Level of stress and coping strategies used by nursing interns

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1 Level of stress and coping strategies used by nursing interns Charanjeev Singh, Sunita Sharma, Ravinder Kumar Sharma Abstract :The effects of stress on nursing students have been well documented. High perceived stress levels and lack of effective coping skills could be a barrier to achieve the challenges of profession. Keeping this in mind, a study was conducted to find out the level of stress and coping strategies used by nursing interns of National Institute of Nursing Education, PGIMER, Chandigarh. A self-administered Stress scale, Perceived stress scale, Scale of Physio psycho social response to stress and scale to assess the coping strategies were developed and validated with the help of experts in the field of nursing, psychology, Public Administration and Psychiatry. Data was collected by administering all the scales to 44 nursing interns after taking informed written consent from them. Data was analysed by using SPSS -16 statistical programme. Results showed that two third of interns had moderate to severe stress, especially during their clinical practice. Students were found to cope up stress by using various coping strategies like avoidance, transference, problem solving and optimism. It is recommended that to have stress reduction among students, nurse educators should find out the most stressful areas and give a serious thought to encourage the use of healthy coping strategies to improve the productivity of students in nursing. Key words : Stress, Coping, Coping strategies, Nursing interns Correspondence at : Sunita Sharma, Lecturer, National Institute of Nursing Education, PGIMER, Chandigarh Introduction Everyone has stress and we face it in our daily life. Student nurses might be facing interpersonal and environmental stresses. Stress brings advantages and disadvantages to us, it depends on how nursing students look upon and take over them. Stresses can cause us to become stressful, feel distress and emotional affected while on the other hand, stresses give us motivation and evoke us to be more upholding and persistence in the 152

2 study in order to reach the optimum target and achieve further success. 1 The word stress is derived from the Latin word "stringi", which means, "to be drawn tight". Stress can be defined as any factor that threatens the health of the body or has an adverse effect on its functioning, such as injury, disease, or worry. According to Randy and David (2008) "Stress is the subjective feeling produced by events that are uncontrollable or threatening." Constant stress brings about changes in the balance of hormones in the body which may lead to the situation or thought that makes us feel frustrated, angry, nervous, or anxious 2 Students face many challenges and stressors, however, as a "nursing" student they are likely to experience even "more stress" than their friends and colleagues enrolled in other programs. Therefore, researchers have documented that perceived stress levels are high among nursing students (Burke, 1999; Mahat, 1996; Shiver 2000). Nursing students are prone to stress due to the transitional nature of college life. High levels of stress are believed to affect students' health and academic functions. 3,4,5 If the stress is not dealt with effectively, feelings of loneliness, nervousness, sleeplessness and worrying may result. Effective coping strategies facilitate the return to a balanced state, reducing the negative effects of stress. Basically, the stress among the student nurses can be divided into four categories, which are the social stress, financial stress, academic stress and clinical area stress. Social stress is not just the fear of being around people. It can also encompass the fear of public speaking, confrontations, and dealing with authority figures. Students are under financial stress when they find that they are lacking money or possess limited resources. According to Bandura A (1986). 6 Academic stress is observed when students can't finish their works on time and the pressure being added on by the lecturers and friends. Some of them can't cope with the problems as they don't have proper management or plan in their studies. Clinical stress is common among student nurses as they find it hard to practice professional skills in clinical area and develop discipline. They also experience stress in clinical area; clinical sites, pressure in procedure performance, fear of committing a mistake, time pressure, dealing with different kind of patients etc. Stress affects the mind, body, and behaviour in many ways, and ever yone experiences stress differently. Long time stress among nursing students or prolonged stress can cause memory problems and inability to concentrate in the studies. Sometimes they feel chest pain, rapid heartbeat, depression or general unhappiness and sleeping too much or too little whenever something goes wrong. It may even lead to burnout. Clinical practice has been identified as one of the most anxiety producing components in nursing programs. Lack of experience, fear of making mistakes, difficult patients, discomfort at being evaluated by faculty members, worrying about giving 153

3 patients the wrong information or medication and concern about possibly harming a patient are just a few of the stressors for student nurse. (Sharif & Masoumi, 2005) 7. "Coping is the process of managing demands that are appraised as taxing or exceeding the resources of the person." (Shelley E. Taylor, 2003). 8 Thus, coping is not a one-time action that someone takes; rather, it is a set of responses, occurring over time, by which the environment and the person influence each others. 1 "How a person copes can influence the degree, duration, and frequency of a stressful event." It's important to learn how to recognize when your stress levels are out of control. One cannot completely eliminate stress from one's life, but can control how much it affects. One may feel like the stress in life is out of control, but can always control the way one responds. 2 Five coping strategies were identified by Klauer and Filipp (1993) that turned up as dimensions in a factor analysis: Seeking social integration, r umination, threat minimization, turning to religion, and seeking information. 9 Coping has been viewed as a stabilizing factor that may assist individuals in maintaining psychosocial adaptation during stressful events. The process of coping is a very complex response that occurs when an individual attempts to remove stress or a perceived threat from the environment. Thus, the actual reaction to an environmental event may be as important as the event itself. Coping responses can be described as positive or negative and as reactive i.e. reacting to an individual's own thoughts and feelings or active i.e.dealing with actual stressful situations or events. Active or reactive coping responses can be positive or negative, depending on the situation and the content of the response. 10 There are some ways of stress management among the student nurses in their studies and their clinical areas i.e. family brings great support mentally and emotionally. During problem they need to talk to family members who are always there to help. Social support networks can also help the students during problem or stress. Developing a positive optimistic attitude can help them to cope more effectively with stress. There are some ways of stress management among the student nurses in their studies and their clinical areas i.e. family brings great support mentally and emotionally. During problem they need to talk to family members who are always there to help. Social support networks can also help the students during problem or stress. Developing a positive optimistic attitude can help them to cope more effectively with stress. Incorporating practices that can reduce some of the stress associated with all of these challenges is important, useful and essential to the well-being. Methods to reduce student stress often include effective time management, social suppor t, positive reappraisal, and engagement in leisure pursuits. Therefore, studying student stress and the methods students use to deal with it 154

4 can have important implications for higher education administrators. Although students cannot avoid these stressors, their ability to adjust to demands and cope with these stressors is important in achieving success in the college academic and social environment. This study is an effort in this direction. Objective To find out the level of stress and coping strategies used by nursing interns of National Institute of Nursing Education, PGIMER, Chandigarh. Methodology The present study was conducted at National Institute of Nursing Education (NINE). It is an integral part of PGI campus and is affiliated to the PGIMER, Chandigarh. College of Nursing, PGIMER was established in 1964 with WHO assistance to implement the Postbasic BSc Nursing programme. This has recently been upgraded to be National Institute of Nursing Education in the year The nursing institute has been contributing to the preparation of clinical nurse practitioners, educators and administrators. Thus it is serving to promote health, prevent sickness and provides bedside care to the sick and suffering. Currently the institute is running three educational programmes i.e. B.Sc. nursing 4 yrs; B.Sc. nursing, Post Basic (2 yrs) and M.Sc. nursing (2 yrs) in five specialities. Total 44 students of B.Sc. Nursing fourth year were selected by using purposive sampling. Tool used for data collection were Stress scale, perceived stress scale, Scale of Physio psycho social response to stress and scale to assess the coping strategies. The tools were prepared and validated by consulting experts in the field of administration, nursing, psychology and Psychiatry. The rating scale used was never (0) almost never(1) Sometimes(2) Fairly of ten(3)and Ver y often(4) The stress experienced by study subjects was rated as mild,moderate and severe based on the scores obtained. The reliability was checked by using split half method which showed that all the scale were reliable. The reliability coefficient was 0.94, 0.95, 0.98 and 0.93 respectively. Data was collected after taking permission from higher authorities. Informed written consent was taken from the subjects and all the scales were administered to them in the class. Collected data was compiled and analysed by using descriptive and inferential statistics. Results As depicted in table no 1 it was found that the age of 63.7 %of the students were in the range between 20-22years and only 36.3 %were between years of age. 54.5% of students belong to sikh families and 38.6% belonged to hindu families.majority of the students belonged to general category (79.5 %) and only 20.5% belonged to SC/ST category.the number of subjects belonging to nuclear families was to 84.1% as compared to that of joint families which was only 15.9%. Two third of the subjects belonged to the state 155

5 of Punjab (68.2%) and only 15.9 % belonged to Chandigarh and other states. Table 1: Socio - demographic profile of subjects N=44 Socio demographic profile N(%) Age (63.7) (36.3) Religion Hindu 17(38.6) Sikh 24(54.5) Other 3(6.9) Category General 35(79.5) SC & ST 9(20.5) Type of family Nuclear 37(84.1) Joint 7(15.9) Native state Punjab 30(68.2) Chandigarh 7(15.9) Other states 7(15.9) As depicted in table no 2 it was highlighted that most of the students (43.2%) who chose nursing as career were the ones who did not get admission in MBBS, followed by 40.9 % students who preferred nursing due to job security. Very few of them had come to nursing with their own choice or parental pressure and peer pressure. At the same time very few students joined nursing in order to go abroad. Table 2 : Reason for choosing nursing as career N=44 Reasons for choosing nursing as career N(%) Own choice 2( 4.5) Parental pressure 2( 4.5) Friend's / peer pressure 1( 2.3) Going abroad 2( 4.5) Job security 18(40.9) Did not get admission in MBBS 19(43.3) Table 3 depicts the levels of stress among nursing students. Two third of the students had moderate stress (63.6%) and 34.1% had mild stress where as 2.3 per cent students had severe stress. Having a closer look at the data it was observed that students exhibited maximum stress due to assignments and workload (63.6%), followed by 52.3 % from taking care of patients and teachers,45.5 % from peers and daily life,40.9% from the clinical environment and minimum stress due to lack of professional knowledge and skills. As depicted in table no 4 it was found that overall physio-psycho-social response to stress, two third of the students had mild stress (65.9%). Due to physical symptoms 79.5 % students were mildly stressed,followed by emotional and social behavioral symptoms ie 63.6% in each. 156

6 Table 3: Level of stress among nursing students N=44 Stress among nursing student Mild Moderate Severe n (%) n (%) N (%) Overall level of stress 15(34.1) 28(63.6) 1(2.3) Level of stress related to specific situations Taking care of patients 20(25.5) 23(52.3) 1(2.3) From teachers and nursing staff 21(47.7) 23(52.3) - From assignments and workload 15( 34.1) 28(63.6) 1(2.3) From peers and daily life 22(50.0) 20(45.5) 2(4.5) Due to lack of professional knowledge and 27(61.4) 17(38.6) - skills From the clinical environment 25(56.8) 18(40.9) 1(2.3) Table 4: Level of Physio-psycho response to stress among nursing students N=44 Physio-psycho response to Mild Moderate Severe stress among nursing students n (%) n (%) n (%) overall physio - psycho social response to stress 29(65.9) 14(31.8) 1(2.3 ) specific response to stress Physical symptoms 35(79.5) 8(18.2) 1(2.3) Emotional symptoms 28(63.6) 15(34.1) 1(2.3) Social behavioral symptoms 28(63.6) 15(34.1) 1(2.3) Looking at the coping strategies used among nursing students it was found that 77.3% students sometimes used tranference as a coping strategy to reduce stress followed by problem solving and optimism ie 63.6% and 61.4 % respectively. Avoidance to cope up with stress was used by half of the nursing student often. (Table - 5). Table 5: Coping strategies utilized by nursing students. N=44 Coping strategies utilized by nursing students Often Sometimes Never n (%) n (%) n (%) Coping strategies Avoidance 22(50.0 ) 20(45.5) 2 (4.5) Problem solving 2 ( 4.5) 28(63.6) 14(31.8) Optimism 1 ( 2.3) 27( 61.4) 16(36.4) Transference 8 (18.2) 34(77.3) 2 (4.5) 157

7 Discussion Stress brings advantages and disadvantages to us, it depends on how nursing students going to look upon them and take over them. Stresses can cause them to become stressful, feel distress and emotional affected while on the other hand, stresses give motivation and evoke them to be more upholding and persistent in the study in order to reach the optimum target and achieve further success. As the eustress is good for them,distress is a disadvantage for them. Stress affects the mind, body, and behaviour in many ways, and everyone experiences stress differently. Long time of stress in nursing student or prolonged stress can cause memory problems and unable to concentrate in the studies, sometimes they will feel chest pain, rapid hear tbeat, depression or general unhappiness and sleeping too much or too little whenever there is something goes wrong and may even lead to burnout. 11 The present study was conducted taking into consideration that students do experience stress during their training period. The socio-demographic characteristics of nursing students. Majority of the students belonged to the age group of years because most of them join BSc nursing after 10+2 at the age of 17-18, hence by fourth year they reach this age. Two-third of them were Sikhs (54.5 per cent) and others were Hindus, since the college is located in Chandigarh. Further looking into the data it was observed that 79.5 per cent students belonged to general category and majority of them came from nuclear families. Almost 68.2 per cent of the students belonged to Punjab. Reasons for choosing nursing as a career were multiple. Some students only join nursing by being pushed by their parents, others feel that there is job security and they can go abroad. In this study it was found that majority of the students who chose nursing were those who did not get selected for MBBS.Many students also considered job security as one of the factors for joining nursing. Regarding the stress and perceived stress among nursing students,it was found that 63.6% of the students experienced stress due to assignments and workload. A similar result was shown in a study conducted by Evans & Kelly (2004), who found that examinations, the intense amount of work, and finding the academic work difficult were the most important source of stress. 12 The present study reflects the stress levels of nursing students at different levels i.e. mild (34.1%), moderate (63.6%) and severe(2.3%). The factor which caused minimum stress was that from peers and daily life as there is lot of moral support provided to the students by friends and seniors. As regards to overall physio - psycho social response to stress, maximum students showed emotional and socio-behavioral response to stress most of the time throughout their training period. Similar results were shown in the study conducted by Mustafa Amr et al (2011) 13. It was highlighted that interpersonal and 158

8 environmental sources are the most common sources of stress among nursing students while, five most frequently repor ted stressors being finding new friends, new responsibilities, increased class workload, being placed in unfamiliar situations, and working with people they did not know, in that order. Another exploration of stress-related disorders among nursing students employed a longitudinal cohort design over a period of two academic years. High 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. (Haack MR 1988). 14 Student nurses face lot of interpersonal and environmental stresses. Stress brings advantages and disadvantages to us, it depends on how nursing students are going to look upon them and take over them. Stresses can cause us to become stressful, feel distressed and emotionally affected while on the other hand, stresses give us motivation and evoked us to be more upholding and persistent in the study in order to reach the optimum target and achieve further success. It was found that students used variety of coping strategies to cope up with stress. The most commonly used coping strategies transference was used by 77.3% of the students. Optimism and problem-solving were also preferred by the students, the least opted coping strategy was that of avoidance. Similar results were depicted in a study conducted by Patra Phuekphan, 2009 on Stressors and Coping Strategies among AU nursing student. 15 Results revealed that finding new friends and work with the unfamiliar people were ranked as the main sources contributing interpersonal stress, intrapersonal sources of stress represented by outstanding personal achievement and speaking in the public, academic stressors, the highly reported stress or were associated with using second language and increasing new responsibilities, and placed in unusual situation was environmental stressor. Fur thermore, coping strategies that students always used to overcome stress composed of developing self-reliance and being humorous. Failure to resolve students stress in the long term could have serious professional and personal consequences. We can't eliminate stress in our daily life no matter when and where we are in, but we can manage and control how it affects us. Stress doesn't only bring troubles, it brings advantage also and it depends on how we handle it. Stress can also promote personal growth or self-improvement. New skill and new knowledge will only being upgraded or gained if we are forced in a particular aspect. Every nursing student has to know that they play an important role in health care service, they have to learn to manage their own stress through stress management training, and they would not be able to take care of the clients if they cannot take care of themselves throughout their nursing career. Nursing students need to assess their stress levels and 159

9 determine what will decrease their tension. Impor tant ways to reduce stress include avoiding change, blocking time, becoming skilled in time management, and setting goals. To avoid change, we need to try to keep the same routines. Establishing healthy patterns of responding to stress and incorporating self-care practices into the daily regimen benefits an individual throughout the entire life. Making use of the information given in the present study regarding the levels of stress and coping strategies used by nursing interns, the nursing educators and administrators can incorporate the positive ways to manage stress as part of their curriculum. Reference 1. Andrew J Durbin. Stress management and personal productivity. Human Relations 10th ed. Pearson Education. New Jersey 2009: Randy JL, David MB. Stress, coping, adjustment, and health. Personality psychology.3rd ed. McGraw-Hill. 2008, New York: Shiver CB, Scott-stiles A: Health habits of nursing verses non nursing students : a Longitudinal study. Journal of Nursing Education 2003;39(7): Burke K. Stress levels on diploma course affecting academic confidence. Nursing standard 1999;13(50):5 5. Mahat G. Stress and coping : First year Napalese Nursing Students in clinical setting. Journal of Nursing Education 1996;35(4): Bandura A. The explanatory and predictive scope of self-efficacy theory. Journal of social and clinical psychology(1986). Special issue;4: Farkhondeh Sharif, Sara Masoumi. A qualitative study of nursing student experiences of clinical practice accessed at Biomedical Central of Nursing, 2005; 4:6. available at http: // / logon/logon.asp?msg =ce 8. Shelley E Taylor. Moderators of the stress experience. Health psychology.5th ed. 2003, New York: Klauer, Filipp. Stress and coping resources: Theory and review, (1993). Retrieved 20 February 2010, from: D:\stress\Stress and coping.mht 10. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer; Gibbons C, Dempster M, Moutroy M. Stress and eustress in nursing students. J Adv Nurs. 2008;61(3): Evans W, Kelly B: Pre-registration diploma student nurse stress and coping measures. Nurse Education Today 2004; 24(6): Mustafa Amr et al.stress among Egypt Bacculareate nursing students. Nursing Research 2011;8: Haack MR. Stress and impairment among nursing students. Research of Nursing Health 1988 Apr;11 (2): Patra Phuekphan presented research on "Stressors and Coping Strategies among AU nursing student" in the Silver Jubilee International Conference of Christian University of Thailand, Bangkok, during November