Experienced Stressors and Coping Strategies among Nursing Students –

A Correlation with State Anxiety

 

Rajesh Kumar

Assistant Professor, INC PhD Scholar, Department of Mental Health Nursing, SGRD College of Nursing, SGRDIMSR, Vallah, Amritsar (Pb)

 

ABSTRACT:

Introduction

Anxiety has a huge impact on learning. Stress in nursing and in nursing students is a well documented phenomenon, but the extent to which it occurs and means of coping with it vary. The objective of this investigation was to identify stressors, coping styles and finding relationship to state anxiety in nursing students.

Material and Methods- A descriptive survey was conducted to enrolled 199 nursing students through simple random sampling (lottery method) and total enumeration technique. The principal measures of the anxiety, stress and coping styles were; The State Trait Anxiety Inventory (STAI) for state anxiety, Perceived Stress Scale -14 (PSS-14) for stress, and Adolescent Coping Orientation for Problem Experiences (ACOPE) for coping styles. Data were analyzed by using descriptive and inferential statistics.

Results- ‘Remaining upset’ (55.3%) marked highest among the stressors in nursing students followed by ‘unable to cope stress’ (49.2%) and feeling that things are going away (48.2%). The most common coping strategies were listening radio or music (47.7%), taking help of rabbi or priest (53.3%), and talking to father about our problems (36.7%). The least common coping styles were use of beer-wine (7.5%), smoking (7%) and use of prescribed drugs (4%). Stress and anxiety have weak negative correlation (r=-.131, p<.05).

Conclusion -Although small sample was the limitation of this study yet it implicate the nursing institute teachers as well as students to aware stress management strategies (i.e. using active coping and avoiding self blame)that may help to prevent deadly consequences of anxiety and stress on physical and mental health on nursing students.

 

 

 

INTRODUCTION:

Nursing profession is currently in a state of crisis. Nursing practice is with distress as well as satisfaction. Nursing students, during their clinical training encounter similar stressful situation of the kind that nurse do in practice¹.  These situations are multifaceted including strange environment, heavy work load, inadequate preparation for clinical work, lack of support from colleagues, teachers and ward personnel and conflict with family members of the patients and physician etc². Improper handling of above defined factors leads to stress in nursing students.

 

The word ‘stress’ derived from the Latin word “Stringi”, which means, “to be drawn tight”. Stress can be defined as any factors that threaten the health and have adverse effects on its functioning³. Stress is almost always seen as something negative that result in impairment of the students’ academic and psychosocial performance. Therefore, the stressors elements may be a situation or experience which generates feelings of tension, anxiety, fear or threat being of internal and external origin⁴.

 

Stress is the subjective feeling produced by events that are uncomfortable and threatening⁵. Chronic and persistent stress being change in the balance of hormones and neurochemicals in brain which makes person frustrated, angry, agitated, nervous and irritable.  

 

One of the main subjective feeling of stress may be anxiety or apprehension deflagrated by something the individual understood as a threat to his or her integrity. So far, scholars have a little agreement on the precise definition of anxiety. However, anxiety may be perceived as an emotion or subjective feeling characterized by tense and alert body phenomena focusing a sensation of imminent and inevitable danger⁶. Anxiety is an emotional experience opposing the possibility of living future situation which may be unpleasant to the individual⁷. At the anxiety study, anxiety state referring to a transitory emotional state characterized by subjective emotion of tension which may vary in intensity through time⁸.

 

If the stress not dealt effectively, feeling of loneliness, sleeplessness and worrying may result. Among the most common factors that have been proposed as related to the appearance of depression and anxiety are coping styles and stressful life events⁹. Lazarus and Folkman used the term coping to describe the “cognitive and behavioral efforts”, a person employ to manage stress, generally categorized as emotional- focused and problem- focused coping¹⁰.  Among several broad categories of coping styles that have been distinguished includes; 1) avoidance oriented coping, 2) emotional oriented and 3) task orient coping styles¹¹.

 

Various coping strategies used by students includes ventilation, diversion, relaxation, self-reliance, social peer group support, avoidance, praying, day dreaming listening to music, smoking, drinking, and joking etc¹². Thus, the current research study was carried out to investigate to identify stressors, coping styles and finding relationship to state anxiety in 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 and 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 300 students residing in the hostel. The institution organizes various co-curricular activities regularly. There is provision of sports 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 2010-2014. Simple random sampling technique was adopted for graduate nursing students’ enrollment and total enumeration techniques was used for master nursing students’ selection. A total 199 nursing students were included in the study. The tools used for data collection were Socio-demographic profile sheet, State Trait Anxiety Inventory (STAI), Perceived Stress Scale-14 (PSS-14^)13,14 and Adolescent Coping Orientation for Problem Experiences (ACOPE)¹⁵. Socio-demographic profile sheet contained items such as age, sex, course, class, parent’s education and occupation, family income, distance from college, residential status etc.

State Trait Anxiety Inventory (STAI)¹⁶ is commonly used measure of trait and state anxiety (Spielberger. Gorsuch, Lushene, Vagg and Jacob 1985). STAI consist Form-X and Form –Y with 20 questions in each form. In the present study Form-X was used to assess state anxiety in nursing students. Internal consistency coefficient for the scale ranged from 0.86- to 0.95. Obtaining higher score indicate greater anxiety.

 

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.

 

Table 1- Socio-Demographic Variables of Nursing Students (n=199)

Table 2- Frequency of Perceived Stressors by Nursing Students on PSS-14  (n=199)

Items	Never n (%)	Almost never n (%)	Some times n (%)	Fairly often N (%)	Very often N (%)
Being upset that happened unexpectedly	20(10.1)	21(10.6)	110(55.3)	32(16.1)	16(8.0)
Feeling of unable to control important things in life	27(13.6)	50(25.1)	80(40.2)	31(15.6)	11(5.5)
Feeling nervous and stressed	13(6.5)	20(10.1)	90(45.2)	40(20.1)	36(18.1)
Able to deal day to day hassles successfully	14(7.0)	17(8.5)	77(38.7)	56(28.1)	35(17.6)
Able to cope with important life changes	03(1.5)	09(4.5)	73(36.7)	79(39.7)	35(17.6)
Confident to handle personal problems	04(2.0)	13(6.5)	68(34.2)	59(29.6)	55(27.6)
Feeling that things were going in my way	18(9.0)	41(20.6)	96(48.2)	36(18.1)	08(4.0)
Feeling unable to cope with all things that you had to do	25(12.6)	33(16.6)	98(49.2)	33(16.6)	10(5.0)
Able to control irritation in life	08(4.0)	24(12.1)	91(45.7)	53(26.6)	23(11.6)
Feeling on top of things	35(17.6)	41(20.6)	93(46.7)	22(11.1)	08(4.0)
Being  angered because on things outside of control	24(12.1)	15(7.5)	90(45.2)	45(22.6)	25(12.6)
Thinking about the things that you have to accomplish	08(4.0)	23(11.6)	72(36.2)	59(29.6)	37(18.6)
Being able to control the way I spent my time	17(8.5)	33(16.6)	94(47.2)	34(17.1)	21(10.6)
Feeling that difficulties were piling up so high that you could not overcome them	28(14.1)	46(23.1)	76(38.2)	28(14.1)	21(10.6)

 

ACOPE developed by Patterson and Mc-Cubbin (1987)15 to assess the coping strategies used by nursing students to overcome stress. It is a 5-point Likert scale varying 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 STAI, PSS-14 and ACOPE were administered to the students 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:

As per socio-demographic details, it is evidenced that all (100%) students were females, Sikh by religion (80.4%), living in college campus (64.3%) and shows positive attitude (63.8%) towards nursing profession. As per nursing education course and class, 40.7% students studying B. Sc Nursing II year followed by 23.1% in Post certificate B.Sc. Nursing I year. Around 57.8% students were in B.Sc. nursing course and 34.2% belong to Post Certificate B. Sc. course.  The mean age of students was 22± 1.96 years.

 

As per family background, majority 89.5% students have family income more than 5001 rupees per month. In term of parents’ education qualification and occupation, around 47.2% students father were educated up to secondary class followed by 42.2% were graduates. 59.8% student’s mother was educated up to secondary education. In term of parent’s occupation, around 59.8% student’s father and 89.9% student’s mother were in private job. 

 

Data also revealed that mean distance from home to college was 67.2 + 60.6 km. It is also revealed that 42.2 % students surfing net less than 2 times per day and reported good health status (73.9%). (Table 1)

 

Student’s mean PSS-14 score was 30.1 ± 6.3. Majority of the students reported that sometimes during last one month, ‘they remain upset’ (55.3%), ‘unable to cope’ (49.2%), ‘feels that things were going away from him’ (48.2%), ‘able to control time they had spent’ (47.2%), ‘feeling on top of the things’ (46.7%),  and ‘unable to control things’ (40.2%). (Table 2)

 

 

The study results further revealed that the students reported that sometimes during last one month, ‘able to control irritation in life’ (45.7%), ‘being angered on the things’ (45.2%) and ‘able to deals daily hassles’ (38.7%). (Table 2)

 

The most common coping strategies used by the students was seeking diversion (14.8±5.09), solving family problems (14.7±4.27), self reliance(13.1±3.47) and ventilating feelings (10.4±3.83) and least common was seeking professional support (1.81±1.67), investing in close friends (3.56+1.86) and avoiding  (5.5±2.72). (Table 3)

 

Table 3- Coping Strategies used by Nursing students (n=199)

 

Table showed that most common coping strategies used by the student to ventilate were, crying (29.1%) and complaining to family members (17.1%) to deal stressful life situation. Further, it has shown that most of times,  the students listen to music and radio (47.7%) try to think good things (27.6%), try to help other people to solve their problems (27.1%), go shopping and buy things they like (26.1%) to relax mind. (Table 4)

Table 4 - Distribution of Nursing students by use of Coping Strategies (n=199)

 

Table 5 - Correlation between State Anxiety, Stress and Coping Strategies among Nursing students (n=199)

		PSS	RSES	Ventilating Feelings	Seeking Diversion	Relaxing	Self Reliance	Development Social Support
PSS	Pearson Correlation	1		0.127	0.171*	0.178*	0.199**	0.207**
	Sig. (2-tailed)			0.074	0.016	0.012	0.005	0.003
	N	199		199	199	199	199	199
STAI	Pearson Correlation	-0.131*	1	0.056	-0.346**	-0.176*	-0.152*	-0.318**
	Sig. (2-tailed)	0.066		0.431	0	0.013	0.032	0
	N	199	199	199	199	199	199	199

 

 

 

		Solving Family Problem	Avoiding	Seeking Spiritual Support	Investing in Close Trends	Seeking Professional Support	Engaging Demanding Activities	Being Humorous
PSS	Pearson Correlation	0.139*	-0.053	0.131	0.212**	0.056	0.158*	0.179*
	Sig. (2-tailed)	0.05	0.459	0.065	0.003	0.431	0.026	0.011
	N	199	199	199	199	199	199	199
STAI	Pearson Correlation	-0.076	0.019	-0.085	-0.119	-0.125	-0.227**	-0.438**
	Sig. (2-tailed)	0.288	0.789	0.235	0.094	0.077	0.001	0
	N	199	199	199	199	199	199	199

** Correlation significant at 0.01 level (2- tailed)

*. Correlation is significant at the 0.05 level (2-tailed).

 

Around 27.1% students try to help other people and 22.1 % apologizes to people to accept their mistake under stressful situation. Further, ACOPE result showed that 36.7% students talk their father to solve problem while 35.7% take help of brother and sister to solve problem. It is also evidenced that 53.3% take spiritual support to and 33.7% meet close friends to discuss their stressful problem. (Table 4)

 

Result also showed that the least common coping strategies used by the students were; use of prescribed drugs (86.9%), illicit drugs (81.9%), ride around a car (59.3%), smoking (54.3%), drinking wine and beer (64.8%), never get professional helps (53.3%), blame others for happening (25.1%), avoid to see good things (64.8%), never talk to counselor (44.7%) and least bother to pray (44.7%) to cope the stressful situation. (Table 4)

 

In the area of self reliance, the students reported that they try to see good things (40.7%), and try to make decision own (35.2%) often and organize their disturbed life (42.2%) some times to deal stressful life situation. (Table 4)

 

In the area of social support development, students reported that they talk to their friends (40.2%) and say nice things to (35.7%) other sometimes to conquer on stress in their life. Table 5 depicts relationship between anxiety, stress and coping strategies used by nursing students. It shows that there is negative relationship between stress and state anxiety (r= -0.131, p<0.01). It indicates that higher state anxiety leads to low stress and vice versa.  Study found a negative correlation between stress and avoiding coping strategies (r=-0.053, p<0.05). However, anxiety found a positive relationship with ventilating feelings (r= 0.056, p<0.05) and avoiding coping strategies (r= 0.019, p<0.05) for nursing students. (Table 5)

 

 

DISCUSSION:

Finding revealed that majority of students perceived that ‘they remain upset’ (55.3%), ‘unable to cope with all things that they happened’ (49.2%), and ‘feeling that things are going away from them’ (48.2%). A study18 conducted at a private college of nursing, Punjab also reported that around 43.3% students unable to cope with all things, 56.2% being upset for unexpected happening and unable to control important things (19.4%).

 

Result shows a positive correlation between state anxiety to ventilating feelings (r= 0.056, p<0.05) and avoidance (r=0.019, p<0.05) coping styles in nursing students. It indicates that nursing students with higher anxiety level use more coping strategies related to self ventilation and avoiding the stressful and anxious situation.

 

The present study findings found in agreement with the study conducted by Shikai N et al¹¹ which reported a positive correlation between anxiety and emotion oriented coping i.e. ventilating feeling (r= 0.560, p<0.01). Present study findings also found in agreement with a study conducted by Shrestha T¹⁷ which reported a positive relation between anxiety and emotion focused coping styles. 

 

Present study shows a negative relationship between perceived stress and avoiding coping styles (r=-.053, p<0.05). The findings supported by the study¹¹ which reported a negative correlation between stressful life events and avoiding coping styles (r= -0.078). Perceived stress also shows a positive relationship with emotion oriented coping strategies (ventilation; r= 0.462, p<0.001) in nursing students. Study findings supported by the study conducted by Lim YM¹⁸ which reported a positive relationship between stress and coping strategies among nursing students. Current study result revealed that least common use coping strategies were seeking professional support (1.81±1.67) among nursing students. Similar findings presented in a study¹⁹ conducted on nursing students to assess stress and coping strategies.

 

The study finding generalize that most common used coping strategies were; talking to priest (53.3%), listening music or radio (47.7%), living close to someone who care (33.7%), trying to help other people (27.1%), and day dreaming (26.1%). Close similar findings displayed in  studies^20,21 which reported that seeking social support (62.25%), plan problem solving (23.73%), positive thinking, listening music radio, indulging in creative activities, and talk to parents were most frequently used coping strategies in nursing students. 

 

In term of negative coping strategies, study portrayed that use of beer and wine (7.5%), use of illicit (1.5%) and prescribed drugs (4%) and smoking (7%) were least commonly used coping strategies. Study findings found parallel to the previous studies ^{19, 20, 22} conducted on nursing students. 

 

CONCLUSION:

Stress has become chronic and pervasive phenomena in the students today. Every person experience stress at some point of time in life therefore a nursing students is no exception. Coping with stress is a dynamic and ongoing process. Use of healthy coping mechanism aimed at survival, growth and maintenance of individual.  A student tries to restore mental and physiological equilibrium by attempted adjustment and use of various coping strategies.

 

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13.     Copeland EP, Hess RS. Differences in young adolescents' coping strategies based on gender and ethnicity. Journal of Early Adolescence 1995; 15:203-19.

14.     Dr. Cohen’s Scale [online] Available from  url:http://www.psy.cmu.edu/~scohen/perceived%20Stress%20Scale%20(PSS)%2014-item.doc.

15.     Patterson JM, McCubbin HI. Adolescent coping style and behaviors - Conceptualization and Measurement. Journal of Adolescence 1985; 10(2):163-186.

16.     Spielberger CD. State trait Anxiety Inventory (2nd ed) Palo Alto, CA : Counseling Psychologist Press

17.     Shreshta T. Self esteem, stress, and anxiety among professionally certificate level nursing students in nursing campus Maharajgun Jand Lalitpur Nursing Campus. J Nepal Health Res Counc 2013;25(11):283-88

18.     Lim YM. Perceived stress, coping strategies and general health – A study on accounting students in Malaysia, Journal of Arts, Science and Commerce2013; 4(1):88-95

19.     Kumar, R., and Nancy. (2011). Stress and coping among nursing students. Nursing and Midwifery Research Journal, 17(4), 141-51

20.     Dhar, R., Walia,  I.,  and Das, K. (2009). 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,  5(1), 31-37

21.     Hsiao YC, chien L, Wu L, Chaing c, Huang S. Spiritual health, clinical practice stress, depressive tendency and health promoting behaviors among nursing student. Journal of advanced nursing 2010;66(7):1612-22

22.     Ellawela YG, Fonsekap. Psychological distress, associated factors and coping strategies among female student nurses in the nurses’ training school Galle. Journal of the college of community Physician of Sri Lanka 2011;16(1):5-20

 

 

 

Received on 10.10.2014           Modified on 27.10.2014

Accepted on 11.11.2014           © A&V Publication all right reserved