Stressors affecting academic and clinical progress of ākonga in a bachelor of nursing programme

Shivann Ramaekers	Sandra Jones	Tia Minnoch	Cath Tuohy	Katie Owen
About the authors: Shivann Ramaekers, RN, MNS, is a senior nursing lecturer in the bachelor of nursing programme at Whitireia. Sandra Jones, RN, MH, works for Te Whatu Ora­—Health New Zealand, and was formerly a senior nursing lecturer at Whitireia. Tia Minnoch, RN, MPP, Dip child & adolescent psych, is a nursing lecturer at Whitireia. Cath Tuohy, RN, MEd, is a senior nursing lecturer at Whitireia. Katie Owen, RN, MSci, is an MHAIDS (Mental Health, Addiction and Intellectual Disability Service) nurse educator for Te Whatu Ora—Health New Zealand and formerly a senior nursing lecturer at Whitireia. Keywords nursing student stressors, clinical placements, financial hardship, nursing student wellbeing

Abstract

THIS MIXED-METHOD PILOT STUDY aimed to identify nursing ākonga (students) experience of stressors while enrolled in an undergraduate pre-registration nursing programme and to explore how these stressors affected academic and clinical success. In developing this study, we recognise that ākonga report multiple significant stressors at different points of their degree, which calls for high levels of pastoral care from programme kaiako (tutors). Ākonga also engage with Learner Support Services at their educational institution and external agencies such as primary health services, secondary mental health services and Women’s Refuge.

Introduction

Nursing education is demanding, and many ākonga face not only academic and clinical pressures but also personal and financial challenges, such as bereavement, housing instability, single parenting, and hardship (Baylis et al., 2024; Flynn et al., 2025; Gillett-Swan & Grant-Smith, 2018; Zheng et al., 2022). These pressures frequently intersect and accumulate, contributing to heightened overall stress (Alkhawaldeh, 2023).

The World Health Organization (2023) reports that stress arises when demands exceed coping capacity, and is shaped by both major life events and cumulative pressures. Literature identifies two forms of stress: stress that can be anticipated, such as that associated with study and finances, and stress from the impact of unexpected life events (Haight et al., 2023). High levels of stress among tertiary ākonga are well documented (Beks et al., 2024; Denovan, 2017; Pérez-Jorge et al., 2025; Zegwaard & Adams-Hutcheson, 2025) and are reported to have impacts on health and academic outcomes (Slykerman & Mitchell, 2021). In Aotearoa, the New Zealand Nurses Organisation–Tōpūtanga Tapuhi Kaitiaki o Aotearoa (NZNO) undertakes a biennial student survey. The most recent survey (Baylis et al., 2025), completed by 1243 student ākonga, confirms ongoing, and in some areas, increasing pressures. Financial hardship is the primary stressor, with nearly two thirds of survey participants struggling to meet daily costs of living and over half considering withdrawing from their programme. Placement-related costs and reduced ability to work continued to drive stress, with almost 80 percent reporting moderate or high stress, and nearly one third experiencing excessive stress (Baylis et al., 2025).

This research brief outlines a pilot study exploring the nature and impact of these stressors and aims to contribute to ongoing discussions about learner wellbeing and the role of institutions in supporting ākonga in nursing education. Aligned with the Education (Pastoral Care of Tertiary and International Learners) Code of Practice (2021), it centres ākonga voices to provide insight beyond enrolment data and support an organisation-wide approach.

Methodology

Study aims

The aims of the study were to:

• Identify the causes and prevalence of stress experienced by ākonga while studying for a nursing degree.
• Explore ākonga perceptions of how this stress affected their academic and clinical success.
• Invite ākonga insights as to the types and timing of support which might have ameliorated the stress and/or improve the study experience for future cohorts.

Study overview

Methods
This study used an exploratory mixed-method design to provide both breadth and depth of understanding. The quantitative component, a Likert-scale survey, captured patterns and prevalence of stress, while the qualitative component, a focus group, offered richer insights into how stress affected learning and clinical practice. This combination ensured a comprehensive view of the issue.

The sample comprised final-year bachelor of nursing ākonga at a polytechnic in Aotearoa New Zealand. Recruitment was voluntary and occurred through an in-class presentation, followed by distribution of study information and an emailed survey link. Data collection began after ākonga completed their state finals in November 2024. Of the 59 ākonga invited, 32 completed the survey and four participated in focus groups. Survey responses were analysed using descriptive statistics to summarise stress-related trends, while focus group transcripts underwent thematic analysis to identify recurring themes and suggestions for support (Braun and Clark, 2006). Six themes were identified by first coding and then grouping similar ākonga quotes and experiences. The themes were then reviewed and agreed upon by research team members to ensure they accurately reflected participants’ perspectives. Quotes are included verbatim from focus group participants to illustrate the quantitative data and give ākonga voice to the themes. Together, these methods provided a nuanced understanding of stress experiences and informed recommendations for improving student wellbeing and success.

Ethical review
The original survey of third-year BN students was approved by the institute’s Ethics and Research Committee in September 2024; an amendment adding a focus group for deeper data exploration was approved in February 2025 (Full approval: RP 472–2025).

Findings

Demographics

Thirty-two responses were received (45 percent response rate), with lower returns likely due to the timing of the study. Ākonga reported they’d have preferred to participate after final clinical placements but before the State Final exam.

Respondents reflected the institution’s 2024 year-three BN cohort: 84 percent identified as women, while 41 percent were under 25. Participants were able to select multiple ethnicities. Nearly half of respondents (45 percent) identified as New Zealand European, with the next largest ethnic group being Asian (42 percent). Sixteen percent identified as other ethnic groups, including Middle Eastern, Latin American, and African. Another six percent identified as Māori and three percent as Pacific. Lower numbers of ākonga Māori and Pacific reflect the availability of dedicated BN Māori and BN Pacific programmes on this campus, who were not part of the surveyed cohort.

Findings

The prevalence and experience of stress
Stress stemmed from academic and environmental sources: workload, assessments, online learning, finances, caregiving, relationships, and housing. Overlapping stressors led to burnout:

“You know, you look at stress levels and it’s not just one… the layers build… But you put those layers on top of one another. Your resilience gets low. Your performance is impacted and your ability to stay the course is impacted.”

Seventy-two percent reported significant stress during their degree, peaking in year two (81 percent) when academic demands and clinical learning intensified: “I was doing more hours on clinical than in my new grad job… you’re exhausted.”

Causes of stress

Specific stressors
Respondents reported high levels of both anticipated and unexpected stress. Nearly all (88 percent) experienced at least one major life event during their studies, commonly bereavement, relationship breakdown, or sudden health issues, adding emotional strain to academic and clinical demands.

Financial hardship and housing stress
Forty-two percent of respondents experienced severe hardship (unable to pay housing costs or buy enough food) at some point during their studies and 16 percent experienced the threat of homelessness. Housing insecurity and high rents added to the pressure: “We lived out of boxes as there was no storage facility nearby… we slept on the floor, for two months.”

Unforeseen events and health issues
Over half (52 percent) reported ongoing physical health issues, while 42 percent reported ongoing mental health challenges. “… I wasn’t able to afford going to the doctors for myself even if I needed to. I put off going a lot.”

Transport and clinical placement
Lack of a full New Zealand driver’s licence or reliance on public transport compounded stress, particularly during clinical placements, due to cost and long commutes: “It wasn’t just the money side… it was also the time side of it.”

Caring responsibilities
One-third cared for dependent children; another third cared for elderly or sick family members. The stress of this was highlighted in the focus group: “I was single parenting, going on clinical placements, with an infant who had been to hospital 15 times.”

Acculturation and learning support
Ākonga represented 15 nationalities; 42 percent spoke English as an additional language, 26 percent reported learning difficulties, and 25 percent had cultural commitments, such as marae, church, or ethnic societies. Participants described the stress of balancing study with cultural and family obligations: “I was questioning so many things… what will happen to my family back in India? What if I get sick? Then I’ve not achieved anything.”

The demands of a nursing degree

Ākonga reported consistently high stress throughout their degree, with clinical placements identified as the most challenging component. Over 80 percent indicated they needed greater financial and emotional support during this time. Stressors included heavy workload, preceptor relationships, assessments and logistical issues.

Focus group participants described the programme as “intense”, particularly for those with caregiving responsibilities, learning needs, or English as an additional language: “It was very difficult to manage the competencies, learning objectives, placements, assignments, and work.”

Placement stress was compounded by shiftwork, mandatory attendance, and balancing clinical hours with illness or childcare: “A friend was off with COVID over placement and ended up having to do a week extra… that was a stress.”

Clinical learning is harder than classroom learning

Ākonga reported greater stress during clinical placements than in class theory weeks. Table 1 (below) compares stress levels across these periods. While kaiako support was valued, preceptor relationships and preceptor support often shaped placement experiences and could be a major source of stress: “You can tell a tick-box nurse from a nurse that actually gives a damn.”

Table 1: Comparing stressors experienced in theory and clinical weeks

Percentage feeling significantly or extremely stressed in relation to:	Theory weeks (on campus)	Clinical weeks (on placement)
Financial pressure	26%	55%
Housing issues	16%	36%
Transport issues (cost, reliability, parking)	16%	52%
Managing employment	14%	37%
Family and personal relationship issues	20%	45%
Caring responsibilities	10%	35%
Managing physical wellbeing	9%	39%
Managing mental wellbeing	31%	58%
Managing a disability	3%	6%
Managing specific learning difficulties	16%	16%
Issues related to English as an additional language	16%	30%
Managing cultural commitments	3%	3%

Overall, clinical learning was described as more demanding than classroom learning because of placement intensity, preceptor dynamics, and added financial and domestic challenges.

Financial pressures and an ongoing debate

Most respondents worked part time, sometimes up to 30 hours a week, while completing full-time study and clinical placements, creating constant tension between managing employment and course requirements: “Finishing an eight-hour shift on clinical and then going to a paid shift elsewhere… it’s just not doable.”

Placement-related costs such as transport and parking added to the strain: “How do you pay for the roof over your head? How do you pay for petrol if you’re not able to work?” Unexpected expenses were common, and while scholarships and vouchers offered some relief, financial pressures and placement costs remained significant stressors, often requiring personal sacrifices.

The importance of kaiako and learner support

Data was gathered on perceived support and its impact on stress and wellbeing. Eighty-five percent of ākonga felt well supported by kaiako, valuing understanding, empathy and practical help: “No matter what, whether it was personal or study-related, [kaiako] listened and genuinely cared.”

Two-thirds accessed institutional Learning Support Services for academic, pastoral, financial and career assistance, describing it as “invaluable,” especially when sought early. Some faced barriers due to stigma or feeling undeserving, yet overall, felt that support contributed positively to coping.

Despite the challenges shared, ākonga demonstrated resilience and growth. Programme completion rates remain high, with participants reflecting on the transformative nature of studying: “I was so close to not getting there… But it’s also the most empowering experience I have ever had. I am a different person now; I believe in myself again.”

Recommendations

1) Institutions should advocate for systemic change and work with relevant organisations to address financial stressors associated with clinical placements, including considering placement stipends or travel subsidies, or improved access to emergency hardship funds.

2) To recognise the multiple overlapping stressors, institutions could establish early identification systems and clear escalation pathways to ensure timely support for ākonga.

3) Support services should be actively promoted and integrated throughout the programme, with a focus on reducing stigma and ensuring they are accessible to diverse student needs (eg. caregiving, language, cultural commitments, neurodiversity and health challenges).

4) Further research in this area is needed, including higher numbers of diverse ākonga groups, institutions, and year levels to deepen understanding of stress and support needs.

The findings in this study suggest stress during the bachelor of nursing programme is significant, but varied, with many key stressors impacting the ākonga journey. The findings underscore the need for improved, coordinated support for ākonga across the programme, and add to growing concern about the impact of placement-related stress. For ākonga, clinical placements are stressful enough in themselves, and this is only compounded by the growing economic pressures they face.

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