This study was conducted to assess nursing students’ perceived stress levels and its association with anxiety as well as the coping behaviors used to reduce the effect of stress during clinical training.
Overall, 47.92 % of the students were found to experience moderate level of perceived stress and only (25%) perceived a high degree of stress. Furthermore, the correlation between perceived stress and anxiety was significant in the present study, i.e. students with high scores on perceived stress had higher scores for anxiety.
The prevalence of stress among nursing students found in the literature is variable, which could be due to the different academic programs available worldwide and the use of different scales for measuring the same (Gazzaz et al., 2018; McCarthy et al., 2018). However, stress levels may also become affected because of different perceptions regarding stress across cultures and among different individuals. Lazarus and Folkman defined 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”(Lazarus and Folkman, n.d.). Besides these academic and personal differences, according to this definition of stress, it is important to include the effects of the environment, and more concretely in our case, the different clinical placements the students visited throughout their training, on the levels of stress or anxiety presented by the student. The results of other studies suggest that mental health nurses are much more vulnerable to stress and have fewer resources to face the same (John Galvin et al., 2015). In this sense, and despite our study not being a specific study on mental health nurses, our students displayed higher levels of stress precisely when they were in mental health services. Regarding other specialized services such as intensive care or emergency care, our study suggested that the students had higher levels of anxiety and stress during this clinical placement units.
Regarding the year of studies, our findings support previous studies where the students with the most experience displayed higher levels of anxiety, whereas the most inexperienced showed lower levels of stress and anxiety (Deary et al., 2003; Watson et al., 2008). This may be because they feel that their teachers and other nurses expect more from them as they are more experienced and therefore more knowledgeable students, thus increasing their stress levels. However, this interpretation of data should be linked to the previously cited findings, i.e., considering the clinical placements performed by the students. For example, clinical placements in more specialized services are usually completed during the later years, whereas during the first years of study, training takes place in more general services requiring more basic competencies for care and patient responsibility. Therefore, students who have more extensive training, but who are also required to have a greater level of competencies and skills during patient care are those that are exposed to a greater level of anxiety and stress. However, as suggested by Jimenez et al.(Jimenez et al., 2010), it is important to exercise caution in these interpretations as, in this sense, the different training programs, despite being based on the ECTS system, should not be centered only on the number of credits that should be completed each year, but they should insist on coordinating and developing parallel competencies over time, as differences in training programs exist even within the same country.
In the current study the coping strategies most frequently used by students were problem-solving followed by social support and cognitive restructuring. According to Folkman and Lazarus, problem solving is one of the more effective ways to deal with stress as it focuses on behaviors in order to manage or alter the problem(Lazarus and Folkman, n.d.). Problem solving has been found to be the most utilized coping strategy in different studies with nursing students (Al-Gamal et al., 2018; Al-Zayyat and Al-Gamal, 2014; Chen and Hung, 2014), despite the fact that these studies have used a measurement scale for facing stress that is different to the one used in this study. In terms of the relationship between perceived stress and coping strategies, our findings indicate that among these three domains (problem solving, cognitive restructuring and social support) an inverse correlation exists, indicating that people who suffer less stress, will use these strategies more. Similarly, the positive correlation with the following domains shows how people with greater stress have more anxiety trait and state and use strategies such as wishful thinking, self-criticism, social withdrawal and problem avoidance. Results of this study showed that the greatest predictor of perceived stress were anxiety trait. As for the domains or strategies used to cope with stress, in our study, the use of certain strategies such as problem solving and cognitive restructuring, were found to be considered predictors of less stress while the use of wishful thinking appeared as a predictive factor of greater stress. In other studies, using other coping tools, they found a positive relationship in terms of protection regarding the mental health of the student, in those students who used an optimistic strategy. In this sense, it may be that our study sample did not understand culturally speaking what wisful thinking meant or that they did not know strategies really framed in this state of optimism or illusion and that on the one hand could be a protective factor in terms of mental health but that are not giving truly optimal results in terms of reducing the stress they suffer (Karaca et al., 2019).
In a qualitative study by Lopez V et al., nursing students of a University in Singapore reported that talking about their negative emotions with their peers and positive reframing of their negative circumstances were the most used strategies when facing perceived stress (such strategies would be framed within the domains of social support and/or expression of emotion). However, relationships between students and their clinical educators and nurses and medical staff have been widely reported in the literature (Al-Zayyat and Al-Gamal, 2014; Bagcivan et al., 2015; J. Galvin et al., 2015; Jimenez et al., 2010), as being difficult relationships based on a lack of emotional or social support. Both teachers and mentors should be responsible for the proper implementation of coping strategies as basic tools in the skills to be acquired during their competencies in the clinic. The university faculty should not only be aware of the stress levels of students, but also consider how they manage this stress, i.e. whether they use good and effective tools for coping with the same, as this will be key in their development as a nurse. Getting to know the level of stress and/or anxiety that is experienced by our students is important to determine which negative effects should be changed in their behaviors to improve coping.
Implications for education
In this sense, and in line with other research, the study of coping strategies appears instrumental for the prevention of stress and it is essential that these strategies should begin to be trained within the university facilities. These programs could help prepare nursing students to cope with the challenges they are about to face during their clinical rotations. For example, in Spain no university uses a nurse student peer mentoring or support program. This peer mentoring program, where third year students mentor first year students, was implemented in other foreign universities in order to reduce the anxiety experienced by first year students nurses and to facilitate a smooth transition to clinical practice situations (Hogan et al., 2017). Other strategies have demonstrated to be effective in the management of stress and anxiety in nursing students, such as the use of biofeedback and mindfulness and meditation interventions (Ratanasiripong et al., 2015) or emotional freedom techniques (Patterson, 2016).
These findings call for a greater challenge to nurse educators in create a planning strategy to prevent recurrence of stress based in the use of the coping strategies most closely correlated with lower levels of perceived stress.
Limitations
This study has limitations that must be considered when interpreting these results. First, these findings cannot be generalized, as the study was conducted in nursing students of only one faculty of nursing and therefore, the socio-demographic structure of the sample was not necessarily the same as that of other faculties in Spain. The performance of longitudinal studies conducted over several academic years is recommended as these could show changes in perceived stress over time. Further studies based on qualitative techniques would provide more detail regarding the stressor factors and its relationship with levels of anxiety and coping strategies. However, despite these limitations, the results of this study appear to concur with previous findings on this topic.