Perceived stress and coping strategies of baccalaureate nursing students in clinical practice. Title. Author(s) Chan, Kit-lin.; 陳 結 連.

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1 Title Perceived stress and coping strategies of baccalaureate nursing students in clinical practice Author(s) Chan, Kit-lin.; 陳 結 連. Citation Issued Date 2006 URL Rights The author retains all proprietary rights, (such as patent rights) and the right to use in future works.

2 Perceived stress and coping strategies of baccalaureate nursing students in clinical practice by Chan Kit Lin A thesis submitted in partial fulfilment of the requirements for the degree of Master of Nursing at the University of Hong Kong August 2006

3 2 Abstract of thesis entitled Perceived stress and coping strategies of baccalaureate nursing students in clinical practice Submitted by Chan Kit Lin for the degree of Master of Nursing at the University of Hong Kong in August 2006 Abstract Purpose: The purpose of this study was to examine Hong Kong baccalaureate nursing students stress, physio-psycho-social health and their coping strategies in clinical practice. Design: A cross-sectional and descriptive study design was used. Sample: All baccalaureate nursing students studying at the University of Hong

4 3 Kong who have clinical experiences were invited to participate in this study. Among 342 eligible subjects, 205 completed and returned the survey (response rate was 60%). Methods: A self-administrative survey including demographics, Perceived Stress Scale (PSS), Physio-psycho-social Response Scale (PPSRS), and Coping Behaviour Inventory (CBI) was used. The researcher approached the eligible subjects at the end of lectures. Those who were willing to participate in the study were required to sign a consent form, fill in the questionnaire and then return it to the researcher immediately. Results: The findings revealed that students perceived a moderate level of stress [mean (SD) = 2.10 (0.44)] and were in good physio-psycho-social health [mean (SD) =1.40 (0.65)]. The most common stressor came from lack of professional knowledge and skills [mean (SD) = 2.34 (0.63)]. Emotional symptoms commonly occurred in response to clinical stress. Students frequently used transference coping strategies, which they found most effective in dealing with stress in clinical practice. Furthermore, year of study and level of stress were the two factors affecting students health. Year of study and stress from taking care of patients were the two predictors of the frequency of use of the problem-solving approach. Year of study, religion and stress from teachers and nursing staff affected the frequency of use of avoidance strategies. The frequency of four coping strategies, stress from peers and daily life,

5 4 stress from taking care of patients and religion predicted the effectiveness of coping. Conclusion: The results provided valuable information for clinical educators and clinical staff in identifying students needs, facilitating their learning in the clinical setting and developing effective interventions to reduce the stress they encounter.

6 5 Declaration I declare that this thesis represents my own work, except where due acknowledgement is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or to any other institution for a degree, diploma or other qualification. Signed.. CHAN Kit Lin

7 6 Acknowledgements I would like to express my appreciation to the following: Assistant Professor Winnie So, my thesis supervisor, for providing professional guidance, ongoing support as well as patience, and unlimited care and love. Dr Felix Yuen, my thesis reader, for the questions he raised which helped me to make important revisions to the study. My lovely family members, for their continuous support and for sharing my troubles as well as my happiness. Debbie Yeung, Ida Chung, Ivy Leung, Mabel Poon, Sandy Luk and So Mui Hung, my valued classmates, for their continuous encouragement and support, and for sharing my achievement and difficulties in studying. CHAN, Kit Lin

8 7 Table of Contents Abstract....5 Declaration..5 Acknowledgements...6 Table of contents..7 List of tables...10 List of figures List of appendices...12 Chapter I Introduction Introduction Chapter II Literature review Definitions of stress Levels of stress Stressors Emotional responses Coping strategies Chapter III Theoretical framework The stress theory of Lazarus & Folkman (1984) Chapter IV Methods Purposes of the study Research questions Research design Sample... 31

9 8 Setting Data collection procedures Ethical considerations Instruments Statistical analysis Chapter V Results Recruitment and response Demographic background of the sample The most stressful clinical setting Levels of stress and types of common stressors Physio-psycho-social responses to stress Coping strategies frequently used and their effectiveness Factors affecting students physio-psycho-social health Factors affecting the frequency and effectiveness of the coping strategies used by students Chapter VI Discussion The most stressful clinical setting Level of stress and types of stressors Physio-psycho-social responses to stress Coping strategies frequently used and their effectiveness Factors affecting students physio-psycho-social health Factors affecting the frequent use of coping strategies Factors affecting the effectiveness of the coping strategies Limitations of the study Nursing implications for clinical practice... 62

10 9 Chapter VII Conclusion.. 66 References Appendices....70

11 10 List of tables Table 1 Participants demographic data Table 2 The most stressful clinical settings as rated by participants Table 3 Stressors perceived by nursing students Table 4 Physio-psycho-social symptoms occurring during clinical practice Table 5 Frequently used coping strategies and their effectiveness in clinical practice. 46 Table 6 Multiple regression analysis of the predictors of physio-psycho-social health Table 7 Multiple regression analysis of the predictors of frequently used coping strategies Table 8 Multiple regression analysis of the predictors of the effectiveness of coping strategies 52

12 11 List of figures Figure 1 The stress theory of Lazarus & Folkman (1984) Figure 2 The modified stress theory of Lazarus & Folkman (1984)... 29

13 12 List of appendices Appendix 1 Consent of instruments (duplicated copy) Appendix 2 Letter of ethical approval (duplicated copy) Appendix 3 Questionnaires Appendix 4 Informed consent... 82

14 13 Chapter I Introduction Empirical research supports the view that nursing students suffer stress in their clinical practice (Pagana, 1988; Beck & Srivastava, 1991; Lindrop, 1991; Mahat 1996; Mahat, 1998; Oermann & Sperling, 1999; Oermann & Lukomski, 2001). Without doubt, clinical practice is one of the crucial components in nursing education. However, students may face many challenges or threats in dynamic and complex clinical environments, such as how to use high-tech medical equipment, how to maintain good relationships with clinical staff and instructors, how to manage sudden changes in a patient s condition and how to deal with the demands of patients relatives (Elliott, 2002). These clinical experiences may lead students to perceive stress. Prolonged experience of stress may have negative impacts on students clinical learning and on their health. For example, their eagerness to learn in clinical settings may be inhibited; or they may experience emotional responses to stress, such as nervousness or anxiety, vertigo or dizziness during clinical practice (Oermann, 1998; Sheu, Lin & Hwang, 2002). Little is known about the effectiveness of coping strategies for relieving stress. Some studies have found that problem solving, social support, tension reduction and avoidance are used by nursing students (Mahat, 1996 & 1998; Jones & Johnston,

15 ). However, the effectiveness of these strategies was not further examined. It is important for faculty and clinical educators to have a clear perception of stress among nursing students, of their emotional responses towards stress, and of their coping strategies to relieve it. Then effective coping or stress-management strategies can be formulated and taught to the students. Since there are limited studies examining the perception of stress among Hong Kong Chinese baccalaureate nursing students during clinical practice and the apparent efficacy of self-initiated coping strategies, the purposes of the study are therefore to examine such students stress levels, the types of stressful events they encounter, their emotional responses to stress and coping strategies during clinical practice.

16 15 Chapter II Literature review Definitions of stress There are various definitions of stress. Selye (1976) defines it as a non-specific response of the body to any demand, regardless of its nature. This response includes a series of physiological reactions called the general adaptation syndrome (GAS). Responses to stress can be classified into undesirable (distress) and desirable (eustress) responses. Severe and prolonged GAS results in a disease state. Pollock (1984) defined stress as a whole set of physiological and psychological phenomena, including the objective event or stressor, the person s perception of the stressor, the conditioning factors or contextual stimuli, the various intervening processes or residual stimuli, and the manifestations of response to the stressor. However, Lazarus & Folkman (1984) defined psycho-social stress as a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being. With these definitions in mind, Lazarus and Folkman s theoretical framework is appropriate for use in this study because it can well describe the nature of nursing students stress in clinical practice. Once students encounter a new and unfamiliar clinical area, a particular relationship between students and new clinical settings is

17 16 created. Sometimes, unskilled students appraise clinical placement as stressful because they perceive the skill demanded in the clinical area as greater than they have encountered before. Also, nursing students in clinical practice frequently report more psycho-social stressful events and emotions than physical problems (Pagana, 1988; Mahat, 1996 & 1998; Oermann, 1998). Moreover, established theory shows the relationships among stress types and levels, stress appraisal, emotions, coping processes and adaptational outcomes (Lazarus & Folkman, 1984). This framework can therefore provide a complete picture of baccalaureate nursing students stress in clinical practice. Levels of stress Several studies have examined the levels of stress among nursing students in clinical practice. Results show that the level of stress varies according to students seniority, the types of nursing programme they are in, and the particular specialities they are allocated to during their clinical placement. Inconsistent results were found when comparing nursing students levels of stress against their seniority. Kleehammer, Hart & Keck (1990) found that junior nursing students showed a higher anxiety score than senior students. Further, another study of 262 sophomore or junior nursing students found that they suffered considerable stress during clinical practice, suggesting they had a moderate degree of stress in

18 17 clinical learning [mean (SD) = 2.7 (0.97); range=0-4] (Pagana, 1988). In contrast, Oermann (1998) found that stress experienced by nursing students in clinical practice increased as they progressed through the programme. Also, students found that the semester prior to graduation was the most stressful time in terms of clinical practice. From the above, it is seen that junior and senior nursing students perceive different levels of stress in clinical learning. However, there are no consistent studies that can show junior or senior students have higher levels of stress in clinical practice when the two groups are compared. Several studies, however, report a significant association between the level of stress among nursing students and the types of programme they study in. Student nurses in diploma or associate-degree programmes (ADN) experience significantly higher stress in clinical learning than baccalaureate nursing (BSN) students. Oermann (1998) found that 211 ADN students and 204 BSN students experienced a moderate amount of stress in clinical practice. However, the ADN students perceived significantly higher levels of stress in the clinical setting than BSN students (mean ADN = 2.45, mean BSN = 2.22; t= 2.16, p< 0.05). A similar result was reported by Jones & Johnston (1997). In their study, 220 nursing students perceived significantly higher levels of affective distress compared with those of the degree nursing students in Beck & Srivastava s (1991) study. Oermann (1998) suggested

19 18 that one might need to combine the demands of clinical practice with family and work commitments when comparing two groups of nursing students. This is because family and work commitments may bring extra stress or may influence the students in appraising stress. Even though the ADN group was older (mean age = 32.2) than the BSN group (mean age = 28.2), this might not be the major factor in students stress perception. Admi (1997) found that there was no significant difference in stress levels between younger and older people among 46 freshman nursing students aged from 18 to 32. Overall, nursing students in ADN programmes reported higher stress levels in clinical practice than those in BSN programmes. Nursing students have inconsistent levels of stress in various clinical courses and settings. Oermann & Standfest (1997) found that there were significant differences across the clinical courses in terms of students stress, challenge and threat. In their study, 33 students enrolled in paediatric clinical courses experienced the highest stress in a care-of-children course (mean = 2.9) when compared with classmates in various other clinical settings (mean = 2.34). On the other hand, Oermann & Lukomski (2001) reported that there were no significant differences in the degrees of stress experienced by students in paediatric clinical practice and other settings within nursing programmes. In their study, 75 students at the end of their paediatric nursing clinical course reported similar (moderate) levels of stress (mean = 2.44) when

20 19 compared with a group of students (n = 383) enrolled in non-paediatric clinical courses in the same nursing programme (mean = 2.25). The inconsistent stress levels in paediatric courses may relate to the small sample of paediatric nursing students. Stressors Stressors are sources of stress or events that produce stress. According to Lazarus and Folkman (1984), a stressor is perceived as stressful when the situation is appraised by the person as taxing or exceeding his/her resources and endangering his/her well-being. Stressors are categorised into four types according to their frequency of occurrence in published studies. They are stress from lack of professional knowledge and skills, stress from taking care of patients, stress from teachers and nursing staff, and stress from the clinical environment. The stressful events can provoke different level of stress depending on the student s appraisal. Stress from lack of professional knowledge and skills This category is the most frequently reported by nursing students. Sheu et al (2002) found that a sample of 613 nursing students rated unfamiliarity with medical history and terms, lack of professional nursing skills, and unfamiliar patients diagnoses and treatments as three major sources of stress in their first clinical practice. Also, Pagana (1988) found 202 out of 262 students described threatening feelings of

21 20 inadequacy because of a lack of knowledge and simultaneously increased responsibility and expectations of them. The students mentioned that the extensive preparation of trying to absorb an incredible amount of material in a very short time was also a stressor in clinical learning. Moreover, diploma student nurses in Ireland complained that the theory-practice gap was a clinical stressor too (Evans & Kelly, 2004). Of course, lack of professional knowledge and skills is a stressor in nursing students in clinical practice. Stress from taking care of patients Nursing students in Sheu et al (2002) study experienced a moderate level of stress in providing physical, psychological and social care to patients. Moreover, the highest anxiety-producing factor for both junior and senior students was the fear of making mistakes (Kleehammer et al, 1990; Kim, 2003). Other predominant threats for ADN students were fear of harming the patient and of failing clinically. For BSN students, threats were the fear of contracting disease and lack of self-confidence in arriving at clinical decisions (Oermann, 1998). Oermann & Standfest (1997) and Oermann & Lukomski (2001) reported that nursing students had higher level of stress in giving medication to children. Furthermore, Mahat (1998) found that clinical stressors such as administering injections, providing care and communicating with patients for the first time were most frequently perceived by junior baccalaureate

22 21 nursing students in the United States. Third-year students enrolled in a 3-year nursing diploma in Ireland described the death of a patient and relationships with ward staff as stressful events (Timmins & Kaliszer, 2002). Stress from teachers and nursing staff. Nursing students described negative interaction with instructors as the most frequent source of stress in a study by Kleehammer et al (1990). 52 out of 104 Nepalese nursing students reported having negative interpersonal relationships with teachers, visitors, community people etc. Students mentioned that it was very distressing to be often told off by teachers in front of others. Moreover, the Nepalese students perceived their teachers as demanding, intimidating and strict (Mahat, 1996). Kim (2003) reported that students rated being observed by instructors and being late as anxiety-producing clinical situations. Also, poor relationships with clinical staff were a leading stressor reported by Irish diploma student nurses (Evans & Kelly, 2004). Stress from the clinical environment Initial clinical experience on a unit was anxiety-producing for most baccalaureate nursing students because of fear of the unknown and a new clinical environment (Kleehammer et al, 1990; Beck, 1993; Kim, 2003). Parallel to Western nursing students appraisal of stressors, Hong Kong

23 22 psychiatric student nurses (n=77) had similar stressors during clinical practice such as working with nursing staff with a negative attitude, being afraid of making mistakes while working in ward/unit and finding yourself with inadequate nursing skills while working in ward/unit (Hui et al, 1995). Further, Keltner & Leung (1995) reported poor supervision, heavy workloads with frequent deadlines, a very wide theory-practice gap, little authority to carry out many responsibilities and uncertainty about the future of a nursing career these appeared to be the Hong Kong student nurses major clinical stressors. The two Hong Kong studies mainly focused on student nurses under the hospital-based training programmes of the 1990s. However, since nursing education in Hong Kong has now changed from hospital-based training to tertiary education, little is known about the stressors affecting baccalaureate students in clinical practice. Emotional responses Several studies have measured challenge, threat and harm emotions that are consistent with Lazarus and Folkman s (1984) theory of cognitive appraisal of stress; several found that nursing students had both positive and negative emotions during clinical learning. For example, Oermann & Standfest (1997) reported that students in maternity clinical practice experienced more positive emotions - stimulating, exciting and pleasurable - than those in other clinical courses (F[5,407] =5.54,

24 23 p<0.0001). However, students asserted that caring for children was a stressful experience and likely to evoke a high degree of response and emotions associated with threat, such as anxiety, worry, fear and feelings of being overwhelmed. By contrast, in Oermann and Sperling s (1999) study, nursing students in psychiatric clinical practice most frequently reported positive emotions, such as being stimulated by their clinical experiences [mean (SD) = 2.36 (0.98)], developing confidence in caring for psychiatric patients [mean (SD) = 2.22 (0.92)], and being pleased with their clinical experiences [mean (SD) = 2.13 (1.02)]. Taiwanese nursing students reported their responses to stress as tend to be nervous and anxious lately [mean (SD) =2.16 (0.86)], and have difficulty in making decisions [mean (SD) = 2.06 (0.93)]. The response scale is from never (0) to very often (4) (Sheu et al, 2002). Only one study investigated Chinese nursing students emotions or responses to stress during clinical practice. There is a need to explore further nursing students responses to stress, because they are the result of the subject s appraisal and adjustment to stress. However, the types of response most likely to occur when encountering stress have not been studied. Coping strategies Types of coping strategies, relationships between stressors or other factors, coping methods and the effects of coping strategies in terms of adaptational outcomes

25 24 are examined in several studies. There are two types of coping strategies: problem-focused (eg problem solving and seeking social support), and emotion-focused (eg tension reduction and avoidance), according to Lazarus and Folkman (1984). The majority of nursing students used a problem-focused rather than an emotion-focused strategy. For instance, Mahat (1996) reported that 55 out of 104 certificated nursing students utilised the seeking social support coping category. Furthermore, Mahat (1998) found that 59 out of 107 baccalaureate nursing students frequently used problem-solving and 53 sought social support. Evans & Kelly (2004) reported that Irish nursing students most commonly coped with stress by means of a social support strategy, eg talking to relatives, friends and peers. However, the Taiwanese students mostly adopted stay optimistic coping methods and a problem-focused strategy during their initial clinical experience (Sheu et al, 2002). Nursing students who perceived higher levels of stress in clinical practice always used avoidance coping measures. The findings in Mahat s study (1998) suggested that higher levels of stress with poor interpersonal relationships were associated with greater avoidance coping. Moreover, Jones & Johnston (1997) found that nursing students reporting few sources of stress tended to use problem-solving strategies. However, students reporting high distress used wishful thinking, escape, fantasy and

26 25 hostility to cope with stress. In conclusion, it seems that high levels of distress were associated with low direct-coping scores. There is limited research on the effects of nursing students coping strategies in clinical practice. Sheu et al (2002) identified four types of coping strategies - staying optimistic, transference, problem solving and avoidance - that were commonly used by nursing students to relieve stress in clinical practice. Among these four coping strategies, avoidance behaviour had a negative main effect on students health; optimistic behaviour and problem-solving had positive main effects on students physio-psycho-social status; and transference behaviour was found to have no effect on students health. It is essential for faculty and clinical educators to identify types of coping strategies commonly used by students and its effectiveness for relieving stress so that guidance and advice can be given to those in need.

27 26 Chapter III Theoretical framework The stress theory of Lazarus & Folkman (1984) The present study is guided by Lazarus & Folkman s stress framework (Figure 1), in which the transactional model explains the relationships among stress types, emotions and responses, appraisal, coping and adaptational outcomes. Lazarus & Folkman described stress as a transactional relationship between person and environment. It also feeds back to the person and the environmental relationship. Stress is not categorised as good or bad, but is instead determined to be of various types, degrees, frequency and intensity by the individual s subjective perceptions and interpretations of a given transaction as taxing or exceeding his or her resources and endangering his or her well-being (Lazarus & Folkman, 1984, p19). Emotions such as anger, envy, jealousy, anxiety, fright, guilt, shame or sadness that usually arise from stressful conditions are called stress emotions. However, positive emotions, such as happiness, pride, love or gratitude, may also arise from stressful situations, alongside the negative ones (Lazarus, 1999). Physical and emotional symptoms and social behavioural systems also arise from stressful situations (Lazarus, 1999). Such situations can be appraised as harmful, threatening or challenging, the assessment varying from person to person. Cognitive appraisal

28 27 of stress is an evaluative process that determines why and to what extent a particular transaction or series of transactions between the person and the environment is stressful. Primary appraisal of stress refers to assessing the changing environment as threat, harm or challenge. The person s responses or emotions are the outcomes of this primary appraisal. Secondary appraisal is seeing what might or can be done to tackle the stress. In other words, the products of the secondary appraisal are coping strategies to manage specific external or internal demands that are assessed as exceeding the person s resources. Reappraisal of stress seeks to identify any new information relevant to the situation. Coping is the process through which the individual manages the demands of the person-environment relationship that are appraised as stressful, and the emotions they generate. While stressors are being appraised, stress emotions appear and disease may follow. However, coping, defence and adaptation act as mediators to blunt the perceived threat and to smooth away stress emotions. Broadly speaking, coping can manage or alter the problem causing distress and also regulate the emotional response to that problem. The former is called problem-focused coping, where a person can define the problem, generate alternative solutions, weigh and choose suitable solutions according to their costs and benefits, then put them into effect. The latter is known as emotion-focused coping, which

29 28 allows the person either to lessen or to increase emotional distress. However, no single coping strategy is superior to any other. The efficacy of a coping strategy is determined only by its effect in a given encounter over the long term. The effect of coping can be measured in terms of adaptational outcomes (physical, psychological and social well-being). Such outcomes of stress are achieved while the person s physical, psychological and social states are healthy. Figure 1. The Stress Theory of Lazarus & Folkman (1984) Stressors Emotional responses Coping Adaptatioal outcomes This theoretical framework is suitable for explaining the phenomenon of nursing students stress in clinical practice. During their practice in the clinical area, students may perceive different type of stressors, and the symptoms, responses or emotions associated with stress occur. Coping strategies, whether problem-focused or emotion-focused, are then brought into play. If effective coping strategies are used, the adaptational outcomes (social functioning, morale, somatic health) are achieved.

30 29 If not, the health of the subject is at risk, and the whole process can regress to the original stress stage (Figure 2). Lazarus & Folkman s (1984) stress theory was therefore used to guide this study in examining baccalaureate nursing students stress, their physio-psycho-social responses to stress and the coping strategies they used in clinical practice. Figure 2. The modified stress theory of Lazarus & Folkman (1984) Demographics Stressors Physio-psycho-social health Frequency of using coping strategies Effectiveness of coping strategies

31 30 Chapter IV Methods Purposes of the study To examine Hong Kong baccalaureate nursing students stress, physio-psycho-social health and coping strategies used in clinical practice. Research questions 1. To examine the level of stress perceived by baccalaureate nursing students in clinical practice. 2. To identify the most stressful clinical setting reported by the students. 3. To identify types of stressors commonly experienced by the students during clinical practice. 4. To investigate the physio-psycho-social health status of students during the practice. 5. To identify the coping strategies students frequently use to relieve their stress and the effectiveness of such strategies. 6. To examine factors affecting the physio-psycho-social health of students during the practice. 7. To examine factors affecting the frequency and effectiveness of coping strategies used by the students.

32 31 Research design The study used a cross-sectional descriptive design to examine Hong Kong baccalaureate nursing students stress, their emotional responses and the types of coping strategies used to relieve that stress during clinical practice. The study is a piece of descriptive survey research in which the relationship and differences existing between two variables or more groups are examined. Also, the cross-sectional design reports variables changing at one point in time. This research design is an efficient and effective means to collect a large amount of data about the phenomena of stress in clinical practice. Sample All baccalaureate nursing students at the University of Hong Kong with clinical experience were invited to participate in this study. Other nursing students in other universities could not be approached. Year-1 students were excluded because they had no clinical experience prior to data collection. Setting The students were approached in the lecture theatre at the University. This proved an easy way to collect data from large numbers of eligible students. Data collection procedures Data were collected in October The researcher approached the students

33 32 at the end of lectures and explained the purpose of the study. An information sheet with the details of the study was also provided. Confidentiality and anonymity of the collected data were assured. Those who were willing to participate in the study were required to sign a consent form, fill in the questionnaire and then return it to the researcher immediately. Ethical considerations The proposal for the study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority (Hong Kong West Cluster). The researcher approached all eligible students at the end of lectures and explained the nature of the study to them. They were informed that participation in the study was voluntary and they could withdraw from it at any time. A refusal to participate would not affect their learning process and academic results. Anonymity and confidentiality of the collected data were also assured. An information sheet with details of the study was given to the students. Opportunities for asking questions about the study were provided. Those students who were interested in the study were asked to sign the consent form, fill in the questionnaire and return it to the researcher immediately. All data collected were kept strictly confidential. For example, only the research team had access to the data file, all questionnaires were kept in a locked cabinet and they will be destroyed within five years of the study.

34 33 Instruments The questionnaires The self-report survey consisted of four parts: 1) demographic information, 2) Perceived Stress Scale (PSS), 3) Physio-psycho-social Response Scale (PPSRS), and 4) Coping Behaviour Inventory (CBI). Since nursing students at the University of Hong Kong are proficient in using English and only an English version was available for the adopted scales, an English version of the survey was used. A pilot study was conducted with ten first-year nursing students to ensure the survey was readable and could be understood by those who would be using it. Modifications were made as follows: 1) bad grades was replaced by poor grades ; and 2) examples were added to explain the word giddy (ie, unsteady and in danger of falling). Part 1. Students demographic information Students demographic data included personal details such as age, religion, gender, working experience of TUNS, year of study, and the most stressful clinical area. These demographic data are potential variables influencing students stress and coping in clinical practice. Part 2. Perceived stress scale (PSS) PSS was used to examine nursing students stress levels and types of stressors.

35 34 This instrument was developed by Sheu et al (1997). It is a five-point Likert-type scale that consists of 29 items grouped into six factors, labelled as follows: Stress from taking care of patients (8 items), Stress from teachers and nursing staff (6 items), Stress from assignments and workload (5 items), Stress from peers and daily life (4 items), Stress from lack of professional knowledge and skills (3 items), and Stress from clinical environment (3 items). Each item is rated on a five-point Likert scale (0=never, 1=almost never, 2=sometimes, 3=fairly often and 4=very often). Usually, both total scores and individual subscale scores are measured. Higher scores indicate higher level of stress. Reliability and validity were measured in a pilot study of 150 nursing students (Sheu et al, 2002). Cronbach s alpha was The one-week test-retest reliability was 0.60 (p<0.01) and the content validity index was Furthermore, 50.7% of the total variance was accounted for by the six factors, which confirmed the construct validity of this instrument. In this study, Cronbach s alpha for the entire scale was 0.89 and ranged from 0.87 to 0.89 for the subscales. Part 3. Physio-psycho-social response scale (PPSRS) Sheu et al (2002) developed PPSRS, which is used to describe nursing students responses to and emotions caused by stress in clinical practice. It also measures the physio-psycho-social health status of students during clinical practice. The PPSRS

36 35 consists of 21 items and each item is rated on a five-point Likert-type scale (0=never, 1=almost never, 2=sometimes, 3=fairly often and 4=very often). The 21 items are divided into three subscales: Physical symptoms, Emotional symptoms and Social-behavioural symptoms. Usually, both subscale scores and total scores are calculated. Higher scores indicate the presence of more and serious symptoms reported and poorer physio-psycho-social health status. This instrument showed internal-consistency reliability and test-retest reliability. The Cronbach s alpha was 0.9 and the one-week test-retest reliability was 0.72 (p<0.001). The validity of the scale was verified by a content validity index of The construct validity was supported by factor analysis and three factors explained 65.7 % of the total variance (Sheu et al, 2002). In this study, Cronbach s alpha for the entire scale was 0.94 and ranged from 0.91 to 0.94 for the subscales. Part 4. Coping behaviour inventory (CBI) Sheu et al (2002) developed CBI, which is used to identify nursing students coping strategies. It consists of 19 items, divided into four types: Avoidance behaviours (6 items), Problem-solving behaviours (6 items), Optimistic coping behaviours (4 items) and Transference behaviours (3 items). Each item is rated for frequency and effect on a five-point Likert-type scale, where (frequency) 0=never, 1=almost never, 2=sometimes, 3=fairly often and 4=very often; and (effect) 0=not at

37 36 all, 1=somewhat, 2=moderately, 3=moderately so and 4=very much. Higher scores for each factor indicate more frequent use and greater effectiveness of a certain type of coping behaviour. The reliability and validity of the instrument were reported in the pilot study of 150 nursing students (Sheu et al, 2002). Cronbach s alpha coefficient was The one-week test-retest reliability of the four factors was 0.57, 0.57, 0.59 and 0.55 (p<0.001). The construct validity was demonstrated by identifying four factors after factor analysis, where 38.2 % of the total variance was accounted for by these four factors. In this study, Cronbach s alpha for the entire scale was 0.80 and ranged from 0.75 to 0.84 for the subscales. Statistical analysis This study used Statistical Package for the Social Sciences (SPSS) 14.0 for data analysis. Descriptive statistics were reported on all variables including demographics, degree and types of stressors, physio-psycho-social responses, and frequency and effectiveness of coping strategies. The Friedman test was used to compare the mean score among the six stressors and the mean score of frequency and effectiveness among the four coping strategies. Pearson s correlation coefficient was used to examine the relationship between mean frequency and effectiveness of the coping strategies. Multiple regression analysis was used to identify factors affecting

38 37 students physio-psycho-social health, and the frequency and effectiveness of the coping strategies they used. A p-value equal to or less than 0.05 was regarded as the appropriate level of statistical significance. It was hypothesised that students physio-psycho-social health was affected by their demographic data and by stress. The demographic factor (Group 1) was a cluster of variables including: age (continuous), sex (1=male, 2=female), religion (1=yes, 2=no), year of study (1=second year, 2=third year, 3=fourth year) and clinical work experience (1=yes, 2=no). The other co-variate, stressors (group 2), included the total mean score for stress (continuous) and six subscale scores (continuous). Similar to the model for physio-psycho-social health, the variables were clustered into two groups (group 1 = demographic variables, group 2 = stressors) to determine predictors of the frequency of coping strategies. To identify the predictors of the effectiveness of coping strategies, the variables were clustered into three groups: group 1 included demographic variables; group 2 covered stressors; while group 3 was the mean frequency of the coping strategy used by the students (continuous). The researcher hypothesised that the variables in a group could affect those in subsequent groups, but not vice versa. In order to account for such causal relationships among demographics and stressors, a structured multiphase regression

39 38 analysis was performed in phase 1; a forward step-wise regression was performed on group 1 variables; in phase 2, all variables that were significant in phase 1 were entered and another step-wise variable selection procedure was performed on group 2 variables; in phase 3 (for the model of effectiveness of coping strategies), variables that were significant in either phase 1 or 2 were entered while a step-wise procedure was performed on phase 3 variables.

40 39 Chapter V Results Recruitment and response 205 baccalaureate nursing students at the University of Hong Kong were successfully recruited to the study in October The researcher invited students to participate after their lectures and while still in the lecture theatre. The researcher explained that the data would be kept confidential and anonymous and that it was a voluntarily-based study. The students recruited were in their second, third or fourth years, with different periods of clinical placement experience at the time of data collection. The response rate was 60% (205/342 x 100%). Because of the lack of attendance records, the response rate was calculated on the assumption of full attendance. Demographic background of the sample Demographic information on the students is presented in Table students completed the questionnaire. Their mean age was 21.3 ± 1.2, with a range of The majority were female (89%). 38.5% were from Year II, 35.1% from Year III and 26.3% from Year IV. Only 40% professed any religious belief. 24% had worked for the Hospital Authority as Temporary Undergraduate Nursing Students (TUNS).

41 40 Table 1 Participants demographics (N=205) Characteristics n % Sex Female Male Religion No Yes Christianity & Catholicism Buddhism & Taoism Others Year of Study Second year Third year Fourth year Work experience as TUNS No Yes Work settings as TUNS Nil Surgical Medical Accident & Emergency (A & E) Geriatric Obstetric Paediatric Others Mean (SD) Range Age 21.3 (1.2) Duration of TUNS experience (days) 16.0 (50.0) Note. Number of missing values for different variables are as follows: age =6, religion =2, sex =2, work experience as TUNS =9, work settings of TUNS =2, duration of TUNS =13.

42 41 The most stressful clinical setting The most stressful clinical settings perceived by nursing students are presented in Table 2. The five most stressful clinical settings were: (1) accident & emergency unit (32.8 %), (2) medical unit (27.4%), (3) surgical unit (14.0%), (4) intensive care unit (8.6%) and (5) operating theatre (8.6%). Students rated community settings as the least stressful setting (0.5%). Table 2 The most stressful clinical settings rated by participants (N=186) Rank Clinical settings n % 1 Accident & Emergency (A & E) Medical unit Surgical unit Intensive care unit (ICU) or High dependency unit Operating theatre (OT) Psychiatric unit Geriatric unit Obstetrics unit Paediatric unit Sub-acute hospital Community settings Others Note: Number of missing values=19 Level of stress and types of common stressors The level of stress and types of stressors perceived by nursing students are tabulated in Table 3. On the whole, students perceived a moderate level of stress during clinical practice (mean=2.10, SD=0.44). The most common type of stressor

43 42 perceived by students was the lack of professional knowledge and skills (mean=2.34, SD=0.63). Students felt stressed when they were unfamiliar with medical terminology, or with patients histories, diagnoses and treatments. The second and third most common stressors encountered by students were stress from assignments and workload (mean=2.21, SD=0.61) and stress from taking care of patients (mean=2.20, SD=0.50). Students also worried about receiving poor marks and about their ability to provide nursing care and make judgment in their clinical practice. The difference in level of perceived stress induced by six stressors was found to be significant (χ²=167.93, df=5, p<0.001). Table 3 Stressors perceived by nursing students (N=205) Stressors Rank Mean SD Overall perceived stress I. Stress from lack of professional knowledge and skills Unfamiliar with medical history and terms Unfamiliar with professional nursing skills Unfamiliar with patients diagnoses and treatments II. Stress from assignments and workload Worry about poor grades Pressure from the nature and quality of clinical practice Feelings that performance does not meet teachers' expectations Feelings that dull and inflexible clinical practice affect family/social life Feelings that the demands of clinical practice exceed physical and emotional endurance

44 43 III. Stress from taking care of patients Lack of experience and ability in providing nursing care and in making judgments Not knowing how to help patients with physio-psycho-social problems Unable to reach expectations Unable to provide appropriate responses to doctors, teachers and patients' questions Worry about not being trusted or accepted by patients or their families Unable to provide patients with good nursing care Not knowing how to communicate with patients Difficulties in changing from the role of a student to that of a nurse IV. Stress from clinical environment Feelings of stress in the environment where clinical practice takes place Unfamiliarity with ward facilities Feelings of stress from rapid changes in a patient s condition V. Stress from teachers and nursing staff Seeing a discrepancy between theory and practice Not knowing how to discuss a patient s illness with teachers or medical and nursing personnel Feelings of stress when a teacher s instruction is different from expectations Medical personnel lacking empathy and willingness to help Feelings that teachers do not evaluate students fairly Lack of care and guidance from teachers VI. Stress from peers and daily life Experience of competition from peers in school and clinical practice Feelings of pressure from teachers who evaluate students performance by comparison Feelings that clinical practice affects involvement in extracurricular activities Inability to get along with group peers

45 44 Physio-psycho-social responses to stress Nursing students physio-psycho-social responses to stress during clinical practice are presented in Table 4. Overall, students physio-psycho-social health was good (mean=1.40, SD=0.65). Emotional symptoms (mean=1.70, SD=0.77) were the most common responses to stress. Students tended to be worried or nervous when they were in clinical practice. Table 4 Physio-psycho-social symptoms occurring during clinical practice (N=205) Physio-psycho-social status Rank Mean * SD Overall physio-psycho-social status* I. Emotional symptoms I tend to be worried and nervous I tend to be nervous and anxious lately I often feel depressed and miserable I feel afraid without any reason I feel I am going to have a nervous breakdown I feel more anxious lately I cannot calm down II. Social behavioural symptoms I am not optimistic about my future My life is not very colourful I cannot work as usual I have difficulty in making decisions I do not feel needed or valued I cannot think as clearly as before

46 45 III. Physical symptoms I often feel giddy I experience nausea and vomiting I often have vertigo and feel dizzy I feel pressure in the chest My fingers and toes feel numb or painful I have stomach-ache and diarrhea I have difficulties in breathing for no reason I catch cold more often Note: * A higher score represents a poorer health status # The scale is 0 (never) to 4 (very often) Coping strategies frequently used and their effectiveness Coping strategies commonly used by nursing students during clinical practice and their effectiveness are presented in Table 5. The most frequent coping strategy was transference (mean=2.73, SD=0.71) for example, sleeping, watching TV or movies, having a shower or taking physical exercise - followed by staying optimistic (mean=2.38, SD=0.51), problem solving (mean=2.33, SD=0.58) and avoidance (mean=1.57, SD= 0.60). The most and least effective coping strategies were consistent with frequency of use (Table 5). A significant correlation was found between the mean frequency and efficacy of each coping strategy (r= , p<0.01). Students who used coping strategies more frequently were more likely to regard them as effective. Significant results were also reported as far as the mean frequency (χ²=273.24, df=3, p<0.01) and efficacy (χ²=256.14, df=3, p<0.01) of the four coping strategies were concerned.

47 46 Table 5 Frequently used coping strategies and their effectiveness (N=205) Coping strategies / items Rank Frequency Effectiveness Freq./Eff. Mean SD Mean SD I. Transference 1 / Eating large meals and taking a long sleep Saving time for sleep and maintaining good health in the face of stress Relaxing, via TV, movies, a shower or physical exercise (ball-playing, jogging) II. Staying optimistic 2 / Keeping an optimistic and positive attitude in dealing with everything in life Seeing things objectively Having the confidence to overcome difficulties Crying, feeling moody, sad and helpless III. Problem solving 3 / Adopting different strategies to solve problems Setting up objectives to solve problems Making plans and listing priorities to solve stressful events Finding the meaning of stressful incidents Employing past experience to solve problems Having confidence in performing as well as senior colleagues IV. Avoidance 4 / Avoiding difficulties during clinical practice Avoiding teachers Quarrelling with others and losing one s temper Expecting miracles to avoid facing difficulties Expecting others to solve the problem Attributing everything to fate Note: Freq=frequency and Eff=effectiveness Frequency, 0 (never) to 4 (very often); effectiveness, 0 (not at all) to 4 (very much)