CHAPTER II

REVIEW AND RELATED LITERATURE AND STUDY

Nursing students experience multiple stressors as they are expected to apply

theoretical learning and develop critical thinking skills while in the professional
environment. Perceived overwhelming negative stressors can lead to absenteeism, job
dissatisfaction, and a high employment turnover rate.

This research compared levels of stress fourth year and third year nursing
students at Pilar College of Zamboanga City, utilizing the Student Nurse Stress Index
(SNSI, Jones and Johnson, 1999) and the Nursing Student Demographic Survey.
According to third and fourth year nursing students higher levels of stress main areas
including: Clinical areas, Clinical Instructor, Patient, Family and relatives, Key words:
nursing student stress management.

Nursing students experience a high level of stress and anxiety throughout their
education.  In fact, nursing students experience more anxiety, especially test anxiety,
than students from any of the healthcare disciplines (Turner & McCarthy, 2016). Many
factors contribute to stress and anxiety in nursing students. Students in nursing
programs often have other competing priorities, which can lead to higher stress levels. 

Stress has been defined as a barrier to concentration, problem solving, decision

making, and other necessary abilities for students’ learning; it also has some symptoms
and illnesses in the students such as depression and anxiety. In reviewing stress and its
consequences, the methods of coping with stress in the method of response to it would
be more important than the nature of stress itself. Therefore, this study aimed to
determine the effectiveness of stress management training program on depression,
anxiety and stress rate of the nursing students.

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  Having to balance didactic and clinical courses while simultaneously balancing
financial, family, and other life issues has the potential to exacerbate any stress or
anxiety caused by the nursing program alone. The high rigor of nursing curricula also
leads to stress and anxiety, because failure in either a course or a program results in
lost time and investment in the student’s education, which in turn causes a delay in
future earning potential (Tagher & Robinson, 2016).

  Additionally, peer mentoring has other benefits by providing an outlet for support
and promoting connectedness, which can decrease stress and foster academic success
(Lombardo, Wong, & Sanzone, 2017).

Nursing curricula are stressful and tend to cause anxiety for many students.  It
often seems as if nursing students are just stressed in general.  However, there are a
variety of ways to promote stress reduction, both formally and informally, throughout
nursing programs.  Nursing faculty should be cognizant of the stress experienced by
their students and encourage activities to mitigate stress and foster success.

Nursing students in the clinical setting experience a high level of stress. The
understanding of people involved in nursing education, from coping strategies of nursing
students with clinical stress, is highly important for any kind of planning in this field.

The exploration of nursing students’ experiences of coping with clinical stressors,

increases students’ awareness of their coping strategy. The academic authorities in
recognizing the coping strategies of students with stress in clinical setting, can provide
necessary training on effective coping strategies for students.

Clinical experiences are another stressor for nursing students. Remember what it was
like to walk into a patient’s hospital room for the first time?  Studentsare terrified of
doing something wrong.  Today, simulation can help ease
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the stress associated with the clinical experience.  Faculty can use simulated scenarios
with either high-fidelity simulators or standardized patients to help familiarize students
with clinical situations prior to their first clinical experience (Turner & McCarthy, 2016).
 Nursing students experience higher levels of stress than students in other health
sciences. The clinical part of nursing education is more stressful than the theoretical
part (1). A study in Bahrain found that all nursing students experienced moderate to
severe stress in the clinical setting percent of nursing students reported the level of
perceived stress as moderate to high. The common causes of clinical stress in nursing
students included the fear of unknown events, working with equipment. The fear of
making a mistake and communication with staff, peers and patients. Stress from lack of
professional knowledge and skill was also reported as one of the major sources of
stress in this study. In spite of the rigid and rigorous training both in classroom and
clinical area, students still felt that they still have a lot more to be learned while in the
school and thus, they feared of committing mistakes while performing nursing skills in
the clinical area. Stress, Stressors, and Stress Responses of Student Nurses in a
Government Nursing School.

Caring is the core of nursing and should be cultivated in student nurses.

However, there are serious concerns about the caring concern in the clinical
environment and in nursing education. Clinical instructors are ideally positioned to care
for student nurses so that they in turn, can learn to care for their patients.

Third and Fourth year nursing students had a positive perception of their clinical
instructors' caring. No relationship could be found between the course the respondents
were registered for, the frequency of contact with a clinical instructor, the ages of the
respondents and their perceptions of clinical instructor caring.

Student nurses experience high levels of stress, due to rigorous academic

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and emotional demands when they begin to take responsibility for patient care. That
stress decreases student nurses' ability to think critically and impacts on their
experiences while involved in a nursing programme. It may also later impact on their
lives and journeys as registered nurses (Roe, 2009, p. 211). Stress is perceived as a
challenge when student nurses have a relationship of care with their clinical instructors,
when clinical instructors model effective communication, when they inform the
registered nurses about student nurse skills levels, and, when they set realistic goals for
clinical experiences. Student nurses are then less anxious and more satisfied with their
programmes.

 Poor relationships between student nurses and clinical instructors are a source
of stress and could result in them losing interest in learning. Creating and establishing a
clinical instructor-initiated caring transaction, linked to taught self-care interventions, has
the potential to reduce their anxiety while enhancing learning outcomes and critical
thinking.

According to Hutchinson & Goodin, 2013, pp. 22–23; Tiwaken et al., 2015, p.

70).The caring transaction is a vehicle for clinical instructors to assist student nurses to
find meaning in the anxiety, and guide them to engage in self-care, using the practice
of mindfulness and reflection. Student nurses have multiple emotional needs. These are
varied and personal in nature. It is essential that clinical instructors ensure that time is
provided to focus on emotional needs.

Caring clinical instructor interaction with student nurses in the clinical

environment causes them to perceive this environment as stimulating, and a challenge.
stress include negative interaction with instructors,14, 21 being observed by instructors
and being late,17 poor relationships with clinical staff,that students with higher scores
for the stress factor “relationships with teachers and clinical instructors” were less likely
to engage in the coping behavior “changing mood.” Masamura et al. [8] reported that
nurses’ relationships at the clinical practice site were a source of stress for nursing
students (Table 4). Students had
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only limited contact with clinical instructors or faculty members, and they felt stress
because they could not contact their clinical instructors whenever they needed briefing
or guidance.

One of the most important—but often forgotten—tasks for nursing student is

caring for themselves. A nursing student’s physical, emotional, and mental health is vital
to the well-being of the person who has cancer. To be a good caregiver, you must be
good to yourself may experience periods of stress, anxiety, depression, and frustration.
The following suggestions can help keep you from feeling overwhelmed or burned out.
Feeling angry, guilty, alone, afraid, and/or sad can be common for nursing
students.Feeling exhausted all of the time. Feeling impatient, irritated, or forgetful
because of too much demand coming from the patients.

During nursing education and training, nursing students are frequently exposed
to various stressors which may directly or indirectly impede their learning and
performance. The nature of clinical education presents challenges that may cause
students to experience stress. Moreover, the practical components of the program
which is important in preparing students to develop into professional nurse role by its
nature have made the program even more stressful than other programs. Studies
indicated that nursing students perceived high level of stress and are prone to stress
than other students. This phenomenon is true regardless their academic level. Stecker8
found that nursing students reported higher academic and external stress than students
in physical therapy, pharmacy, dentistry and medicine.

According to Pryjmachuk and Richards,22 they found out that stress in nursing
students arises from a combination of personal and extracurricular factors rather than
from the educational program itself.

Stress in their families also contributes to the third year and fourth year nursing
students. Perceived levels of stress increase according to family monthly
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income. Students who belong to a family with higher income tend to perceived higher
stress related to their workload and assignment. This may due to the fact that families
with higher income tends to be more busy with regards to their business, personal and
social relations that they may not be able to spend much
time doing their assignments and other academic workload.

A connection to family provides a certain type of social support that you can’t get
from other people. Provided they aren’t severely emotionally toxic, we can generally
depend on our families in times of crisis for emotional and practical support, and
sometimes even financial support when we’re desperately in need. 

Dealing with difficult people is never easy. But while it may be better for your
stress level and even improve your health to eliminate strained relationships from your
life, it's not always a simple undertaking when the difficult people are relatives, co-
workers, or people you otherwise must have in your life.

Social support is a great stress reliever, but family and reltives relationships can
also be a major source of stress. As conflict is virtually inevitable in relationship.

The role your family plays in your life, and the health of your family relationships,
can really affect your stress levels. Remember, strong family relationships can be a
source of strength that you can draw upon in times of stress, and use to expand your
enjoyment of the good times you experience in life. 

  A conflicted family relationship cannot just deprive you of that support, but they
can create additional stress that depletes your ability to cope. You may notbe able to
completely control the types of relationships you have with your family members.
Relationships are dynamics that involve more than just one person--but there are many
things that you can do to create greater harmony in your relationships, and protect
yourself from unnecessary stress and pain.

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Accoding to Lazarus & Folkman Core finding of this investigation was the
significant correlations between perceived level of stress and perceived physio-
psyhosocial health. Students who perceive a higher level of stress were more likely to
have poorer physio-psychosocial health. Tully 2 reported that high level of stress as
possible risk for the health of the student. That asserts that stress can affect people’s
physical, psychological and social health if adaptation outcomes cannot be achieved.

Students’ needs, facilitating their learning both in the academic and clinical
setting, and planning effective interventions and strategies to reduce or prevent stress in
nursing education and training. Moreover, nursing educators must be perceptive of
these stressors and should strengthen students’ coping skills to deal with the different
stressors during nurse education and training. Furthermore, curricular revisiting and
review should be conducted especially on the Related Learning Experiences or training
hours requirement.

Patient safety is a key element of the quality of health services. Nurses are the
largest group that care for patients, observing safe in nursing care would reduce
injuries, disability, morbidity and mortality. However, high stress can lead to a decline in
the quality of nursing care. Other factors such as communication with patients and their
companions also cause stress in nursing students.

If these stresses continue, the will lead to burnout, the worst consequence of
which is the reducing of quality of care patients receive because the patient was
deprived of adequate care and his human rights.

 Since safe procedures are the core of nursing care to maintain and improve
patient safety and if unsafe procedures are done, has not only legal consequences but
also irreparable harms are incurred to patients, which can have dire consequences for
the patients and their family, including long-term accommodation, patients suffering,
additional costs, dissatisfaction with the hospitals.

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Since the relationship of a nursing students and patients’ family is the essential
and effective prerequisite on the successful care results. Therefore, this issue was not
yet evaluated and the elements of relation in its interactive, psychic, intellectual and
dynamic components were ignored. By considering the lack of standard pattern for
patients’ family –nursing student relationship and its different communicating methods,
study about the interactions of patients-nursing student can increase the knowledge of
nursing students toward how to communicate with the patients, especial during an
interaction with them, and how to understand the patients via a communication between
patient and their family.

A literature search was performed using key terms of stress, college student
stress, Millennial, mature college student stress, student nurse education, student nurse
clinical education, nurse stress, nursing student anxiety, graduate nurse retention and
burnout; with a focus on research in nursing student stress since 2009.

According to (Beck & Srivastava, 1991). The literature review demonstrated

changes over time in the areas of nursing student stress evaluated by researchers. Past
researchers evaluated student nurses in regard to stress in the clinical setting and the
developmental phase of the students. Stress in both novice and experienced nursing
students was explored by Jimenez et al. (2009), revealing stress at similar levels from
three grade levels.

Research studies with part-time nursing students noted students must be

educated on the demands of the nursing program they are entering, particularly the
workload.The study included flexibility of class scheduling, clinical placement during
school hours or on weekends, and financial support as stress reducing strategies. The
most significant concern these students identified was relationship with the patient,
followed clinical areas, clinical instructor and family/relatives.Family support, peer and
faculty support, advisors, were reported as valuable by the students.

Clinical experience remains an integral component of nursing education. It

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provides nursing students with the opportunity to demonstrate physical

competency, utilize critical thinking skills and incorporate didactic nursing theory under
supervision of a clinical nursing instructor.

According to Melincavage’s (2011) Nursing students’ initial clinical experiences

may have significant effects on their basic nursing education and future studies. Multiple
researchers have concluded nursing students have increased stress or anxiety when
they begin clinical work. Research agreed that a positive clinical atmosphere, provided
by both staff and faculty, decreased student anxiety and increased self-esteem.

Feelings of pressure were described as most stressful, and included preparing

for clinical patients, lack of sleep, overlapping assignments, and timely submission of
assignments to instructors.Challenging relationships was the second theme noted, and
included interactions with patients and families, communication with clinical staff, co-
operative peer work, and social relationships with families and the community.

Students described their response to a stressful situation, and what coping

strategies they utilized to relieve the stress. Responses were both physiological
and psychological. Sleep deprivation, altered appetite, and headaches were reported.

Physiological responses to stress were noted as being upset, panic, anxiety,

sadness, withdrawal, sensitivity, and mood changes. Students may be unaware of their
perception to stressors, and may need assistance with coping strategies (Lazarus and
Folkman, 1984).

According to (Levett-Jones, Lathlean, Higgins, & McMillan, 2007, 2009; Levitt-

Jones & Lathlean, 2007, 2009). Additional stress may come from a continually
changing clinical environment. Students need some time to develop a working
relationship with a new clinical advisor, settle into a new environment,
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become familiar with the routines and norms on the new clinical area, and become
acquainted with friendly supportive floor staff to develop a sense of belonging.

Positive, or adaptive coping mechanisms identified by students included a period

of reflection, engagement in a physical activity, and the decision to persist and carry on
with the program.

Maladaptive coping included ignoring the stress, crying, irritability, isolation, and
depression. Familiar coping strategies were utilized by students as they became new
graduate nurses.

As nurse educators we need to develop an awareness of possible student nurse

stress and facilitate students’ ability to cope effectively with new and challenging
stressors.It may be beneficial to prepare students before a very stressful time in the
nursing program.
 According to (Jimenez et al. 2009) Recommendations from the study include
support and guidance from clinical instructors, faculty meetings with students to discuss
stressful times in the program, and possible coping interventions for the students.

The students were taught how to identify stressors in their lives either in patients,
clinical areas, clinical instructors, family/relatives and the effect of the stressors upon
both personal and academic life.

The nursing profession is seeing increasing numbers of motivated nurses who

are interested in increasing their knowledge, at a significant price to themselves.The
study of stress in nursing students continues to play an important role in nursing
education. The purpose of this research study is an evaluation of three grades of
nursing students and to consider the implications for nursing education and practice.

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Stress is in inescapable fact of life. We’re bombarded daily with challenges

ranging from traffic to bills -- from deadlines to last minute changes. We’re also faced
with a variety of personal problems such as health concerns, poor nutrition, and aging.
And we have to deal with our thoughts, which often make us question the wisdom of our
decisions, performance, and worth. The answer to why some people manage much
better than others with these universal problems has to do with how stress works.

Reacting to various events as threats triggers the “fight or flight” response, which
speeds up the heart rate, breathing rate, raises blood pressure, metabolism, and
muscle tension. In addition, various chemicals are released that slow down digestion,
growth, reproduction, and tissue repair. In other words, chronic stress can be very
harmful to your health.

  Stress management and stress reduction methods include a variety of coping

tools used to recognize and assess stress and interpret it in a more positive way. They
are tools that are used to release stress and reduce its negative effects on our lives. 

There are numerous benefits to be had from reducing and managing stress,
beginning with an increase in concentration, a decrease in anxiety, and a reduction
in pain. Effectively managing stress often leads to improved health. Stress management
programs are drug-free. Most importantly, stress management programs put you in
charge and give you a sense of control, which leads to enhanced self-esteem, less
likelihood of depression, and an overall improvement in quality of life. The primary cost
consideration is an investment of your time.

(https://library.ndsu.edu/ir/handle/10365/27601)