Stress and Coping Strategies among Nursing Students

Stress and Coping Strategies among Nursing Students Rajesh Kumar, Nancy Abstract :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. A descriptive study was conducted in a private nursing institute of Punjab affiliated with Baba Farid University of Health sciences, Faridkot to assess stress level and coping strategies among nursing students. Total of 180 students participated in the study. Perceived Stress Scale -14 (PSS-14) was used to assess stress level and ACOPE was used to identify the coping strategies. Results revealed that 34% students were having moderate stress and 33% each were having mild and severe stress. Class of the students and their courses were found to be significantly associated with the stress level of nursing students. Majority of subjects tend to use more of healthy coping strategies as compared to negative or un-healthy ones. "Seeking diversion" is the most common and "Seeking professional support" is the least common coping strategy identified in nursing students. Key words : Stress, Coping Strategy, Nursing Students Correspondence at : Rajesh Kumar Lecturer, X-311. Sarojni Nagar New Delhi 110023 Introduction 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 1. Moreover the transition between the middle childhood and adolescence represents a confluence of social, academic, cognitive, physiological and physical changes. Pubertal maturation brings morphological changes heralding reproductive maturity as well as increase in gonadal hormones which influence central and peripheral stress response. 141

systems throughout the body and brain 2. Thus, stress among young brings socioemotional changes. Earlier studies have classified stressors into three main categories: academic pressures, social issues and financial pressures 3. Academic stress among college students has been a topic of interest for many years. College students, especially freshmen, are par ticularly prone to stress due to transitional nature of college life, for e.g. many college students move away from home for first time, which can necessitate leaving all previously learned support system such as parents, siblings and high school friends. Students may need to develop entirely new social contacts and are expected to take responsibility for their own needs. They may have difficulty in adjusting to more rigorous academic expectations and the need to learn to deal with individuals of different culture and belief. Thus, stress may result from being separated from home for the first time, the transition from personal to impersonal academics and the vary structure of academic experience at the college level. In nursing, students experience increased tension prior to their clinical rotation and written examination especially their finals. Dhar R et al reported 48.83% mild stress and 11.62% moderate stress among nursing students 4. Clinical sources of stress include working with dying patient, interpersonal conflict with other nurses, insecurity about clinical competence and fear of failure and interpersonal relations with patients, work overload and are concerned about nursing care given to the patient. Other potential sources of stress are assignment submission, excessive homework, assessment deadlines, unclear assignments, uncomfor table classrooms and relations with faculty members. Stress can have a significant effect on adolescent's long term physical and mental well-being. The adolescents may become irritable, show lack of concentration, decreased academic performance, poor interpersonal relations, insomnia and absenteeism 5. Previous studied have shown fairly high level of distress such as symptoms of depression and even suicidal thoughts 6, 7, 8. among medical undergraduates Learning to cope with a stress is a useful skill for nursing career and a life ahead. By setting priorities, planning ahead by organizing self, one can minimize the impact of stress. Lazarus and Folkman used the term coping to describe the "cognitive and behavioral effor ts", a person employ to manage stress, generally categorized as emotional- focused and problem- focused coping 9. Various coping strategies used by students include ventilation, diversion, relaxation, self-reliance, social peer group suppor t, avoidance, praying, day dreaming listening to music and smoking, drinking, joking etc 10. The investigator found that least number of research databases is available to assess stress level among nursing students due to their transitional age and academic 142

pressure. Thus, the current study is taken up to assess the "stress level" and "coping strategies" used by nursing students METHODOLOGY A study was conducted on nursing students in one of the private nursing college situated in Punjab and affiliated to Baba Farid University of Health Sciences, Faridkot. The college runs various nursing programs such as General Nursing & Midwifery (GNM), B.Sc. Nursing, B.Sc. (Post-Basic) Nursing and M.Sc. Nursing. It has total covered area of 12.35 acre with all the basic amenities available within the campus. There are approximately 100 students residing in the hostel. The institution organizes various cocurricular activities regularly. There is provision of spor ts ground and sports equipments for all the students. The institute organizes various religious activities from time to time. Target population for the study involved all the nursing students enrolled during 2008-2010. Total enumeration technique was adopted and 180 nursing students were included in the study. The tools used for data collection were Socio-demographic profile sheet, Perceived Stress Scale-14 (PSS-14) 11 and Adolescent Coping Orientation for Problem Experiences (ACOPE). 12,13 Sociodemographic profile sheet contained items such as age, sex, course, class, parent's education and occupation, family income, distance from college, residential status etc. PSS-14 developed by Dr. Cohen was used to assess the stress level among nursing students based on their feelings and thoughts in a last one month. It is a 5-point likert scale varying from 0=Never, 1=Almost Never, 2=Sometimes, 3=Fairly Often to 4=Very Often with a total of 14 items. The score range from 0-56. The reliability of the scale was 0.85. ACOPE developed by Patterson & Mc- Cubbin (1987) was used to assess the coping strategies used by nursing students to overcome stress. It is a 5-point likert scale var ying from 0=Never, 1=Hardly, 2=Sometimes, 3=Often to 4=Most of the time. It contains total 54 items under 12 domains. The reliability of the scale was 0.85. Pretesting of the tool was done to check its clarity, feasibility and practicality. It took around 20-30 minutes to fill the questionnaire and it was found clear and feasible. The permission for data collection was obtained from the competent authority of the college. An informed verbal consent was taken from the students. After filling the demographic profile sheet, the standardized PSS-14 and ACOPE were administered to the subjects during their free period time. Anonymity and confidentiality of the study subjects was maintained during the study. They were given full autonomy to withdraw from the study at any time. The final data was then transferred to SPSS 15.0 evaluation version and analyzed using descriptive and inferential statistics. RESULTS A study found that 58.3 % of nursing students were 19-25 yrs age whereas 41.7 % were below 18 yrs. Majority of the nursing students were females (87.2 %), from 1st year 143

(41.6%), from B. Sc. Nursing 4 years programme (72.3 %) and belonged to nuclear family (72.8 %). Fur ther data indicated that only 28.3% and 16.1% nursing student's father and mother respectively had their education up to graduation. Around 35.6% student's fathers were farmers and 75.6% student's mothers were house wife. About 50.6 % of the subjects belong to families having monthly income more than Rs.10, 000/-. Study indicates that 40.6 % of the students resided in the college campus. Stress Level among Nursing Students The nursing student's stress was measured using Perceived Stress Scale (PSS-14). The average score of each student's score on PSS-14 was calculated. The total scores of the all the subjects were further averaged and categorized using interquar tile range into three categories: Low (25%), Moderate (50%) and Severe (75%) stress. Findings revealed that out of 180 nursing students 62 (34.4%) had moderate stress whereas 59 (32.8%) and 59 (32.8%) fall in the category of low and high stress respectively (Fig.1) Fig 1: Stress level Among Nursing Students Student's mean PSS-14 score was 43.33 ± 6.22. Majority of the students reported that sometimes during the last month, they remain upset (56.7%), unable to control important things of life (49.4%), felt nervous or stressed (48.9%), could not cope up with the things (43.3%), exhibit anger (45.6%) and thought about the accomplished things (42.2%). It was further found that the students reported that sometimes during the last month, they use coping strategies to overcome stress (44.4%), control irritation (46.7%), feel that thing are going their way (44.4%) and they were on the top of the thing (48.9%) and able to control the way they spent their time (41.7%) (Table1). Table 2 depicts the relationship of stress level of nursing students to the demographic characteristics. It shows that stress level of nursing students is found to be significantly associated with their class (p=0.000) and the type of course (p=0.000) i.e. significantly higher percentage of 1st year students reported moderate and higher level of stress as compared to other classes and the students undergoing post-graduation experienced high level of stress in higher percentage followed by BSc nursing 4years programme, BSc Nursing Post basic and GNM in descending order. The other demographic variables did not show any association with the stress level of the study subjects. However it was observed that students between 19-25 years of age, female students, and students from nuclear families were having high level of stress in higher percentage as compared to their counterparts. 144

Table 1: Frequency of Perceived stress during the last one month by nursing students as measured on Perceived Stress Scale (PSS-14) (N=180) Items Never Almost Some Fairly Very n(%) never times often often n(%) n(%) n(%) n(%) Being upset that happened unexpectedly 23 13 102 25 17 (12.8) (7.2) (56.7) (13.9) (9.4) Feeling of unable to control the important things in life 33 23 89 22 13 (18.2) (12.8) (49.4) (12.2) (7.7) Feeling nervous and "stressed" 14 16 88 40 22 (7.8) (8.9) (48.9) (22.2) (12.2) Able to deal successfully with day to day problems and annoyances 27 29 54 58 12 (15.0) (16.1) (30.0) (32.2) (6.7) Feeling effectively coping with important changes that were occurring in life 12 14 80 50 24 (6.7) (7.8) (44.0) (27.8) (13.3) Feeling confident about ability to handle personal problems 9 20 60 42 49 (5.0) (11.1) (33.3) (23.3) (27.2) Feeling that things were going according to own way 34 28 80 29 9 (18.9) (15.6) (44.4) (16.1) (5.0) Feeling unable to could not cope with all things that should be do 15 34 78 35 18 (8.3) (18.9) (43.3) (19.4) (10.0) Able to control irritation in life 13 21 84 39 23 (7.2) (11.7) (46.7) (21.7) (12.8) Feeling on top of things 31 29 88 20 12 (7.2) (16.1) (48.9) (11.1) (6.7) Being angered because things were happening outside of control 14 12 82 40 32 (7.8) (6.7) (45.6) (22.2) (17.8) Thinking about the things that to be accomplished 15 20 76 39 30 (8.3) (11.1) (42.2) (21.7) (16.7) Able to control the way of spending time 13 31 75 43 18 (7.2) (17.2) (41.7) (23.9) (10.0) Feeling that difficulties were piling up so high that they could not be overcomed 29 31 60 36 24 (16.1) (17.2) (33.3) (20.0) (13.1) 145

Table 2: Stress Level Based on Socio Demographic Changes n=180 Socio Demographic characteristics Level of Stress Chi-Square Low Moderate High value n(%) n(%) n(%) p- value Age(yrs) <18 28(37.33) 26(34.67) 21(28.00) p=0.425 19-25 31(29.52) 36(34.29) 38(36.19) Sex Male 07(30.44) 12(52.17) 04(17.39) p=0.113 Female 52(33.12) 50(31.85) 55(35.03) Class Fresher 28(33.74) 27(32.53) 28(33.73) p=0.000* Senior 31(31.97) 35(36.06) 31(31.97) Course GNM 28(59.58) 11(23.40) 08(17.02) B.Sc 26(23.42) 43(38.74) 42(37.84) p=0.000* B.Sc (post basic) 05(26.32) 08(42.10) 06(31.58) M.Sc 00(0.00) 00(0.00) 03(100.00) Type of Family Joint 20(42.56) 16(34.04) 11(23.40) p=0.168 Nuclear 39(29.32) 46(34.59) 48(36.09) Education of father Upto 10th 25(37.31) 24(35.82) 18(26.87) More than 10th 34(30.08) 38(33.64) 41(36.28) p=0.395 Education of mother Upto 10th 41(37.96) 35(32.41) 32(29.63) More than 10th 18(25.00) 27(37.50) 27(37.50) p=0.185 Occupation of father Govt. Employee 14(25.00) 21(37.50) 21(37.50) Non-Govt. Employee 45(36.29) 41(33.06) 38(30.65) p=0.318 Occupation. of mother Housewife 44(32.35) 51(37.50) 41(30.15) Working 15(34.09) 11(25.00) 18(40.91) p=0.257 Monthly income Below Rs 10,000 36(40.45) 25(28.09) 28(31.46) Above 10000 23(25.27) 37(40.66) 31(34.07) p=0.069 Distance Within the campus 22(30.14) 28(38.35) 23(31.51) Between 1-30 km 29(43.94) 16(24.24) 21(31.82) p=0.075 Above 30 km 08(19.51) 18(43.90) 15(36.59) Type of residence Living in Hostel 27(32.92) 31(37.81) 24(29.27) Living with Parents 25(31.25) 25(31.25) 30(37.50) p=0.776 Others 07(38.89) 06(33.33) 05(27.78) p*<0.05, significant 146

Coping strategies The coping strategies used by nursing students to overcome stress were measured by using ACOPE. It contains total 54 items under 12 domains. The mean score of coping strategies used by nursing students under 12 domains of ACOPE showed that from the most commonly used to least commonly used coping strategies are in the following order: seeking diversion (21.3±4.86), solving family problems (18.6±4.85), developing social suppor t (17.7±3.61), self-reliance (17.5±4.19), ventilating feelings (15.03±4.23), engaging in demanding activities (12.2±2.86), avoiding (10.7 ±3.56), relaxing (10.5±3.37), seeking spiritual support (7.67±2.55), being humorous (5.6 ±2.02), investing in close friends (5.52±2.04), seeking professional support(4.14±2.19) (Fig.2). Fig.2 Coping strategies used by nursing students Table 3 shows that most commonly used strategy by the students for ventilating feelings was complaining to their friends (36.7%) and crying (22.8%). Further, it has been seen that most of the times, the students listen to music, stereo or radio (36.7%), engaged in day-dreaming (23.3%) or hobby (14.1%) or eat food (13.9%) to divert their mind and to relax themselves during the periods of stress. In the area of self-reliance, students reported that most of the times, they try to think of or see good things (26.7%), try to organize their life (19.4%) and try to make their own decisions (18.3%). Around 32% of the students tried to cope with the stress by helping other people in solving their problems or by blaming others for their problems respectively. ACOPE showed that most of the times, nursing students try to reason with parents (21.1%), talk with mother (30%), brother or sister (21.7%) about their problems and feelings or go along with parents request (22.2%). Around 36% of the nursing students seek spiritual support by performing prayers during periods of stress. More than 30% of the students try to cope with the stressful situations by figuring out the way to solve their problems while improving their work performance. Around 25% of the nursing students reported that the stress was relieved to some extent by being close to someone who cares or loves (Table 4). It has been further shown that the least common strategies used by nursing students to cope with stress were smoking (76%), using drugs (73.3%), liquor, wine or beer (71.7%), drugs prescribed by the doctor (71.7%), talking to minister, priest or rabbi (58.9%), getting professional help (58.9%), being with the boyfriend or girlfriend (57.8%) and riding around in the car (53.9%) (Table 3&4). 147

Table 3: Coping strategies used by nursing students Ventilating feelings Never Hardly Sometimes Often Most of time n (%) n (%) n (%) n (%) n (%) Ventilating feelings Say mean things to people be sarcastic 80 (44.4) 26 (14.4) 38 (21.1) 18 (10.0) 18 (10.0) Swear 73 (40.0) 28 (15.6) 54 (30.0) 11 ( 6.1) 14 ( 7.8) Let off stream by complaining to your friends 15 ( 8.6) 14 ( 7.8) 45 (25.0) 40 (22.2) 66 (36.7) Get angry and yell at people 49 (27.2) 23 ( 12.8) 69 (38.3) 21 ( 11.7) 18 (10.0) Let off stream by complaining to family members 75 (41.7) 24 (13.3) 58 (32.2 ) 16 (8.9) 07 ( 3.9) Cry 35 (19.4) 13 (7.2) 62 (34.4) 29 (16.1) 41 (22.8) Seeking diversions Go To Movie 73 (40.6) 24 (13.3) 48 (26.7) 21 (11.7) 14 ( 7.8) Play Video Games 75 (41.7) 28 (15.6) 42 (23.3) 13 (7.2) 22 (12.2) Use Drugs 132(73.3) 14 (7.8) 18 (10.0) 07 (3.9) 09 (5.0) Listen To Music, Stereo or Radio 15 (8.3) 14 (7.8) 45 (25.0) 40 (22.2) 66 (36.7) Read 60 (33.3) 30 (16.7) 59 (32.8) 14 (7.8) 17 (9.4) Go Shopping, Buy Things You Like 53 (29.4) 16 ( 8.9) 66 (36.7) 18 (10.0) 27 (15.0) Watch T.V 32 (17.8) 19 (10.6) 68 (37.8) 31 (17.1) 30 (16.7) Sleep 28 (15.6) 25 (13.9) 55 (30.0) 38 (21.1) 34 (18.9) Relaxing Work on a hobby 50 (27.8) 20 (11.1) 56 (31.1) 28 (15.6) 26 (14.1) Eat food 67 (32.2) 33 (18.3) 38 (21.1) 17 (9.4) 25 (13.9) Day dream 39 (21.7) 12 (6.7) 52 (28.9) 42 (23.3) 42 (23.3) Ride around in the car 97 (53.9) 18 (10.0) 26 (14.4) 23 (12.8) 16 (8.9) Self-reliance Get a job or a work harder 67 (32.2) 30 (16.7) 37 (20.6) 25 (13.9) 21 (11.7) Try to think of good things 21 (11.7) 18 (10.0) 51 (28.3) 42 (23.3) 48 (26.7) Try to make your own decisions 23 (12.8) 13 (7.2) 69 (38.3) 42 (23.3) 33 (18.3) Organize your life that what you have to do 46 (25.6) 08 (66) 66 (36.7) 25 (13.9) 35 (19.4) Get more involved in activities in school 60 (33.3) 29 (16.1) 66 (36.7) 14 (7.8) 11 (6.1) Tell yourself that problem(s) is not important 27 (15.0) 29 (16.1) 71 (39.4) 31 (17.2) 22 (12.2) Developing social support Blame others for what's going on 77 (42.8) 26 (14.4) 43 (23.9) 14 (7.8) 56 (31.1) Apologize to people 36 (20.0) 23 (12.8) 73 (40.6) 26 (14.4) 22 (12.2) Try to help other people solve their problems 16 (8.9) 15 (8.3) 59 (32.8) 32 (17.8) 58 (32.2) Try to keep up friendships or make new friends 41 (22.2) 26 (14.4) 48 (26.7) 30 (16.7) 35 (19.4) Say nice things to others 40 (22.2) 26 (14.4) 69 (38.3) 20 (11.1) 25 (13.9) Talk to friends about how you feel 24 (13.3) 15 (8.3) 67 (37.2) 37 (20.6) 37 (20.6) 148

Table 4: Coping strategies used by nursing students Coping strategies Never Hardly Sometimes Often Most of time n (%) n (%) n (%) n (%) n (%) Solving family problems Talk to your father about what bothers you 57 (31.7) 18 (10.0) 66 (36.7) 13 (7.2) 26 (14.4) Try to reason with parents and talk things out, compromise 27 (15.0) 13 (7.2) 69 (38.3) 33 (18.3) 38 (21.1) Go along with parents request 23 (12.8) 20 (11.1) 68 (37.8) 29 (16.1) 40 (22.2) Do things with your family 37 (20.6) 14 (7.8) 61 (33.9) 33 (18.3) 35 (19.4) Talk to a brother or sister about how you feel 41 (22.8) 24 (13.3) 46 (25.6) 30 (16.7) 39 (21.7) Talk to your mother about what bothers you 21 (11.7) 25 (13.9) 55 (30.6) 25 (13.9) 54 (30.0) Avoiding Smoke 137 (76.1) 8 (4.4) 15 (8.3) 09 (5.0) 11 (6.1) Use drugs prescribe by doctors 129 (71.7) 20 (11.1) 13 (7.2) 05 (2.8) 13 (7.2) Try to stay away from home as much as possible 81 (45.0) 20 (11.1) 39 (21.7) 21 (11.7) 19 (10.6) Try to see the good things 21 (11.7) 18 (10.0) 51 (28.3) 42 (23.3) 48 (26.7) Drink beer,wine, liquor 129 (71.7) 09 (5.0) 16 (8.9) 11 (6.1) 15 (8.3) Seeking spiritual support Talk to minister, priest or rabbi 106 (58.9) 22 (12.2) 31 (17.2) 14 (7.8) 07 (3.9) Go to church 88 (48.9) 21 (11.7) 38 (21.1) 12 (6.7) 21 (11.7) Pray 21 (11.7) 13 (7.2) 45 (25.0) 37 (20.6) 64 (35.6) Investing in close friends Be close with someone you car e about 22 (12.7) 14 (7.8) 56 (31.1) 37 (20.6) 51 (28.3) Be with a boy friend or girl friend 104 (57.8) 13 (7.2) 30 (16.7) 35 (19.4) 44 (24.7) Seeking professional support Get professional counseling 106 (58.9) 19 (10.6) 34 (18.9) 11 (6.1) 10 (5.6) Talk to counselor at school about what bothers you 83 (46.1) 24 (13.3) 37 (20.6) 16 (8.9) 20(11.1) Engaging in demanding activities Do a strenuous physical activity 86 (47.8) 21 (11.7) 50 (27.8) 11 (6.1) 12 (6.7) ( jogging, biking etc) Try, on your own, to figure out how to deal with 08 (4.4) 17 (9.4) 58 (32.2) 42 (23.3) 55 (30.6) your problems and tensions Try to improve yourself 14 (7.8) 19 (10.6) 48 (26.7) 40 (22.2) 59 (32.8) (get body in shape, get better grades, etc.) Work hard on school work or school projects 46 (25.6) 30 (16.7) 50 (27.8) 26 (14.4) 28 (15.6) Being humorous Joke and keep a sense of humor 54 (30.0) 23 (12.8) 6.5 (36.1) 19 (10.6) 19 (10.6) Try to be funny and make it light of it all 38 (21.1) 14 (7.6) 72 (40.0) 22 (12.2) 34 (18.9) 149

DISCUSSION Stress in nursing students is an area of growing concern and it may result in psychological distress, physical complaints, behavior problem and poor academic performance. The present study was conduct in one of the private nursing college situated in Punjab and affiliated to Baba Farid University of Health Sciences, Faridkot to assess the stress level and coping strategies used by nursing students. Findings revealed that out of 180 nursing students 34.4% had moderate stress whereas 32.8% and 32.8% fall in the category of low and high stress respectively which was slightly consistent with the study conducted among undergraduates students of CMH Lahore medical college, Pakistan on 200 students which reported 30.84 overall mean perceived stress 14. However, stress level of first year and third year B.Sc. Nursing students is found to be significantly high than other classes (p=0.000, p=0.000 respectively). The findings were consistent with the findings of an Iranian study conducted by Seyedfatemi et al 10 among nursing students. This may be because the students face more of stressors when they come to college during first year of their training because of being placed in an unfamiliar environment, separation from the parents and the demand of making new social groups apart from academic pressures and clinical training. However, the nursing students were constantly facing demands and challenges of the curriculum which had being a source of stress during their total training program. Coping strategies refer to the specific efforts, both behavioral and psychological, that people employ to master, reduce tolerate or minimize stressful events. Coping with stress for a student nurse is a dynamic and ongoing process, aimed at sur vival, growth and maintenance of the individual integrity. She tries to restore the imbalance and disequilibrium within her by attempted adjustment through the use of various coping strategies which can be healthy or unhealthy. WHO/EHA guidelines have stated that there are no standard for coping strategies; rather they were depending on socio-economic factors. In the present study, majority of subjects tend to use more of healthy coping strategies as compared to negative or unhealthy ones. "Seeking diversion" is the most common and "Seeking professional support" is the least common coping strategy identified in nursing students which are consistent with the findings of a similar study among nursing students at Chiang Mai University which revealed that the most frequently used coping strategies were seeking social suppor t (62.25%), planful problem solving (23.73%) and accepting responsibility (8.47%) 15. Another study at the NINE, PGIMER, Chandigarh reported the five most frequently used coping strategies were positive thinking, listening to the music/radio, indulging in creative activities, talk to parents and pray more 4. However, the study findings was inconsistent with the findings of the study done on Iranian students which repor ted solving family problems and being humorous as the most common and least common used strategy respectively 10. 150

Stress has become a chronic and pervasive condition in the world today. Every person experience different forms of stress throughout their life, therefore a student nurse is no exception as she has to adjust to an entirely new environment on joining a training course in nursing. It has been concluded that the nursing students perceived different levels of stress due to academic, clinical and other psychosocial factors. Further, they use a mix of coping strategies to overcome stress so as to maintain a balance on a wellness-illness continuum. Coping with stress for a student nurse is a dynamic and ongoing process, aimed at survival, growth and maintenance of the individual integrity. She tries to restore the imbalance and disequilibrium within her by attempted adjustment through the use of various coping strategies which can be healthy or unhealthy. It is important for nurse educator to find out the sources of stress and coping strategies used by the students so that they can be helped to cope well with upcoming problems and situations. REFERENCES 1. Chrousos GP, Torphy DJ, Gold PW. Interaction between the hypothalamic -pituitaryadrenal axis and the female reproductive system: clinical implications. Annals Intern Med 1998; 129(3): 229-40 2. Spear LP. The adolescent brain age - related behavioral review 2000; 24(4):417-63 3. Fisch, Niles MA. Health students in college environment. Public Health Nursing 1996 ;13:104-11 4. Dhar R., Walia I, Das K. A descriptive study to assess the causes of stress and coping strategies used by the newly admitted basic B.Sc nursing students. Nursing and midwifery research journal 2009; 5(1):31-37 5. Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross sectional study. Med educ 2005; 39:594-604. 6. Zocolillo M, Murphy GE, Wetzel RD: Depression among medical students. J affect disord 1986;11:91-96. 7. Pheukphan AP. Stress and coping strategies among AU (Australian) nursing students 2009 Available at url: www.nurse.au.edu/. Accessed on 23.03.2011 8. Papazisis G, Ulasidis I. Depression and anxiety among students in Greece 2008 Available at url: www.annals-general-psychiatry.com/ content/7/s1/s209. Accessed on 23.03.2011 9. Lazarus RS, Folkman S: Stress, appraisal and coping. Newyork: Spinger 1984. 10. Seyedfatemi N. Experienced stressors and coping strategies among Iranian nursing students, BMC nursing 2007, 6(1). Available at url: http:/www.biomedcentral.com/1472-6955/6/ 11. Accessed on 25.03.2011 11. Copeland EP, Hess RS. Differences in young adolescents' coping strategies based on gender and ethnicity. Journal of Early Adolescence 1995; 15:203-19. 12. Patterson JM, McCubbin HI. Adolescent coping style and behaviors - conceptualization and measurement. Journal of Adolescence 1985; 10(2):163-186. 13. Dr. Cohen's Scale [online] Available from url: http://www.psy.cmu.edu/~scohen/ Perceived%20Stress%20Scale%20(PSS)%2014- item.doc 14. Shah M, Hasan S, Malik S, Seeramareddy CT. Perceived stress, sources and severity of stress among medical undergraduates in Pakistani medical school. BMC medical education [online] 2010, 10(2). Available at url: http://www.biomedcentral.com/ 1472-6920/10/2. 15. Hsiao YC, Chier LY, Wu Lt, Chiang CM, Huang ST et al. Spiritual health, clinical practice stress, depressive tendency and healthpromoting behaviors among nursing students, Journal of Advanced Nursing 2010; 66(7) 1612-1622 151