing adaptive coping strategies compared to non-interested students.

The current research reveals a statistically significant inverse relationship between different dimensions of academic stress and adopting the deep learning approach. The most substantial negative correlation was observed with stress arising from a lack of professional knowledge and skills, succeeded by stress associated with the clinical environment, assignments, and workload. Nursing students encounter diverse stressors, including delivering patient care, handling assignments and workloads, navigating challenging interactions with staff and faculty, perceived inadequacies in clinical proficiency, and facing examinations [ 30 ].

In the current study, the multivariate linear regression analysis reveals that various factors positively influence the deep learning approach, including age, female gender, educational year level, and stress from teachers and nursing staff. In contrast, stress from a lack of professional knowledge and skills exert a negative influence. Conversely, the surface learning approach is positively influenced by female gender, educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, but negatively affected by male gender. The models explain 17.8% and 25.5% of the variance in the deep and surface learning approaches, respectively, and both are statistically significant. These findings underscore the intricate interplay of demographic and stress-related factors in shaping nursing students’ learning approaches. High workloads and patient care responsibilities may compel students to prioritize completing tasks over deep comprehension. This pressure could lead to a surface learning approach as students focus on meeting immediate demands rather than engaging deeply with course material. This observation aligns with the findings of Alsayed et al. (2021), who identified age, gender, and study year as significant factors influencing students’ learning approaches.

Deep learners often demonstrate better self-regulation skills, such as effective time management, goal setting, and seeking support when needed. These skills can help manage academic stress and maintain a balanced learning approach. These are supported by studies that studied the effect of coping strategies on stress levels [ 6 , 31 , 32 ]. On the contrary, Pacheco-Castillo et al. study (2021) found a strong significant relationship between academic stressors and students’ level of performance. That study also proved that the more academic stress a student faces, the lower their academic achievement.

Strengths and limitations of the study

This study has lots of advantages. It provides insightful information about the educational experiences of Egyptian nursing students, a demographic that has yet to receive much research. The study’s limited generalizability to other people or nations stems from its concentration on this particular group. This might be addressed in future studies by using a more varied sample. Another drawback is the dependence on self-reported metrics, which may contain biases and mistakes. Although the cross-sectional design offers a moment-in-time view of the problem, it cannot determine causation or evaluate changes over time. To address this, longitudinal research may be carried out.

Notwithstanding these drawbacks, the study substantially contributes to the expanding knowledge of academic stress and nursing students’ learning styles. Additional research is needed to determine teaching strategies that improve deep-learning approaches among nursing students. A qualitative study is required to analyze learning approaches and factors that may influence nursing students’ selection of learning approaches.

According to the present study’s findings, nursing students encounter considerable academic stress, primarily stemming from heavy assignments and workload, as well as interactions with teachers and nursing staff. Additionally, it was observed that students who experience lower levels of academic stress typically adopt a deep learning approach, whereas those facing higher stress levels tend to resort to a surface learning approach. Demographic factors such as age, gender, and educational level influence nursing students’ choice of learning approach. Specifically, female students are more inclined towards deep learning, whereas male students prefer surface learning. Moreover, deep and surface learning approach scores show an upward trend with increasing educational levels and study hours. Academic stress emerges as a significant determinant shaping the adoption of learning approaches among nursing students.

Implications in nursing practice

Nursing programs should consider integrating stress management techniques into their curriculum. Providing students with resources and skills to cope with academic stress can improve their well-being and academic performance. Educators can incorporate teaching strategies that promote deep learning approaches, such as problem-based learning, critical thinking exercises, and active learning methods. These approaches help students engage more deeply with course material and reduce reliance on surface learning techniques. Recognizing the gender differences in learning approaches, nursing programs can offer gender-specific support services and resources. For example, providing targeted workshops or counseling services that address male and female nursing students’ unique stressors and learning needs. Implementing mentorship programs and peer support groups can create a supportive environment where students can share experiences, seek advice, and receive encouragement from their peers and faculty members. Encouraging students to reflect on their learning processes and identify effective study strategies can help them develop metacognitive skills and become more self-directed learners. Faculty members can facilitate this process by incorporating reflective exercises into the curriculum. Nursing faculty and staff should receive training on recognizing signs of academic stress among students and providing appropriate support and resources. Additionally, professional development opportunities can help educators stay updated on evidence-based teaching strategies and practical interventions for addressing student stress.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to restrictions imposed by the institutional review board to protect participant confidentiality, but are available from the corresponding author on reasonable request.

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Acknowledgements

Our sincere thanks go to all the nursing students in the study. We also want to thank Dr/ Rasha Badry for their statistical analysis help and contribution to this study.

The research was not funded by public, commercial, or non-profit organizations.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

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Nursing Education, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Rawhia Salah Dogham & Heba Fakieh Mansy Ali

Critical Care & Emergency Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Nermine M. Elcokany

Obstetrics and Gynecology Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Asmaa Saber Ghaly

Faculty of Nursing, Beni-Suef University, Beni-Suef, Egypt

Mohamed Mahmoud Seweid

Psychiatric and Mental Health Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Ayman Mohamed El-Ashry

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Contributions

Ayman M. El-Ashry & Rawhia S. Dogham: conceptualization, preparation, and data collection; methodology; investigation; formal analysis; data analysis; writing-original draft; writing-manuscript; and editing. Heba F. Mansy Ali & Asmaa S. Ghaly: conceptualization, preparation, methodology, investigation, writing-original draft, writing-review, and editing. Nermine M. Elcokany & Mohamed M. Seweid: Methodology, investigation, formal analysis, data collection, writing-manuscript & editing. All authors reviewed the manuscript and accept for publication.

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Correspondence to Ayman Mohamed El-Ashry .

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The research adhered to the guidelines and regulations outlined in the Declaration of Helsinki (DoH-Oct2008). The Faculty of Nursing’s Research Ethical Committee (REC) at Alexandria University approved data collection in this study (IRB00013620/95/9/2022). Participants were required to sign an informed written consent form, which included an explanation of the research and an assessment of their understanding.

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Dogham, R.S., Ali, H.F.M., Ghaly, A.S. et al. Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study. BMC Nurs 23 , 249 (2024). https://doi.org/10.1186/s12912-024-01885-1

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Received : 31 January 2024

Accepted : 21 March 2024

Published : 17 April 2024

DOI : https://doi.org/10.1186/s12912-024-01885-1

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