Students in higher education face increasing levels of stress, particularly academic-related stress (Mason 2017:138; Pascoe, Hetrick & Parker 2020:104–112; Ribeiro et al. 2018:70–77). In comparison to the general student population, nursing students experience even higher levels of stress (Bartlett, Taylor & Nelson 2016:89), which may be largely due to the nature of nursing education (Gomathi, Jasmindebora & Baba 2017:108). The nursing curriculum comprises a theoretical and practical component, which commences during the first year of study. Busy timetables, examinations requiring critical thinking, as well as clinical practice are just some of the demands faced by nursing students (Aedh, Elfaki & Mohamed 2015:34–36). The sources of stress of nursing students can be broadly categorised as clinical, academic, and personal. They include stress from lack of professional knowledge, clinical environment, taking care of patients, assignments and workload, teachers and nursing staff, peers and daily life (Aedh et al. 2015:34–36; Ahmed & Mohammed 2019:119; Alsaqri 2017:3; Hamaideh, Al-Omari & Al-Modallal 2017:200; Karaca et al. 2017:34; Khater, Akhu-Zaheya & Shaban 2014:198; Labrague 2013:427–428; Labrague et al. 2018:404–405; Mohamed & El-Hafez 2015:42; Ugwoke et al. 2018:13214–13215), long working hours, poor study methods (Langtree, Razak & Haffejee 2018:92), poor grades, inability to balance work and leisure, difficulty in balancing clinical work and studying and the humiliating behaviour of doctors (Parveen & Inayat 2017:3–4).

According to Lazarus and Folkman (1984):

Stress experienced by higher education students, including nursing students, impacts their mental and physical health and may lead to a range of academic (Pascoe et al. 2020:108) and social problems (Gomathi et al. 2017:108; Ribeiro et al. 2018:75–76).

Whilst stress amongst nurses has been well studied, there are few instruments to measure stress amongst nursing students specifically (Watson et al. 2013:160). Systematic reviews of studies conducted from 2000 to 2015 (Labrague et al. 2017:471–480) and 2010–2016 (McCarthy et al. 2018:197–209) on stress in nursing students revealed that the majority of the studies utilised the Perceived Stress Scale (PSS) developed by Sheu et al. (1997:341–351). The PSS was developed to determine the type of stress perceived and levels of stress experienced in clinical settings by nursing students at Taiwanese Universities. Whilst the PSS has been widely used internationally (i.e. Europe and Asia), previous studies have not fully examined the psychometric properties of the scale (Algaralleh, Altwalbeh & Alzayyat 2019:778). Furthermore, there are limited African studies that have utilised this instrument, and neither tested the factor structure of the scale (Labrague et al. 2018:402–408; Ugwoke et al. 2018:13212–13218). In particular, Langtree et al. (2018:91) reported developing a new questionnaire to identify the causes of stress in first-year South African nursing students, as there was not an appropriate research instrument for their study. With this in mind, the paper aims to test, for the first time, the hypothesised six-factor latent structure and establish the construct validity and internal consistency of the PSS for South African nursing students.

Whilst numerous international studies have focused on stress in nursing students, there are few validated instruments to measure stress (Watson et al. 2013:160), with the PSS by Sheu et al. (1997:341–351) being the most cited scale (Labrague et al. 2017:471–480; McCarthy et al. 2018:197–209). Despite the frequent use of the PSS, few studies have tested its validity, with most researchers referring to the original work done by the developers (Sheu et al. 1997:341–351, 2002:165–175) except for Algaralleh et al. (2019:777–787) who validated the Arabic version of the PSS amongst Jordanian nursing students. Based on a review of published literature, it appears as if the PSS has not been used in South Africa to determine perceived stress amongst nursing students. This is supported by the work of Langtree et al., who in 2018 noted the lack of an appropriate instrument to measure the causes of stress amongst first-year nursing students in South Africa and therefore developed their own scale.

Given the international popularity of the PSS and the dearth of research on the psychometric properties of the scale, this was the first study to measure the construct validity and internal consistency of the PSS for South African nursing students. The results confirmed the internal consistency and construct validity of the PSS for South African nursing students. More specifically, the six-factor model of the PSS identified in earlier research (Sheu et al. 1997:341–351, 2002:165–175) was confirmed. There were significant positive correlations amongst all six latent factors – (1) taking care of patients, (2) teachers and nursing staff, (3) assignments and workload, (4) peers and daily life, (5) lack of professional knowledge and skills and (6) clinical environment – indicating that participants who showed high perceived stress in one dimension were also likely to show high perceived stress in the other dimensions as well.

With regard to the internal consistency, alpha coefficients for the total scale and subscale scores were above the 0.70 cut-off, suggesting an acceptable degree of internal consistency (Taber 2018:1278). The alpha coefficient for the total scale was 0.93, which is higher than that found in other studies (Alsaqri 2017:3; Khater et al. 2014:196; Labrague 2013:426; Labrague et al. 2018:403; Sheu et al. 2002:168; Ugwoke et al. 2018:13214).

The overall mean score for the PSS was 1.48 (s.d. 0.61), which is indicative of moderate levels of stress. Similar findings were reported in studies conducted in Saudi Arabia (Ahmed & Mohammed 2019:120–121; Shdaifat, Jamama & Al Amer 2018:38) and Jordan (Khater et al. 2014:200–201). Higher scores, although still within the ‘moderate’ category, were reported in Saudia Arabia (Aedh et al. 2015:35; Alsaqri 2017:3), Turkey (Karaca et al. 2017:36), Philippines (Labrague 2013:427–428; Labrague et al. 2018:405), Greece (Labrague et al. 2018:405) and Nigeria (Labrague et al. 2018:405). Stress from assignments and workload was the main source of stress in the current study, whilst stress from lack of professional knowledge was the least reported. A possible explanation for this is that the survey was undertaken in the month prior to the commencement of examinations, when the students were finalising classes and assignments and not engaging in clinical work.

Increased levels of stress result in burnout which is correlated with poorer psychological and physical health and may influence the work of individuals in helping professions and eventually also the well-being of their patients (Enns et al. 2018:230). There is evidence that increased levels of stress and burnout in nursing students are negatively related to caring behaviours (Li et al. 2020:5–6); they also result in poorer job proficiency and nurses who are more inclined to leave the profession (Rudman & Gustavsson 2012:998; Rudman, Gustavsson & Hultell 2014:620). Given that nursing is already a highly stressful occupation (Dlamini & Visser 2017:1068; Khamisa et al. 2015:660; Van der Colff & Rothmann 2014:381) and the importance of retaining nurses in the profession (Van Rensburg 2014), stress should be addressed at the level of the nursing student. Therefore, the importance of valid and reliable scales to measure stress levels and sources of stress amongst nursing students should be acknowledged, so that meaningful and useful inferences can be made when recommending strategies to address stress in nursing students. The current study established that the PSS is a useful tool for nursing educators and researchers to help identify the main sources of stress amongst nursing students. As the nursing curriculum is both academically and clinically demanding, it is important for institutions providing nursing education to introduce preventative measures, such as teaching coping strategies and providing mentorship programmes, so that students are taught how to deal with stress at the outset of their education.

As with all research, this study has limitations. The study was undertaken at a single university amongst a convenience sample of nursing students, although slightly more than a third of the group was reached. As such, caution is required when generalising the findings to other university settings. A self-administered questionnaire was used, which implies that there may be some level of response bias. It is recommended that future research should replicate the present study and that further confirmatory factor analysis be undertaken to confirm the six-factor structure of the PSS for nursing students in South Africa.

This study confirms the six-factor structure and internal consistency of Sheu et al.’s (1997:341–351) PSS, suggesting that it is a valid and reliable instrument to test the perceived stress from (1) taking care of patients, (2) teachers and nursing staff, (3) assignments and workload, (4) peers and daily life, (5) lack of professional knowledge and skills and (6) clinical environment for South African nursing students.