Journal of Advanced Nursing, 1999, 29(4), 967973

Experience before and throughout the nursing career

A comparative study of stress between pre- and post-Project 2000 students

Edward Lindop
PhD BA (Hons) Cert Ed RGN RMN RNMH RNT

Lecturer in Nursing, Department of Nursing and Midwifery, Keele University, Stoke-on-Trent, UK

Accepted for publication 22 April 1998

LINDOP E. (1999)

Journal of Advanced Nursing 29(4), 967973 A comparative study of stress between pre- and post-Project 2000 students This paper reports upon a comparative study in an English health authority of stress experiences between 146 current Diploma in Nursing (Project 2000) Adult Branch students and a prior study of a sample of 146 students who undertook a Certicate course leading to Registered General Nurse (RGN) in 1988. Both groups were administered the same questionnaire. The number of stressors common to both groups were two in education and nine in the clinical environment. Three prominent feelings of stress were expressed by both groups along with two methods of coping with stress. A constellation of 11 personality type characteristics labelled `determination', which enabled students to sustain themselves, was identied. Three characteristics of `determination', plus a feeling of uselessness and inability to contribute to the nursing team effort, and the intense amount of academic work were statistically signicantly higher for Diploma students. Six prominent clinical stressors were experienced more intensely by third-year Diploma students than rst- or second-year students. Stress was found to increase with the level of training. This nding replicated the picture found among 324 students in 1988. Differences in stress experiences for different age groups were not statistically signicant with the exception of physical hard work. A number of stressors experienced by students in 1988 were also experienced by students in 1997. Keywords: student, nurse, stress, education, coping, Project 2000, Registered Nurse, Diploma, Certicate

INTRODUCTION
A questionnaire study of student nurses' experiences in the North Staffordshire Health Authority in 1988 showed that stress experiences were widespread, although their specic manifestation in individuals was diverse. However, a core of stated stress experiences were identied for 95% or more of respondents (Lindop 1996).

Correspondence to: Edward Lindop, Lecturer in Nursing, Department of Nursing and Midwifery, Keele University, City General Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG, UK.

Differences associated with age and work experience were found in a number of questionnaire answers. These variables were interesting, both because they were simple parameters on which learners differed, and because the former reected attitudes and coping styles students brought to training, while the latter might have indicated changes in these brought about by nurse training and education. Former Certicate level training leading to Registered General Nurse (RGN) differs from current Project 2000 Diploma level training (Adult Branch), the former being more practically orientated while the latter is more academic. Training for RGN was an employed apprenticeship

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E. Lindop while the Diploma provided supernumerary training accompanied by academic insight. It can be argued (Elkan & Robinson 1993) that the advent of Project 2000 Diploma courses has widened the gap between theory and practice. Stress experiences of students undertaking these two programmes might be considerably different given the contrasts in training and education outlined above. In the light of this, a comparison of stress experiences among students undertaking RGN training in 1988 with those undertaking the current Diploma (Adult Branch) was made. While the work of Birch and Parkes focused predominantly upon the students' clinical experience, others have identied students' stress experiences during their formal education. For example, Smith (1989) showed how stress can be created among student nurses if they perceived their appraisal of practical tests being handled in a negative way. Lindop (1991) identied two prominent stressors related to academic work as examinations and the intensity of work, a nding supported in more recent times by Ferguson & Cerinus (1996). Ferguson and Cerinus commented that the educational research underpinning the new Higher Education Diploma courses in nursing led to a single most important message that academic work overload should be avoided and was cited as a major factor in non-learning. These studies shed light upon stress experiences related to education, but suffer from limitations. Smith (1989) uses a variety of methods, but her research involved only four wards. Lindop (1991) reported stress experiences in only one health authority in England while Ferguson & Cerinus (1996) surveyed only four classes of students at different stages of the course, involving 67% of the 289 student nurse population. Orr (1990) argued that publications over a 20-year period showed that the nursing profession was just as traditional today as it was in the 1960s, which produced conict for current diploma supernumerary students who have to confront the reality of practice while being provided with theoretical and questioning insights. Many of these issues were summarized by Clarke & Rufn (1992) in an Australian study which had considerable compatibility with the English context, in terms of the transfer of nursing into Higher Education. Clarke and Rufn, from a sample of 306 students in three different learning situations (university, college and hospitalbased education programmes), found that there was more stress associated with study demands on university and college students than hospital-based students. Methodologically, the Clarke & Rufn (1992) study had a good element of control in that three groups from varied nursing institutions were compared by means of a wellstandardized questionnaire. Their study also found that ve stress factors accounted for 67% of the variance related to stress items in their questionnaire. In order of signicance these were interpersonal interaction (fellow students, qualied nurses and other professionals), emotional demands (emergencies, terminal illness and a fear of making mistakes), study demands (total amount of work to be completed, examinations, organizing study schedule), family/personal (nding time for personal friends and interests) and technology (computers and specialist nursing equipment). Despite a difference between the academic and less academic courses, in terms of study demands, the stress responses of students were notable for their similarities rather than their

BACKGROUND LITERATURE
A considerable literature has been published to describe the stress experienced by qualied nurses (e.g. Boxall 1982, Brunt 1984, Campbell 1985, West & Rushton 1986, Adey 1987, Errington 1989). Less research has focused specically upon the position of nurses in training. However, well designed and executed studies into students' stress experiences have been published. Notable among these was the work of Birch (1975), who measured anxiety among 207 student and pupil nurses. Birch examined potential anxiety related to 56 areas of nursing practice, which ranged from the disposal of sputum and urine to dealing with death and dying (the latter stressful experience was also detailed by Knight & Field 1981). Apart from indicating clearly dened activities producing stress, Birch found that stress for students was high at the start of training and, while reducing during year 2, rose to a high level again during the third year of training. While these studies provide valuable information about student nurses' stress experiences, they all have limitations. For instance, Knight & Field (1981), in their naturalistic approach to research methodology, paint a graphic picture of student nurses struggling to cope with death experiences. However, the picture relates to only one surgical ward containing 29 beds. Thus, generalizations from their ndings are problematic. Birch, on the other hand, while providing more reliable and valid results, which may be meaningful to other areas, conned his sample to four schools of nursing in the North-East of England. Parkes (1980a, b, 1982, 1984, 1985), while measuring students' stress experiences, managed to create a wellcontrolled study and maintained something of a natural experiment by balancing the rotation of students through their medical and surgical experiences. In the papers mentioned above, Parkes detailed both statistically and descriptively the stress experiences of nurses during training and the probable environments for producing stress. Despite the use of a longitudinal study utilizing sophisticated methodology, Parkes conned her study to the Oxford region. However, her ndings accord with those of Birch (1975).

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Experience before and throughout the nursing career differences in that students from the different courses identied common stress experiences. The statistical analysis of learners' responses (n 413) in the 1988 study (Lindop 1996), showed few interaction effects of age and experience. An important nding in this work was that stress experiences were more intense as students progressed through training. The response to stressors was highest among third-year students. It was speculated that age and experience were different kinds of psychological variables. If true, this nding might suggest that measures to alleviate stress could be considered in relation to either age or experience, but that measures taken to deal with stress in relation to one variable may not be effective with the other. In particular, the time point of training might be an important consideration in terms of alleviating stress.

Stress in pre- and post-Project 2000 students General Division of the North Staffordshire Health Authority in England (n 413) over a 6-month period from March 1988. The questionnaire had statements related to stressful experiences originally formulated from interviews with learners who had left training as well as those in training sampled from the three student and two pupil nurse training years. The questionnaire had a four-point Likert scale ranging from strongly disagree (which scored 1) to strongly agree (scoring 4) and a non-applicable option. The original sample included student nurses (n 324) and pupil nurses (n 89). Because of the difference in sample sizes between this student group and students currently in training (n 46), a random sample of 146 students from the population of 324 students was obtained by means of the Statistical Package for the Social Sciences (SPSS). This was done by instructing the computer program to select 146 students at random from the original data, producing an equal number for the two populations. The random sample contained 60 rst-year, 37 secondyear and 49 third-year students. In this sample there were 14 males and 132 females. Age ranges were 1725 (n 60), 2635 (n 37) and 3656 (n 49). The procedure for administration of the questionnaire to current students was the same as that used in the original 1988 sample. Students were administered the questionnaire in groups during their periods of study in the Department. They were requested not to share information while completing the questionnaire and to respond to statements in terms of their agreement or disagreement or to respond that a statement was not applicable to them. Students were also encouraged to ask for clarication if necessary. Only one item was identied for clarication related to the meaning of `kardex', which was a former nursing-records system now replaced by the nursing process. Questionnaires were collected upon completion. Students had been informed that there were questionnaire statements associated with the categories reasons for wanting to nurse, knowledge of nursing before commencing training, stress experiences in the educational environment, stress experiences in the clinical environment, feelings expressed, methods of coping with stress, feeling like leaving nursing and personal factors which have helped students to carry on. In the present study, only ve categories were analysed. These were stress experiences in the educational and clinical environments, feelings expressed, methods of coping with stress and personal factors which enabled people to carry on. The reason for this was that, in the original study, other categories were associated with wastage of students from the course and a causal relationship between wastage and stress could not be established, making a comparison between those in the current study meaningless.

THE STUDY Aims

1 To compare a sample of student nurses in the 1988 study (Lindop 1996) with those undertaking a current Diploma (Project 2000) course in the same College/ University Department. This would enable a comparison to be made between former training and education (RGN) at Certicate level with the Higher Education Diploma (Adult Branch). 2 To compare the two groups identied in 1 above in relation to stress experiences, methods of coping and factors that sustained students in stressful situations. 3 To explore potential differences among the three age groups and year of training among project 2000 Diploma students in terms of their reaction to stress and to compare the result with those obtained from students in 1988.

Methods
The same questionnaire used in 1988 was administered to a population of 146 student nurses currently in training (58 rst-year, 48 second-year and 40 third-year students) over a 5-week period from May 1997. In this sample, there were 18 male and 128 female students. Age ranges were 1725 (n 99), 2635 (n 29) and 3656 (n 18). The psychometric properties of the questionnaire were related to individual perceptions of nursing before commencing training (previous attitudes and learned experiences); interpretation of threat to personal integrity; emotional reactions to actual and perceived threat; cognitive appraisal of coping and intrinsic coping attributes (after the original work of Lazarus 1966). The original 144-item questionnaire was administered to the population of nurses undergoing training in the

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Table 1 Stressors, coping and `determination' for students in education and clinical practice Stress experiences in the educational environment 1 The intense amount of work 2 Examinations Stress experiences in the clinical environment 3 Too much responsibility without adequate supervision 4 Uncaring attitudes of nurses towards their patients 5 Physical hard work 6 Conict between the ideal practice taught in the school and the real situation on the ward 7 Pressure of work when performing nursing duties 8 Lack of communication and information given to patients 9 Lack of teaching and interest in learners 10 The disregard shown for the emotional needs of patients 11 Feeling useless and unable to contribute towards the nursing team effort Methods of coping with stress 15 Talking to relatives and friends 16 Trying to be calm Personal factors which have helped me to carry on 17 Determination 18 Being assertive and developing my own personality 19 Looking after myself 20 I just don't let things `get to me' 21 22 23 24 25 26 27 Feelings expressed 12 Feeling under pressure 13 Feeling exhausted 14 Obsessed with being careful I desire to obtain the qualication Belief in myself An `inner feeling' to carry on Emotional control The need to nish something I had started Thinking of the future and that one day I'll be able to change things A sense of achievement

RESULTS
Table 1 represents the questionnaire statements found applicable by 95% of students from the original 1988 study and the current one related to Project 2000 Diploma students. A coefcient alpha of internal consistency for the original questionnaire sample was 099 and for the questionnaire given to the Project 2000 Diploma group the coefcient alpha was 086. This indicates that there is a strong relationship between statements in the questionnaire for both groups, signifying reliability of the questionnaire. Table 2 presents the mean scores and statistically signicant differences for ve statements following a t-test of statements in Table 1 between the

original Certicate students (group 1) and Project 2000 Diploma students (group 2). In Table 1, two stressors associated with education were relevant to both groups. However, as Table 2 shows, the intense amount of work is more stressful for current Project 2000 Diploma students than for those on the preProject 2000 course. Both groups of students were in agreement about identied stressors associated with clinical practice (Table 1). The exception was of feeling useless and unable to contribute towards the nursing team effort which was statistically more signicant for current Project 2000 Diploma students (Table 2). Feeling under pressure, exhausted and obsessed with being careful were the same for both groups (Table 1). Two methods

Table 2 Statistically signicant t-test results following a comparison of stressors between pre-Project 2000 and Project 2000 students reported in Table 1 Group 1 (pre-Project 2000) Statement number 1 11 17 18 25 N 144 141 146 144 137 Mean 26 21 35 31 30 Group 2 (Project 2000) N 144 140 143 143 142 Mean 31 26 36 32 33 Probability P P P P P = = = = = 0000 0000 0031 0041 0003

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Experience before and throughout the nursing career of coping with stress (Table 1) were also the same for both groups. Personal factors which helped people to carry on identied by both groups as important were the same, with the exception of determination, being assertive and developing individual personality and the need to nish something that had been started (statistically signicantly higher for Project 2000 Diploma students see Table 2). Questionnaire Items from Table 1 were also analysed by means of a two-way analysis of variance. This compared the means between the three age groups and student year of training. It also tested for potential interaction between age and student year of training. A Scheffe test to correct for post hoc overestimates was applied to statistically signicant differences, the results of which are set out below in Table 3. Table 3 shows that current Project 2000 Diploma students in the second and third year of training experience stress associated with too much responsibility without adequate supervision more than students in their rst year of training. There was no signicant difference between age groups. With regard to physical hard work, third-year students experience this stressor more than second-year students and the younger age group (1725), along with the older age group (3656), identify this as a stressor more than the middle age group (2636). Stress associated with

Stress in pre- and post-Project 2000 students the conict between theory and practice was signicantly greater for second-year and third-year students than for rst-year students. There was no signicant difference between age groups. Stress related to the pressure of work when performing nursing duties was almost identical to that presented for the conict between theory and practice. This pattern was also repeated for the lack of teaching and interest in learners (second- and third-year students scoring signicantly higher than rst-year students) with no signicant difference for age groups. Stress associated with the perception that there was a disregard shown for the emotional needs of patients increases with age and experience in training, but a statistically signicant interaction between age and year of training was observed. This showed that any difference between year of training was dependent upon the inuence also of age and that any differences among age groups are dependent upon the level of training. In short, any conclusions drawn about the effects of this stressor upon either age or year of training could be erroneous.

DISCUSSION
Some stressful experiences remain as much a problem for current students as they did for students in 1988. The major sources of stress associated with physical hard work, conict between theory and practice, perceived negative and uncaring attitudes toward patients, feelings of inadequacy, poor communication, academic workload and examinations remain a problem. Feeling under pressure and feeling exhausted may have a direct relationship to the stress experiences of physical hard work and the pressure of work when performing nursing duties. This may also reect the often-stated stress of having to work and study at the same time (despite supernumerary status for Project 2000 Diploma students). Feeling obsessed with being careful might be directly related to such stressors as having too much responsibility without adequate supervision. Both groups of students had a very small repertoire of skills in relation to coping with their feelings and stress experiences. These consisted of trying to be calm and talking to relatives and friends and neither of these were related to accessing professional support. However, despite these similarities, there were interesting differences between the two groups. Stress associated with the intense amount of academic work was signicantly greater for current students. This was perhaps an expected nding because current Diploma courses operate at a higher academic level. This nding accorded with those of Clarke & Rufn (1992). The comments of Ferguson & Cerinus (1996) conrmed that academic work overload should be avoided and was a factor in non-learning. Indeed, this could be a prominent stressor for students as nurse education has sought to justify its academic

Table 3 Statistically signicant differences following two-way analysis of variance and Scheffe test of questions in Tables 15 Questionnaire statements 3 Too much responsibility without adequate supervision 5 Physical hard work Training year (mean) 1 = 19630 2 = 23830 3 = 24872 (mean) Age (mean) 1 = 23158 2 = 18571 3 = 25556 (mean)

10

Training year 1 = 22545 2 = 20435 3 = 25000 Conict between the Training year ideal practice taught in 1 = 26552 the school and the real 2 = 30870 situation on the ward 3 = 33590 Pressure of work when Training year performing nursing 1 = 25357 duties 2 = 29583 3 = 32250 Lack of teaching and Training year interest in learners 1 = 22264 2 = 29375 3 = 29250 The disregard shown Training year for the emotional needs 1 = 21091 of patients 2 = 25319 3 = 28000

(mean)

(mean)

(mean) Age (mean) 1 = 23264 2 = 25517 3 = 28889

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E. Lindop presence within the current university framework, as one student from the Project 2000 Diploma stated: `some lessons, academically, have too much unnecessary detail'. Examinations appeared to be a universal stressor. It is interesting to note that current students felt more useless and unable to contribute towards the nursing team effort than students in 1988. This could be due to the reduced practical component of the Project 2000 Diploma course and shorter individual placement periods. The way students coped with stress was through being determined to carry on. There were a variety of ways in which students expressed their determination, for example, by being assertive, having emotional control over their feelings as well as an `inner feeling' to carry on. Lindop (1996) argued that there was a constellation of determined feelings and behaviours which were labelled `determination'. This constellation had interesting comparisons with similar constructs such as `hardiness' (Kobasa 1979) and `internal locus of control' (Rotter 1966). It was also interesting to note that prominent items forming the constellation of `determination' were selected as being applicable by 95% of both groups. This nding is an important one and indicated that the ingredients of `success' in nursing courses were not solely academic or, indeed, related to the ability to acquire nursing skills. They might be due principally to determination to carry on, despite the stress encountered in nursing. This raised an issue about wastage rates in preregistration courses which have always been, and still are, high (English National Board for Nursing Midwifery & Health Visiting 1995; Lindop 1996). A factor which seems to have been largely ignored in curriculum development is how to promote hardiness, internal locus of control and determination (Lindop 1993). There was an interaction effect between age and point of training for the Project 2000 group in relation to the disregard shown for the emotional needs of patients. This meant that, as far as this stressor was concerned, any difference between age and point of training was difcult to untangle. The only statistically signicant difference for age among the Project 2000 group was in relation to physical hard work where the younger age group (1725) and the older age group (3656) experienced the stress of physical hard work more than the age group 2635. The probable explanation for this is that nursing is hard work and younger people, usually entering nursing following their college studies, nd nursing exhausting until they begin to adapt to the physical demands. The older age group may nd the physical hard work stressful for the opposite reason of being older and tiring more easily. Such information could be valuable in alerting students to the potential for physical stress while adjusting to nursing. The response to stressors in the clinical environment is prominently different depending upon point in training. Stress increases as training progresses with third-year students experiencing most stress. This is an important nding and replicates the same ndings by Birch (1975) and Lindop (1996). Since the ndings in the present study replicate previous ndings (Lindop 1996) and Birch (1975) it can be argued that third-year students, whether they be pre- or Project 2000, experience greater stress than students from former years of training. There are a number of possible explanations for this. First, professional demands on third-year students are greater because they are perceived by peers to be more knowledgeable and skilful and may therefore be given greater responsibility than they feel able to cope with. Secondly, students may expect more from themselves as they see themselves to be on the verge of qualication. Thirdly, they may have greater insight and empathy into the patient's situation due to their expanded knowledge and awareness of the roles of carer and advocate. Thus, they may perceive some care falling below their expectation of an acceptable standard. This leads to the fourth explanation, related to the third, that they are consolidating a large body of knowledge and skills acquired during two former years of training and may, more than most, be quick to perceive a theory/ practice divide.

Study limitations
The major limitation of this study was that it represented students in only one area covered by two large Trusts, therefore the results need to be considered with caution. In this sense, the study shares the parochial restrictions identied during the discussion of other studies in the background literature review. A retrospective random sample from the 1988 student population was less than ideal, although it could also be argued that this did not prejudice the outcome, especially since the comparison of age against point of training and differences within age categories and training years, reected the ndings from the original questionnaire data analysis. It could also be said that a ve-point Likert scale would have been preferable to a four-point scale and a nonapplicable option, in that all the statements on the questionnaire could have been included in the analysis, rather than restricting this to those that reached a 95% or more applicability rating. However, this has to be considered against the fact that a non-applicability option made the identication of stressors a more rigorous and reliable process.

CONCLUSION
This paper shows that there was a number of stressors, particularly in the clinical environment, which students from pre-Project 2000 Certicate courses and Project 2000 Diploma courses found highly applicable to them. It also

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Experience before and throughout the nursing career demonstrates that the intensity of stress experiences increased as training progressed and that students had few skills associated with coping with stress, and resorted predominantly to talking to relatives and friends and trying to stay calm, despite feeling under pressure and obsessed with being careful, due to a perceived need for greater supervision. However, there appeared to be a constellation of attributes associated with determination to carry on despite experiencing stress which is stronger among the Project 2000 Diploma group. The ndings appear to indicate that little has changed (at least in two Health Trusts) since 1988 in relation to prominent stress experiences for students, especially while undertaking their clinical experience and despite students being supernumerary for part of their training. Education and clinical experience programmes need to take this into account and to consider the inclusion of effective support for students, especially in relation to their point of training, for, it may be erroneous to assume that because a student has reached their third year of training they will be condent at coping with the job. As Parkes (1991) pointed out, a key element in handling stress is associated with the perception of being in control. While students may be too inexperienced actually to be in control in a clinical area, they should at least be encouraged to see themselves as being in control of their own feelings and emotions. The results of this study have implications for both education and practice. Educationalists need to reect upon curriculum demands, especially in relation to the potential for academic overload of students. Clinical practitioners need to be more sensitive to the student's training needs and their actual or potential stress experiences. Educationalists and clinical practitioners need to work closely together in order to minimize the theory practice gap and to provide appropriate support for students. Future research in this area might concentrate upon obtaining a national detailed picture of students' stress experiences. This would preferably be a longitudinal study and should take account of age, point of training and `determination'. Such a study would be valuable for both curriculum developers and clinical practitioners, and all those providing support for students.

Stress in pre- and post-Project 2000 students

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