1. Introduction

1.1. Background to the Study

Considerable number of studies has been conducted on stress among students generally, mainly in developed countries with their early concerns on the sources and management of stress. Evidence from some of these studies show that some students experience high levels of stress. The studies of Abouserie, Andrews et al., Brown and Ralph and Stanley and Manthorpe [1-4] are examples in this regard. There has also been an increased interest in stress research in recent times in developing countries among students and workers. The soaring interest in stress research is probably because we live in a world that includes many stressful circumstances and stress has been tagged a global phenomenon. It has become an integral part of life and is said to be the price we all pay for the struggle to stay alive. According to the American Academy of Family physicians, two- thirds of office visits to family doctors are for stress related problems.

Felman noted that stress is the physical and emotional response we have to events that threaten us and that it is rooted in the primitive fight or flight response wired into human and non- human animals [5]. The challenge stimulating this response is called stressor. Stress has also been considered to be a situation and the state of tension it generates in an individual as a result of the person's perception of that situation as threatening to his or her existence [6]. This implies that nothing is stressful in itself but become stressful depending on the perception and interpretation of the individual of the demands placed upon them. The perceptions and interpretations therefore cause the harm, not the demands themselves [7, 8]. Situations and events that are perceived positively as challenges may lead to positive responses such as studying hard whiles those perceived negatively as threats may lead to negative responses [9].

Past research has shown that stress affect everyone [5, 10]. This is because everything, good or bad can produce stress if it in some way present us with a challenge. Anything that makes one adjust, adapt, or change is stress. Most of the literature on stress consistently attest to the fact that life changes or transition can predispose a person to stress [5] and that both negative and positive events in our lives such as failing an examination, having problems with roommates, illness in the family, getting married or divorce, getting promoted or fired, moving to a new locality or going to the university can produce stress. Life changes, daily hassles, home life and acculturation - the process of adapting and becoming integrated with a new cultural environment, have therefore been identified as sources of stress. If stress affects everyone, it implies that students, teachers, parents, children, business people among others live with stress.

The negative effects of stress has also been documented. For example, stress is believed to be a major contributor to coronary heart disease, cancer, lung problems, accidental injuries, cirrhosis of the liver and suicide, six of the leading causes of death in the United States [11] and beyond. Although the negative effects of stress has been documented, it has also been noted that moderate levels of stress is not bad but may rather be motivating since it makes the individual work hard. It is the extreme or severe forms of stress that is bad and efforts should be made to manage it.

Stress is common among people under pressure and busy people like managers and students who are expected to maintain standards and meet deadlines [12]. College students especially freshmen are a group particularly prone to stress and this is due to the transitional nature of college life [13]. They must adjust to being away from home for the first time, maintain high level of academic achievement, adjust to heavy workload in limited time, crowded lecture halls, harsh learning conditions as well as to a new social environment.

Despite the reported prevalence of stress among college students in western countries, few studies have been conducted on stress among students in Ghana. The studies of Atindanbila and Bayem and Esia- Donkoh [14, 15] are examples in this regard. With regards to nursing students in the nursing training colleges, studies are even almost non-existent in Ghana. The studies of Atindanbila and Bayem and Esia- Donkoh have been done among university students and not among nursing students in the nursing training colleges. The training of nursing students are unique and mainly involves clinical training at the hospitals in addition to the academic training they receive on campus. They may therefore experience unique stressors. Most past studies have also focused on nurses and not nursing students. For example Past research reports that stress is intrinsic to nursing which is a high demanding job with poor support, rapidly changing circumstances, shortage of resources and staff [16]. In Ghana, studies that have been done on stress and related issues among various categories of nurses include the studies of Kyreaa and that of Atindanbila, Abasimi and Anim [17, 18].

The researchers have however not found any study on stress among nursing students in the nursing training colleges in Ghana. This implies that we are not well informed on the levels and types of stressors that various nursing students at the nursing training colleges in Ghana encounter. This is despite the fact that previous research in western countries have found high levels of stress among nursing students due to the clinical experience and exposure to unfamiliar circumstances leading to low confidence [19]. In addition, nursing students are exposed to sources of stress such as separation from home, financial worries, regular clinical and educational assessment and frequently changing clinical environments.

In recent times there is increased interest in General nursing (SRN), Community Health nursing (CHN) and Midwifery programmes in Ghana and this has led to increase intake of students and increased demands on the few successful ones who manage to gain admission to the nursing training colleges. They must be able to adapt to the numerous challenges of college life and maintain high level of academic standards so that they will not be withdrawn. These demands are potentially stressful. It is therefore important to examine the experience of stress among this sample. The present study thus examined stress among the nursing students in the two nursing training Colleges in Tamale, Ghana. These colleges are the main nursing training colleges in Northern Ghana that admit the largest number of students across the country.

1.2. Objectives of the Study

This study is guided by the following objectives:

1. To examine the levels of stress in terms of its severity among the students.

2. To examine which type (category) of stress students report more.

3. To examine the differences in the levels of stress with regards to academic discipline (course type)

4. To assess the differences in level of stress with regards to the biographical variables of, Gender and Marital status.

1.3. Hypotheses

Based on the literature review and objectives of the study, the following hypotheses are tested.

1. The students will report severe level of stress.

2. There will be a significant difference in the reported levels of the various categories of stress among the students. The categories of stress include Academic, Personal and Social stressors.

3. There will be a significant difference in the levels of stress with regards to academic discipline (Course type)

4. There will be a significant difference in stress levels among male and female students.

5. There will be a significant difference in stress levels with regards to marital status.

1.4. Significance of the Study

Since stress is a global phenomenon and have been found to have adverse health implications and adversely affect the studies of students, the findings of the present study will help in effective counseling and management of stress of the students. The findings of the study will also provide information for researchers in the area of stress among students in general and more specifically among Nursing students in the nursing training colleges.

2. Review of Related Literature

A review of the psychological literature reveals a number of stressors common among students. For example a review by Robotham classifies students’ stressors into stressors related to learning or academic stressors, examination related stressors, stressors related to transition to university and stressors related to financial issues [9]. The researcher identified academic stressors as striving to meet assessment deadlines, workload, fear of failure and lack of time or time management issues. Robotham also identified stress related to examinations as a major stressor among students. Generally, researchers have noted that it is the anxiety associated with the tests which creates the physiological and emotional reaction to stress and not the test itself.

According to Robotham, transition to university is stressful because students may be leaving home ( maybe for the first time), taking on new responsibilities, adjusting to a new social environment, maintaining a high level of academic performance as supported by Ross et al. among other things [8, 9]. In addition to all these, the individual may lose his or her social support system such as family and friends and having to make new friends. A study by Bernard and Bernard M. makes clear the importance of social factors in stress [20]. In that study, only 7% of students who attempted suicide attributed it to academic problems or factors while 75% cited social and personal problems. Finally, financial limitations has been identified as a key stressor for students. Robotham noted that a significant relationship exist between financial problems and mental health problems and that limited financial resources can have a great impact on the strains associated with studying [9].

There are generally lack of studies on stress among nursing students in Ghana. The studies of Atindanbila and Banyem and Esia-Donkoh examined stress among undergraduate students in universities in Ghana [14, 15]. To our knowledge, no study has been conducted on stress exclusively among nursing students in the nursing training colleges in Ghana.

Atindanbila and Banyem examined the type of stressors and their incidence among students in the University of Ghana using an adopted student stress questionnaire and found that all students encountered equal number of stressors irrespective of their gender, level of education and residential status [14]. They also found that married students encountered more stressors than unmarried ones and that they encountered stressors throughout the semester. In addition, they also found that Academic stressors were reported by the students more than the other stressors.

Atindanbila and Banyem’s study however, did not exclusively examined stress among nursing students whose training have been noted to be unique due to the clinical aspect of training they go through [13]. Evidence from Seyefatemi, Tafreshi and Hagan and many other studies reveal that the clinical aspect of training which nursing students go through is very stressful [13, 19]. They noted for example that nursing students have to go through a large amount of preparatory work before their clinical work, travel long distances to clinical sites and use highly technical equipment. In addition, they may perform procedures that could cause harm to their patients, and this increases their fear of making mistakes and confidence. All these are potentially stressful to nursing students in addition to other stresses that all students are faced with. In addition, students at the universities differ significantly from those at the training colleges. For example among other things, students at the universities are more likely to have obtained better grades than those at the training colleges since entry requirements at the universities are more stringent. Secondly, students admitted at the university spend four to five years for their nursing programmes whereas those admitted at the Nursing, Community and Midwifery schools spend between 2 to 3 years for their training. This makes a study among nursing students of the nursing training colleges in Ghana such as the present one relevant.

The studies of Seyedfatemi and colleagues and Altiok and Ustun are among the few studies conducted on stress among nursing students [13, 19]. These studies have also been conducted among nursing students in the universities and not on the diploma awarding training college samples. Seyedfatemi and colleagues’ study was conducted among undergraduate nursing students at the Iran Faculty of Nursing and Midwifery to find out the sources of stress and coping strategies using the Student Stress Survey and the Adolescent Coping Orientation for Problem Experiences Inventory (ACOPE) [13]. The researchers found that interpersonal stressors (e.g. finding new friends) and environmental stressors (e.g. working with unfamiliar people) were the most common. According to them the top 5 stressors were “finding new friends”, “ new responsibilities”, “increased class workload”, being placed in “unfamiliar situations” and “working with people they did not know” in that order. They also found that first year students reported greater stress than students in other years.

In a qualitative study using in-depth interviews Altiok and Ustun examined the sources of stress of second year nursing students of Adnan Menderes University High school using 15 students [19]. The researchers identified sources of stress under four categories including clinical practice, theoretical training, social and personal lives. Under clinical practice, stressors students experience include fear of getting low grades, trainers negative attitude, responsibility for patient care plan and humiliating treatment of nurses by medical students and physicians. Other stressors in the clinical setting included the fact that nurses humiliate students and their un willingness to accept male nurses and finally students’ fear of making mistakes.

Stressors identified by Atiok and Ustun under theoretical training included failure in participating actively in courses, lack of interest in some courses, heavy workload, low motivation and test anxiety. Social stressors included lack of accommodation, inability to engage in university social activities due to workload and negative attitudes of students’ family to nursing [19]. Finally, personal stressors identified among the students included lack of time management, control of emotions and confidence.

3. Methodology

3.1. Research Setting

This study was conducted at the Tamale Nurses Training and Tamale Community Health Nursing Training Colleges. These two colleges are the main public nursing training colleges in Northern Ghana and thus enroll a large number of students from all over the country to study towards the award of either a diploma in General nursing (SRN), Community Health nursing or Midwifery. Specifically, the Tamale Nurses Training College offers General Nursing and Midwifery whiles the Community Health Nursing college offers Community Health nursing. The presence and closeness of the Tamale Teaching Hospital to these two training colleges makes the clinical training of the nursing students easy since most of the students do their clinical training in this major hospital. With the recent introduction of the degree nursing training programmes by the University for Development Studies which the hospital is affiliated to, there are numerous senior nurses in the Hospital some of who are graduates of the university and thus better positioned to provide practical clinical training to the students from the training colleges.

3.2. Sample and Sampling Technique

The stratified random sampling technique was used to select a total sample of 273 students from the two training colleges. The stratified random sampling techniques used ensured that the sample was representative of the various courses offered at the nursing training colleges. Since questionnaires were administered in class and collected back immediately it yielded a response rate of 100%. All questionnaires were appropriately completed and as a result, they were all used for the analysis. The sample characteristics are presented in Table 1.

Table 1. Respondent’s demographic characteristics

As shown in Table 1 the modal age range was 19-24 (80.95%). This indicates a relatively young sample and this probably explains why majority (87.9%) of the sample are single. This is not surprising since most of the students in the nursing training colleges are direct graduates from the Senior High schools and most students graduate from the Senior High Schools in Ghana between the ages of 17 and 18.

3.3. Research Design

The cross-sectional survey method was used to gather data since it is the most appropriate technique in assessing the stress experienced by the students.

3.4. Instrument

Data collection was done using self constructed survey questionnaire based on the Student Stress Survey of Seyedfatemi and colleagues and on the review of past studies on stress among students [13]. The Questionnaire consisted of two main sections. Section A consisted of items on demographic data such as age, gender, marital status, academic discipline (course type) and year of study. Section B consisted of 21 structured items on variables causing stress among students. These variables are classified into three categories, that is 7 items representing Academic Stressors (e.g. increased class workload), 7 items representing Personal Stressors (e.g. financial difficulties) and 7 items representing Social Stressors (e.g. change in social activities). Response categories range from applied to me less = 1 to applied to me severely = 5 with higher scores indicating greater level of stress. Participants indicated how much the statement applied to them over the past five months including the moment they were responding to the items. The scale has reasonably good Cronbach alpha reliabilities. These were .65, .71 and .70 for Academic, Personal and Social stressors respectively. The Cronbach alpha reliability for the overall stress scale is .85 for the present sample.

The scale was first pretested on a group of 20 nursing students who did not form part of the actual sample. This enabled the researchers to assess the suitability of the tool for use. Since the pilot study indicated that the tool was adequate, it was used as such.

3.5. Procedure

Permission for the conduct of the study was first sought from the principals of the two training colleges. Teachers from the colleges who some of the researchers know then assisted the researchers with the selection and data collection process. Students who were selected were then made to complete the questionnaire some minutes before their classes began for immediate collection by researchers and assistants. It took respondents about twenty minutes to answer the questionnaire.

4. Results

The results were analysed using SPSS version 17 based on the hypotheses of the study. Details of the analysis are presented below.

4.1. Hypothesis Testing

The first hypothesis stated that the students will report severe level of stress. This hypothesis seeks to find out if the students reported mild, moderate, severe or very severe stress. The results were analysed using the average mean scores on the stress scale. Raw scores on the scale ranged from 21-105. Therefore a raw score of 21-41 represented mild stress, 42-62, moderate stress, 63-83, severe stress and 84-105, very severe stress while 0-20, no stress. The mean rating cut off points are as presented in Table 2B. The results of the levels of stress are as shown in Table 2.

Table 2. Reported level of stress among the students

Table 2B. Criteria for reported levels of stress

As shown in Table 2, the various levels of stress reported among students varied depending on the type of stressor. Respondents reported severe levels of stress for both Academic (M = 13.76, SD = 3.60) and Personal (M = 14.29, SD = 3.94) Stressors while for Social Stressors it was moderate (M = 12.32, SD = 3.64). There was also severe Overall Stress among them (M = 13.45, SD = 2.87).

The second hypothesis stated that there will be a significant difference in the reported levels of the various categories of stress among the students. The categories of stress include Academic, Personal and Social stressors. A One-Way Repeated ANOVA was used to test this hypothesis. A summary of the statistical analysis can be seen in Table 3.

Table 3. Descriptive Statistics and Effect Size of stress Scores of Nursing Students by category

Summary of Post hoc Results by ranking

1^St = Personal

2^nd = Academic

3^rd = Social

Presented in Table 3 are the means and standard deviations of the stress scores. There was a significant difference in the reported levels of the various categories of stress, Wilks’ Lamda = .800, F(2, 271) = 33.83, P < .0005, eta squared = .20. A post hoc pairwise comparison using Turkey’s HSD reveals that a significant difference exist between Academic and Social stressors and between Personal and Academic stressors. In terms of ranking, the highest stressors were Personal, followed by Academic and finally Social stressors. This implies that students experienced more Personal stressors compared to the other categories of stressors.

The third hypothesis stated that there will be a significant difference in the level of stress with regards to Academic discipline or Course type. This hypothesis is concerned with whether the reported levels of stress would vary among the respondents with regards to the course they offer (i.e. SRN, CHN and Midwifery).

A One – Way ANOVA was used to compare the differences in the mean levels with regards to course type. The results are shown below in Table 4.

Table 4. Reported level of stress by course type

The findings shown in Table 4 reveal that there was no significant difference in the various categories of stress with regards to academic discipline. Students offering General Nursing (SRN) reported similar levels of the various categories of stress as compared to those offering Community Health Nursing (CHN) and Midwifery. There was also no significant difference in overall stress with regards to discipline. The scores for SRN students (M=39.32, SD=6.79) is similar to that of CHN (M=41.24, SD=9.41) and Midwifery (M=39.11, SD=8.64), [F(2, 270) = 1.801, P = .167, two-tailed]. Therefore students of all disciplines reported similar level of overall stress.

The fourth hypothesis to be tested stated that there will be a significant difference in the level of stress among male and female students. This hypothesis is concerned with whether the reported levels of stress would vary among the respondents with regards to their gender. The Independent Sample t- test was used to compare the differences in the mean levels of the categories of stress and the overall stress among male and female respondents. The results are shown in Table 5.

As shown in the Table 5, there was no statistically significant difference in the reported levels of the various categories of stress among male and female students. There was also no significant difference in overall stress among the two groups. The stress scores for Males (M=39.32, SD=6.79) is similar to that of females (M=41.24, SD=9.41), [t (271) = -.314, p = .754, two-tailed].

Table 5. Reported level of stress by Gender

The final hypothesis to be tested stated that there will be a significant difference in the level of stress with regards to marital status. This hypothesis is concerned with whether the reported levels of stress would vary among the respondents with regards to their marital status. A One – Way ANOVA was used to compare the differences in the mean levels of stress among the three groups, that is Single, Married and “Other” respondents. The “other “group consist of respondents who were separated/divorced or widowed. The results are shown in Table 6 with effect size.

Table 6. Reported level of stress by marital Status

The findings shown in Table 6 reveal that married respondents reported significantly higher levels of academic stress (M = 15.49, SD = 4.27), [ F(270) = 1.11, p = .042, two-tailed] as compared to single ( (M=13.65, SD = 3.51) and “other” respondents (M = 13.89, SD = 3.37). The effect size was .006. There was however no significant differences in personal and social stressors as well as overall level of stress among the respondents with regards to marital status.

5. Discussion

Stress is a global phenomenon and affects everyone. The incidence of stress among students can have serious and negative effects on their health and studies. Knowledge of the stressors and their severity among nursing students in the nursing training colleges can be helpful in effective management and counseling of the students on how to cope and adapt to stressors. Researchers are therefore interested in assessing level of stress among various categories of students. The present study therefore examined the experience of stress among the General nursing, Community Health nursing and Midwifery students of the nursing students in the nursing training colleges in Tamale, Ghana. Unlike the universities that award degrees in nursing, these training colleges are diploma awarding institutions. Since comparative studies of stress among SRN, CHN and Midwifery students in Ghana are non - existent, the findings of the present study provides baseline information for future researchers. The present study also examined the level of stress with regards to the demographic characteristics of respondents such as gender and marital status. Based on these objectives a number of hypotheses were tested. The findings are discussed in the light of the objectives and hypothesis as follows.

The first objective of the study was to examine the level of stress in terms of its severity among the students. The hypothesis based on this objective stated that respondents would report severe level of stress. The results indicated that the students generally experienced or reported severe levels of stress thus supporting the hypothesis. With the exception of Social stressors which they reported moderate stress, respondents reported severe levels of Academic, Personal and Overall level of stress. This finding is consistent with the findings of previous studies such as that of Seyefatemi et al. and Beck and Srivastava which also revealed that nursing students experience high levels of stress [13, 21]. The findings of these previous studies were however conducted among university undergraduate nursing students. This implies that the degree of stress is regardless of whether the students are in the university or training college.

The second objective was to examine which type or category of stress was reported more by the students. The stress categories are Academic, Personal and Social stressors. Based on this objective, it was hypothesized that there will be a significant difference in the reported levels of the various categories of stress among the students. The results show that students experienced or reported significantly higher Personal stressors compared to the other categories of stressors. This finding was rather surprising since it was expected that students would report more academic stressors. It is however partly consistent with Bernard and Bernard M. study which found that only 7% of students who attempted suicide cited academic problems as a factor while 75% of them cited personal and social problems as key factors [20]. The findings of the present study thus indicate to us how important personal problems or stressors are and the need to focus counseling on them. The result might also mean that probably tutors and counsellors focus counseling more on academic issues to the neglect of personal problems or issues. This finding however is inconsistent with that of Atindanbila and Banyem who found that undergraduate students in the university of Ghana reported more academic stressors than the other stressors [14]. The differences in the findings of these two studies may be understandable since the samples studied although both made up of students were slightly different because whereas Atindanbila and Bayem studied undergraduates in general, the present study’s sample was nursing students in the nursing training colleges.

The third objective was to examine the differences in the levels of stress with regards to academic discipline or Course type . The hypothesis based on this objective stated that there will be a significant difference in the levels of stress with regards to academic discipline (course type). The findings showed that there was no significant difference in the various categories of stress with regards to academic discipline or course type . Students offering General Nursing (SRN) reported similar levels of the various categories of stress as compared to those offering Community Health Nursing (CHN) and Midwifery. There was also no significant difference in overall stress with regards to discipline. Since the present study was one of the first to be done examining this, the findings of the present study serves a baseline information for future studies.

The final objective was to assess the differences in level of stress with regards to the biographical variables of Gender and Marital status. Based on this objective, two hypotheses were stated and tested. The first hypothesis stated that there will be a significant difference in stress levels between male and female students. The findings indicate that there was no statistically significant difference in the reported levels of the various categories of stress among male and female students. There was also no significant difference in overall stress among the two groups. This findings is consistent with that of Atindanbila and Banyem since they also found no significant differences in stress with regard to gender among undergraduate students of the university of Ghana [14].

The second hypothesis based on the above objective was that there will be a significant difference in stress levels with regards to marital status. The findings reveal that married respondents reported significantly higher levels of academic stress as compared to single and “other” respondents. The effect size was .006. There was however no significant differences in social, personal and overall level of stress among the respondents with regards to marital status. The present study’s findings partly agrees with that of Atindanbila and Bayem [14]. It is partly consistent with their study because it found that married respondents reported significantly higher academic stress than their single counterparts. It however did not find significant differences in overall stress among married and unmarried students as Atindanbila and Banyem’s study did. The fact that married respondents were more stressed with regards to academic stressors compared to their single ones might be because they are “torn between two lovers” juggling between family and academic work.

5.1. Recommendations

A key finding of the present study is that stress was found to be severe among the nursing students studied. Due to the negative consequences of stress, it is important that steps are taken to help students cope with it. It is recommended that as part of their orientation, students should be educated on the stresses of college life they would encounter. This will help prepare them psychologically to combat future stress. There should also be counseling services provided by trained psychologists in these colleges to counsel them as well as tackle their adjustment issues. The observation was that unlike the universities where there are counselling and placement centres where counselling services are provided, there were no adequate counselling services in these colleges.

Secondly, the fact that Personal stressors topped the list of stressors indicate that although students are in academic institutions, their personal concerns and difficulties border them more than the academic stressors they experience in college. This is serious since it can affect their health and subsequently their studies although school authorities might have interventions in place mainly to take care of academic stressors. It is therefore recommended that College authorities and counsellors focus on the personal lives and concerns of their students in addition to their academic concerns. Opportunity should be provided for them to have one on one interaction with counsellors and mentors on regular basis to talk about their personal worries. This will help prevent progression to depression and other serious psychological problems.

Based on the finding that married students reported significantly higher academic stress compared to their single counterparts, it is recommended that married students in the nursing training colleges are counselled on how to build resilience so as to enable them balance the stresses of academic demands and that of family life. They should also be counseled on time management and effective learning strategies since that may be the only way they could overcome the academic stress they are overwhelmed with.

For researchers, it is recommended that further studies on the subject of stress using other samples are needed. Since the present study is one of the first to be conducted among nursing students in the training colleges in Ghana, its findings serves as baseline information for future studies. Further studies would therefore serve to validate the findings of the present study. Future researches could also use larger samples, qualitative methodologies or conduct longitudinal studies to enable us see the effect of time on student stress.

6. Conclusions

This study was aimed at examining the level of stress in terms of its severity among the students and examining which type (category) of stress student report more. It also examined the differences in the levels of stress with regards to academic discipline and assessed the differences in level of stress with regards to the biographical variables of Gender and Marital status. The results indicate that there was generally severe stress among the students. Regarding which type (category) of stress students reported more, it was seen that personal stressors were reported more followed by academic and finally social ones. With regards to differences in stress based on Academic discipline or Course type, there were no significant differences. Males and females also reported similar levels of stress. Finally, married respondents reported significantly higher academic stress than their single counterparts although there was no significant difference in overall stress with regard to marital status.

Based on the above findings, recommendations were made for stakeholders and future researchers. Recommendations included educating newly admitted students as part of their orientation on the stresses of college life to be expected and instituting counseling services in the nursing training colleges as is the case in the universities in Ghana. Other recommendations include focusing counselling on students personal concerns or worries as much as on academic ones.