Factors associated with stress among nursing students

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1 Factors associated with stress among nursing students Nitasha Sharma, Amandeep Kaur Abstract : Students are subjected to different kinds of stressors such as pressure of academics with an obligation to succeed, an uncertain future and difficulties of integrating into the system. The objective of the study is to identify the factors contributing to stress among nursing students. A total of thirty seven subjects participated in the study. In first phase, the level of sting a standardized scale.in the second phase, the factors contributing to stress were assessed using in subjects with moderate and severe stress by using a validated tool. 97% of the subjects had moderate level of stress whereas 3% had severe stress. Among the factors contributing to stress, the environmental factors had maximum contribution (40%) followed by the interpersonal factors (30%).The academic factors had only 19% contribution whereas the intrapersonal factors contributed minimally. The findings of the study can be useful in designing a suitable stress management programme for nursing students which shall include the conflict management training, time management training and the social skill training etc. Key words : Stress, nursing students. Correspondence at : Nitasha Sharma, Lecturer, Kular College of Nursing, Khanna Introduction Stress is the emotional and physical strain caused by our response to pressure from the outside world. 1 It is specific response by the body to a stimulus that disturbs normal functioning. A Stressor is an event or any stimulus that cause an individual to experience stress. 2 It s almost impossible to live without some stress and most of us wouldn t want to, because it gives life some spice and excitement. But if stress gets out of control, it 12

2 may harm health, your relationship and your enjoyment of life. Common stress reactions include tension, irritability, inability to concentrate and a variety of physical symptoms i.e. headache and fast heartbeat. 1 Stress results from the interaction between stressors and the individual s perception and reaction to those stressors 3. The amount of stress experienced may be influenced by the individual s ability to effectively cope with stressful events and situations 4. Students are subjected to different kinds of stressors such as the pressure of academics with an obligation to succeed, an uncertain future and difficulties of integrating into the system. The students also face social, emotional, physical and family problems which may affect their learning ability and academic performance. In recent years there is growing appreciation of stressors involved in Medical and nursing training College students, especially freshmen, are a group par ticularly prone to stress 4 due to the transitional nature of college life 3. Too much stress can cause physical and mental health problems, reduce self-esteem and may affect students academic achievement. One such study was conducted to assess stress in medical students at Seth G.S. Medical College Dr Supe. The findings of the study were that 73% of students perceived stress which was more in 2nd & 3rd year MBBS students than 1st year. Academic factors were perceived as greater cause of stress. 6 Another study conducted by Chandrasekhar on medical students revealed that most common sources of stress were sources were staying in hostel, high parental expectations, vastness of syllabus, tests/ exams, lack of time and facilities for students. 7 As far as the nursing programmes are concerned, the various research findings indicate that stress exists for students in both the clinical and academic aspects of the programme. The study conducted by Timmins & Kaliszwer on 3 rd year nursing students at Trinity College, Dublin revealed five major factors as sources of stress. Firstly, academic stress factors. The second and third components concern relationships, the former involving teaching-related staff, and the latter involving the clinical experience. The last two components suggest that finance and death of patients are independent sources of stress. 8 Another study conducted by Beck & Srivastva at School of Nursing, Memorial University of Newfoundland, St. John s, Canada found that the students experienced high stress levels and that they are at risk of having a physical or psychiatric illness. In that study the subjects were divided in two groups: the RN and the generic students. Results showed that while both groups were stressed, the generic students report significantly higher levels of stress. 9 The attempts have also been made in relation to understanding experiences leading to eustress in nursing students. One such study was conducted by Gibbons, Dempster & Moutray to identify experiences that led to both distress and eustress and to make recommendations to help students cope with course demands. The themes identified were clinical experience, suppor t, learning and 13

3 teaching experience and course structure. There were experiences within each that were perceived as sources of distress and eustress. 10 Another study by Gibbons, Dempster & Moutray revealed that sources of stress likely to lead to distress were more often predictors of well-being than were sources of stress likely to lead to positive, eustress states, with the exception of clinical placement demands. Self-efficacy, dispositional control and suppor t were important predictors, and avoidance coping was the strongest predictor of adverse wellbeing. Approach coping was not a predictor of well-being 11. A study was conducted to identify stressful events of first-year Nepalese nursing students in the clinical setting and to determine how they cope with the stressful events. Four stressful events identified were: interpersonal relationships, initial experiences, feeling helpless, and demeaning experiences. The most frequently reported stressful event was interpersonal relationship (50%). Eight categories of coping from students description were problem-solving, accepting responsibility, seeking social support, selfcontrol, tension reduction, avoidance, wishful thinking and negative feelings. The majority of students utilized the seeking social support category of coping 12. A similar study conducted over a period of two academic years found that highly depressive symptoms were reported by 55% of the sample. A majority of students experienced an increase in burnout symptoms and an increase in frequency of alcohol use during their educational years. These behaviors were related to a lack of social support and external attribution style. 13 In addition to educating in a professional course it is also important to take into account the quality of life of the students during the years of nursing training. Keeping these considerations in view, the current study was under taken to identify the factors associated with stress among nursing students. Objective To identify the factors associated with stress among nursing students. Material and Methods Research was conducted on GNM 1 st year students of one of the private nursing institute situated in Punjab and affiliated to Baba Farid University of Health Sciences, Faridkot. The college runs various nursing programmes including General Nursing & Midwifery (GNM), B.Sc. Nursing and Post Basic B.Sc Nursing. It is established in an area of 6 acre with all the modern facilities available in the campus. There are approximately 200 students residing in the campus hostel. The institution organizes various co-curricular activities regularly. There is provision of sports ground and sports equipments for all the students. The institution also organizes various religious activities from time to time. Target population in research study was students of GNM 1 st year and purposive sampling was used. The study was divided into two phases. In the first phase the level of stress was assessed in 37 subjects using standardized 14

4 tool 14. The tool to assess stress was originally published in United Nations stress management booklet. It is a 10 item instrument in which all the items are rated on 3 point scale varying from 1 - often to 3- never. The overall score of less than 15 depict normal stress level, shows moderate stress and above 25 indicate severe stress. In the second phase, the subjects having moderate and severe level of stress were administered the tool to assess the factors associated with stress. The tool was created for this study based on the Student Stress Survey 15, the Taylor Manifest Anxiety Scale 16, and other potential sources of stress that were identified by the researchers. Firstly a preliminary tool was prepared for assessing the factors associated with stress and was given to six nursing experts. Out of six experts four were from the field of medical surgical nursing and two were from the field of mental health nursing who gave their suggestions to refine the tool. The final tool consisted of 41 items that were divided into 4 categories of potential sources of stress: Academic factors: 15 items, Environmental factors: 10 items, Interpersonal factors: 5 items and Intrapersonal factors: 11 items. Prior to data collection a written permission was taken from Principal of the college.. After explaining the purpose of study a verbal consent were obtain from the subjects and they were assured of maintenance of the confidentiality. The data collection was completed in three days by giving self administered tool to all the subjects. Results Age of 46% subjects was in the range of years. Another 19% of the subjects were in the age range of year, 32% subjects were of more than 20 years of age whereas 3 % of them were less than 18 years of age. All the respondents were female. As per the study findings, the 97% of subjects had moderate stress whereas 3% had severe stress. While looking into the major factors which were contributing towards stress among students, the result reveals that the environmental factors had maximum contribution in causing stress (40%) followed by Intrapersonal factors (30%). The Academic factors had 19% contribution and interpersonal factors have least contribution i.e.11 %. While exploring the individual stress inducing environmental factors, change in living environment and inadequate telephone facilities were two such factors which were perceived as stressor by all the subjects.(table1) The inadequate provision of safety and security was labeled as stress inducing factors by 95 % subjects whereas 89% of subjects attributed to inadequate facilities of mess and canteen as stressors. The lack of recreational activities and poor laundry services was considered stressful by 84% subjects. For 78% of subjects the absence of calm & quiet environment and extremes of climate were stress inducing factors. However inadequate water supply [19%] and inadequate supply of electricity [12%] had minimum contribution towards stress inducing factors 15

5 Table 1: Stress inducing environmental factors. Environmental factors No of subjects perceived stress due to given factors [n]% Change in living environment 37 (100) Inadequate telephone facilities 37 (100) Inadequate provision of safety and security 35 ( 95) Inadequate facility of canteen/mess 33 ( 89) Lack of recreational facilities 31 ( 84) Lack of laundry facilities 31 ( 84) Absence of calm and quiet environment 29 ( 78) Extreme climate factors 29 ( 78) Inadequate supply of electricity 12 ( 32) Inadequate water supply 7 ( 19) Among the intrapersonal factors, 100 % of the subjects perceived change in eating pattern and issues related to marriage/ engagement as stressors. Homesickness in hostel, change in sleeping pattern, and new responsibilities in life were also perceived as stressful factors by more than 90% subjects (Table2) The personal preoccupations was considered as stress inducing factor by 89% subjects. The parental expectations also contributed to stress in 86 % subjects. The 79% of the subjects were considering the decline in personal health as stress inducing factor. The financial problems contributed to stress in half of the subjects. Among the academic factors, all the subjects felt rapid change of the subject teacher as stressful factor. Majority of subjects perceived Less vacations/breaks, Inability to balance study and leisure time and Over burden with study as stressful. The practical work which students have to perform as part of curriculum was also considered as stressful by fifty percent of the subjects.(table3) About half of the subjects felt stress due to poor interest in studies, poor IPR with teacher s and serious arguments with teachers. 16

6 Table 2: Stress inducing intrapersonal factors Intrapersonal factors No of subjects perceived stress due to given factors [n]% Change in eating pattern. 37(100) Engagement /marriage 37(100) Homesickness in hostel 36( 97) Change in sleeping pattern 36( 97) New responsibilities of life 34( 92) Personal preoccupations 33( 89) Parents expectations 32( 86) Decline in personal health 28( 76) Death of significant one 22( 59) Financial problems 19( 51) Change in religious beliefs 17( 46) Table 3 : Stress inducing academic factors Academic factors No of subjects perceived stress due to given factors [n]% Less vacations/breaks 36(97) Inability to balance study and leisure time 36(97) Over burden with study 34(92) Inability to concentrate on study 32(86) Poor satisfaction with class room performance 30(81) Getting lower grade than anticipation 27(73) Inability to enjoy my study 27(73) Class presentations 26(70) Difficulty to understand language used by teachers while teaching 26(70) Poor interest in studies 22(59) Poor IPR with teachers 21(57) Serious argument with teachers 19(51) Practical work 19(51) Missing too many classes 6(16) 17

7 Looking into the contribution of interpersonal factors the change in social activities was perceived as stressor by majority of subjects. Two third of subjects (68%) perceived fight with close one as source of stress. Another half of subjects (49%) perceived that lack of close friends and lack of cooperation from friends (51%) as source of stress and 30% felt that conflict with the roommate was contributing to their stress. (Table4) Table 4 : Stress inducing interpersonal factors. Interpersonal factors No of subjects perceived stress due to given factors [n]% Change in social activities 36(97) Fight with close one s 25(68) Lack of cooperation from friends 19(51) Lack of close and intimate friends 18(49) Conflict with room mate 11(30) Discussion Stress in nursing students is an area of growing concern and it may result in psychological distress, physical complaints, behavior problems and poor academic per formance. The present study was conducted to assess stress level and factors associated with stress among nursing students. The current study has identified various factors like academic, interpersonal, intrapersonal, and environmental contributing to stress among nursing students. A similar study identified the major academic stressors among college students to be tests, grade competition, time demands, professors and classroom environment, and career and future success 17.Another study reported that stress may be associated with the type of institution the student attends (e.g., public, private, undergraduate, professional or graduate 18. The result of present study reveals that the environmental factors had maximum contribution in causing stress (40%) followed by Intrapersonal factors (30%), Academic factors (19%) and interpersonal factors has least contribution (11%). These findings are to some extent consistent with the findings of similar study conducted by Ross in which 38% of the stressors were intrapersonal, 28% environmental, 19% interpersonal, and 15% academic 19. A similar study conducted on 3 rd year nursing students revealed five factors that emerged as sources of stress. Firstly, academic stress factors. The second and third components concern relationships, the former involving teaching-related staff, and the latter involving the clinical experience. The last 18

8 two components suggest that finance and death of patients are independent sources of stress. 8 In the present study, among the environmental factors, almost 100% subjects repor ted change in living environment and inadequate telephone facility as major stressor. Since the subjects were the students of 1 st year who had recently joined which might have raised the number of responses on change in living environment and inadequate telephone facility. The intrapersonal factors reported by most of the subjects as stressor were change in eating and sleeping patterns. The decline in health was also reported as stressor by 76% of the subjects. These factors seem to be interrelated and contributing to each other. The lack of sleep and erratic eating habits lead to the decline in health which fur ther act as independent stressor. Decline in health also lead to decline in the academic performance which is again an independent stressor. The identification of an academic stress component in present study is consistent with other studies The common academic factors leading to stress were lack of leisure time, overburden with the assignments, and poor satisfaction with performance. Similar factors were identified in another study where the sources of stress included excessive homework, unclear assignments, and uncomfortable classrooms 20. In the current study inability to balance study and leisure time was repor ted as stressor by 97% subjects which is consistent with the findings of another study by Brown which stated academic stress is reduced and controlled through effective time management and study techniques 22.Macan found that students who perceived themselves in control of their time reported greater work and life satisfactions 23. The current study also depicted the role of IPR with the faculty or some serious argument with the teacher as contributors for stress. Such factors were also identified as stressors in another study by Sgan-Cohen & Lowental 24. The present study represents a first step in understanding sources of stress for college students. Research should expand on these findings by determining the degree of stress resulting from each source. Such research would permit conclusions on which stressors are most detrimental or severe and which stressors have a negligible effect. The research findings could be useful in designing a suitable stress intervention program for college students. The conflict management training to deal with intrapersonal factors, the time management training to learn to balance study and leisure time and the social skill training to improve interpersonal relations should be incorporated in the college curriculum. Furthermore, students should be informed of the campus resources available to help them address these resources. Another important factor to consider when studying stress is to explore which sources of stress are motivating and beneficial, and which sources of stress are detrimental. It has been established that moderate amounts of stress help motivate us and, at times, increase our performance 25. Certainly, stress in the college setting cannot be eliminated 19

9 but we can and should do a better task by preparing our students to manage it References 1. Stress and how to manage it. Available from ehealth.com/ library/stress/ str_whatis.html.on Basavanthappa B T. Fundamentals of nursing. 1 st edition. Jaypee brothers medical publishers ; New Delhi Romano J L. Psycho educational interventions for stress management and wellbeing. Journal of Counseling and Development 1992; 71: D Zurilla, T J, Sheedy C F. Relation between social problem-solving ability and subsequent level of psychological stress in college students. Journal of Personality and Social Psychology 1991; 61(5): Towbes L C, Cohen L H. Chronic stress in the lives of college students: Scale development and prospective prediction of distress.journal of Youth and Adolescence 1996:25: Supe A N. A study of stress in medical students at Seth G S Medical College. Journal of Postgraduate medicine 1998;44(1): Chandrasekhar T.Psychological morbidity, sources of stress and coping strategies among undergraduate students of Nepal. Available from on Timmins F,Kaliszer M. Aspects of nurse education programmes that frequently cause stress to nursing students fact-finding sample survey. Nurse Education Today 2002; 23(2): Beck DL,Srivastava R. Perceived level and sources of stress in baccalaureate nursing students. Journal Nurse Education 1991;30(3): Gibbons C,Dempster M,Moutray M Stress, coping and satisfaction in nursing students. Journal of advanced nursing 2010;retrieved from j x/on Gibbons C,Dempster M,Moutray M. Stress and eustress in nursing students. Journal of Advanced Nursing 2008; 61(3): Mahat G. Stress and coping: first-year Nepalese nursing students in clinical settings. Journal Nurse Education 1996 ;35(4) : Mary R. Haack. Stress and impairment among nursing students. Research in Nursing & Health 1998; 11(2), United national stress management Booklet. Available from http// ecentre.net/resources/e-library/doc/un%20 stress 620 management %20 booklet proof on Insel P M, Roth W T, Core concepts in health. 4th edition. Core concepts in health. Palo Alto, CA: Mayfield Taylor J A. A personality scale of manifest anxiety. Journal of Abnormal and Social Psychology 1953; 48: Robert J et al. A Comparative Study of Professional Student Stress. Journal of Dental Education2009;73(3): Hudd S et al. Stress at college: Effects on health habits, health status and selfesteem.college Student Journal 2000; 34: Shannon E R, Bradley C, Niebling, Teresa M, sources of stress among college students. College Student Journal 1999;33;2 20. Kohn JP, Frazer G H. An academic stress scale: Identification and rated importance of academic stressors. Psychological Reports 1986, 59, Misra R et al. Academic stress of college students: Comparison of student and faculty perceptions.college Student Journal 2000; 34(2):

10 22. Brown M, Ralph S. Using the DYSA programme to reduce stress and anxiety in firstyear university students.pastoral Care 1999; 17(3): Macan T H, Shahani C, Dipboye R L, Phillips A P. College student time management: Correlations with academic performance and stress.journal of Educational Psychology1990; 82: Sgan, Cohen H D, Lowental U. Sources of stress among Israeli dental students. The Journal of the American College Health Association 1988; 36: Moore K A, Burrows G D, Dalziel J. Stress: How to define and challenge it. Mental Health in Australia 1992:

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