Research Briefs

ABSTRACTThis pilot study’s purpose was to investigate the relation-

ship between stress and nurse self-concept. Specifically, it examined whether enrollment in a wellness course affected stress levels and self-concept acquisition among sopho-more baccalaureate nursing students (N = 52). The findings showed that early in the curriculum these students had a fairly well developed sense of professional self-concept but made gains in facets of leadership and communication over the course of the semester. Students demonstrated high levels of stress that remained unchanged over the semester, regardless of self-concept acquisition. This study concluded that enrollment in a wellness course was insufficient to pre-pare nursing students to manage stress as they transition to professional roles, and it was possible that undergraduate education perpetuated the internalization of stress as part of a nurse’s professional identity. Future studies are needed to determine effective ways to teach stress management and best design nursing curricula to reduce stressors.

The purpose of undergraduate nursing education is to help students acquire the unique knowledge, skills, and atti-tudes of the profession (Cronenwett et al., 2007). Dur-

ing the process, students form perceptions of their adequacy in their professional role. These perceptions are known as a pro-fessional or nurse self-concept. Developing a healthy profes-sional self-concept is important because it empowers nurses to positively affect patient care and may moderate the effects of a stressful work environment, leading to improved retention (Ar-thur & Randle, 2007; Cowin, Johnson, Craven, & Marsh, 2008). However, for many nurses, perceptions of extreme stress actu-ally begins well before entering the workforce in prelicensure education (Pryjmachuk & Richards, 2007; Rella, Winwood, & Lushington, 2008). Perceptions and manifestations of stress may lead to a perpetuating cycle where physical, emotional, cogni-tive, and behavioral symptoms increase the individual’s stress (Benson & Stuart, 1992). As stress inhibits the ability to think clearly, stress and the stress cycle have the potential to negatively affect a student’s professional growth.

Some nurse educators advocate that courses in stress man-agement are needed to promote student success (Billingsley, Collins, & Miller, 2007; Kand, Choi, & Ryu, 2009), but little is known about how such courses affect the acquisition of a strong nurse self-concept. This pilot study investigated how stress and professional self-concept changed over the course of a semes-ter among sophomore baccalaureate nursing students enrolled in a required wellness course and explored whether stress was adversely related to the students’ acquisition of a strong self-concept.

Literature ReviewThe term self-concept is used to describe one’s perceptions of

self-adequacy and is thought to be multidimensional (Shavelson, Hubner, & Stanton, 1976). For nurses, a dimension of their total self-concept is their professional or nurse self-concept (Arthur & Randle, 2007). What exactly constitutes a nurse self-concept is subject to debate. Arising from recommendations from the Institute of Medicine, nursing education leaders proposed that nurses’ perceptions of professional adequacy should be based on their ability to provide patient-centered and safe care, utilize evidence-based practice and informatics, work collaboratively as team members, and use quality improvement strategies (Cronen-wett at al., 2007). However, to date there is little evidence that nurses’ self-concepts are actually based on those recommenda-

Changes in Stress and Nurse Self-Concept among Baccalaureate Nursing StudentsDesiree Hensel, PhD, RN, CNE; and Wendy Stoelting-Gettelfinger, PhD, JD, APN, NP-C

Received: January 18, 2010Accepted: August 31, 2010Posted: January 31, 2011Dr. Hensel is Assistant Professor, and Dr. Stoelting-Gettelfinger is Assis-

tant Clinical Professor, Indiana University School of Nursing, Bloomington, Indiana.

The authors thank Dr. Leanne Cowin for sharing the Nurse Self-Concept Questionnaire.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Desiree Hensel, PhD, RN, CNE, Assistant Pro-fessor, Indiana University School of Nursing, Sycamore Hall 444, 1033 East 3rd Street, Bloomington, IN 47405-7005; e-mail: dehensel@indiana.edu.

doi:10.3928/01484834-20110131-09

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tions. Evolving from the theory of Shavelson et al., research exists supporting Cowin’s (2001) model of nurse self-concept. Cowin used a pilot group and two large samples that consisted of nursing students near graduation (N = 506) and experienced nurses (N = 528) to create a model of self-concept with six sub-scales. Cowin’s model includes facets of caring, communica-tion, knowledge, leadership, staff relations, and a nurse general self-concept or self-esteem. This model provides an effective framework to examine the relationship between stress and pro-fessional self-concept acquisition.

A strong nurse self-concept is thought to mediate the ef-fects of a high stress workplace and empower nurses in their work (Arthur et al., 1999; Siebens et al., 2006). Cowin and Hengstberger-Sims (2006) found that graduate nurses with higher self-concepts were more likely to be retained for at least 1 year in their first job. Job satisfaction has long been thought to be a major factor in retention, but one study found that nurse self-concept was a stronger predictor of retention than job satis-faction (Cowin et al., 2008).

The process by which an undergraduate student develops a nurse self-concept has been described as a social phenomenon where students build on a foundation of knowledge by “taking it all in” (Ware, 2008, p.10). However, stress can cause trouble thinking clearly, impair memory, and suppress creativity (Ben-son & Stuart, 1992) and thus impair real learning. In a longi-tudinal study, Edwards, Burnard, Bennett, and Hebden (2009) found that stress and self-esteem changed over the course of nursing education and that increased stress was related to de-creased self-esteem in nursing students at three of five measure-ment points. Sources of stress arising from prelicensure educa-tion included examinations, deadlines, fear of making an error in patient care, demands of studying after work, and watching suffering. In one study, Randle (2003) also found that nursing education threatened student’s self-esteem, with 95% of the stu-dents having classified themselves as anxious, unhappy, or de-pressed by graduation. In another study, Pryjmachuk and Rich-ards (2007) found that approximately one third of the nursing students could be classified as stressed (N = 937).

Although stress may be endemic in nursing education, fail-ure to teach students adequate stress management may disad-vantage students as they enter the workforce. Seriously stressed new graduates may have had little time to recover from the nursing school experience and this unresolved stress may put them at risk for early burnout (Rella et al., 2008). There is little evidence to suggest that protective self-care practices improve after graduation because stress management and physical ac-tivity have been reported to be nurses’ least practiced aspects of a healthy lifestyle (Hensel, 2008; McElligott, Siemers, Thomas, & Kohn, 2009). Courses in stress management and self-care have been suggested as ways to reduce stress among students (Billingsley et al., 2007; Stark, Manning-Walsh, & Vliem, 2005). In fact, nursing students have identified the need for such courses (Gardner, Deloney, & Grando, 2007), but the most effective way to provide such education is still in question. Short-term reductions in stress and anxiety were found after an 8-week mindfulness meditation course among one group of nursing students, but how long the benefits lasted is unknown (Kand et al., 2009).

One 2-week online stress management course was found to improve physical activity and stress management behaviors for 6 months among a group of college students, but the study in-cluded students from a variety of majors (Chiauzzi, Brevard, Thurn, Decembrele, & Lord, 2008). Benefits from a nursing elective course that included self-care were found to persist up to 7 years (Downey, 2007), but more studies are needed to identify the long term effects of such courses and how stress affects nurse self-concept development. Using Cowin’s (2001) model as a frame work, the research questions for this pilot study were:

l How does nurse self-concept change during the fourth semester of nursing school?

l How does a wellness course that includes stress manage-ment affect students’ stress?

l How are stress and nurse self-concept formation related?

MethodAfter receiving institutional review board approval, all 54

BSN students enrolled in a required wellness course were in-vited to participate in this voluntary pilot study; 52 students completed both the pretest and posttest and were included in the study. Although described as fourth semester students, these students spent their first year taking prerequisites and were actually enrolled in their second semester of nursing courses. The students were concurrently enrolled in nursing fundamen-tals and a communication course. Early content in the wellness course included health behavior theory, nutrition, and pharma-cology for across the lifespan. In the second half of the class, content on exercise, stress management, and complementary and alternative medicine was presented. At the beginning of the course, students were required to select one personal health area that they would like to improve and to devise a plan to meet their goals. The students were then asked to submit progress journals at the middle and end of the semester. The journals provided the instructor with an opportunity to provide student feedback, but they were not used data analysis.

At the beginning and end of the semester, students were asked to assess how they thought and felt about themselves as a nurse and to assess the manifestations of stress that they were experiencing. Measures were repeated at the end of the course. The anonymous data were kept in sealed packet iden-tifiable only by a symbol the students drew. Students claimed the packets at the end of the semester to complete the posttest. Data were collected using the Nurse Self-Concept Question-naire (NSCQ) and the Stress Warning Signals (SWS) check-list. The NSCQ is a 36-item, 8-point ordinal scale that mea-sures the six facets of nurse self-concept identified by Cowin (2001). The NSCQ and has evidence of theoretical and con-struct validity. In this study, the NSCQ showed good inter-nal consistency. Cronbach’s alpha scores for all scales were adequate, with total scales scores of 0.87 at baseline and 0.91 at exit. Designed as a self-assessment tool, the SWS checklist identifies 12 physical, 8 behavioral, 9 emotional, 8 cognitive, 10 spiritual, and 13 relational signs of stress (Benson-Henry Institute for Mind Body Medicine, 2010; Casey & Benson, 2004). When used as a summative scale, checking five or fewer symptoms indicates the user is most likely coping well.

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Checking more symptoms indicates that stress may be nega-tively affecting quality of life.

FindingsData were analyzed using PAWS Statistics for Windows ver-

sion 17 software. Fifty-two students completed both the pretest and posttest. All participants were female and primarily tradi-tional students, with a mean age of 21.3 years. The groups’ eth-nicity was 96% Caucasian. The students could be considered very high achievers, with a mean grade point average of 3.75 on entry into the program.

Baseline mean scores for the NSCQ were 226.7 (standard deviation [SD] = 26.91, range = 135-284). Paired t tests showed nurse self-concept increased significantly over the course of the semester (mean = 231.91, SD = 27.46, range = 166 to 283, p = 0.019). At baseline, the highest self-concept scores occurred for self-esteem (mean = 42.1, SD = 4.68, range = 33 to 48). The lowest scores were seen for leadership (mean = 31.7, SD = 7.35, range = 11 to 48). Over the course of the semester, the facets of self-concept that increased significantly were communication (p = 0.001) and leadership (p = 0.003). Dimensions of knowl-edge, self-esteem, and staff relations decreased but not signifi-cantly. In addition, caring scores increased, but the increases were not statistically significant.

At baseline, students reported mean SWS checklist scores of 16.4 (SD = 8.17, range = 3 to 36). This score did not change significantly over the semester (mean = 16.7, SD = 8.88, range = 4 to 42). In this study, only 4 students at baseline and 6 students at the end of the semester reported experiencing 5 or fewer symptoms on the SWS checklist, indicating that stress was most likely adversely affecting the vast majority of students (Benson-Henry Institute for Mind Body Medicine, 2010). However, this study did not find any significant relationships between stress and nurse self-concept or self-concept acquisition.

DiscussionWare (2008) posited that students enter nursing school with

the foundations of a nurse self-concept that has arisen from life experiences, personal philosophies, role models, and religious beliefs. This study lends support to this theory, as the partici-pants, in only their second semester of their nursing courses, had mean NSCQ scores of 222.7 of a possible 288. Relatively speaking, Hensel (2008) found a mean NSCQ score of 245.3 (SD = 26.39) in a sample of experienced nurses in which 84% of the participants reported having 10 years or more of nursing experience.

How professional self-concept increased over the course of the semester among the students was surprising. The students were concurrently taking a nursing fundamentals course and a communication course. It was anticipated that they would have significant gains in knowledge and communication, but the knowledge and self-esteem scores trended downward. One explanation might be that students were becoming more reflec-tive and gaining an appreciation of how much they still had to learn. Still, the end-of-semester self-esteem scores (mean = 41.7, SD = 4.9) were higher than what Cowin (2001) found in students near graduation (mean = 38.59, SD = 6.9). Following this group longitudinally to graduation would have helped cre-

ate a clearer picture if self-esteem truly began to suffer early in the nursing curriculum.

In this study, stress was not related to nurse self-concept de-velopment, but the instrumentation may not have been sensitive enough to measure differences in stress in this group of students. Perhaps the most troubling finding of this study was the consis-tently high stress levels experienced by these nursing students. At the beginning of the semester, 92% of the students reported enough warning signals to indicate that stress was most likely affecting their lives. At the end of the semester, the percentage of students experiencing high stress decreased only slightly to 88%. Still, posttest data were collected 1 week before the end of the semester, which makes it difficult to interpret whether the stress levels represented a steady trend or were reflective of a temporary increase in stress associated with impending finals.

This study did not attempt to identify the sources of the stu-dents’ stress. Although clinical education and demanding course work have been identified as sources of stress in nursing school, other factors that predict stress include self-reports of feeling pressure, having children, having personal problems, and using emotional coping styles (Pryjmachuk & Richards, 2007). Rella et al. (2008) found that the need to work predicted stress and fa-tigue. Given the cost of nursing education and current economic climate, there is no reason to believe that the number of students having to work will decrease, making it even more important to understand how to reduce student stress.

When evaluating the effectiveness of the wellness course format on reducing student stress, one problem may have been that too much time was spent on lecturing on stress manage-ment theory and too little time was allotted for practicing tech-niques. In addition, the content may have been presented too late in the course. The students may have benefited from having stress management principles introduced earlier in the course instead of being introduced mid-semester. At the same time, a single course may not have been sufficient to help students learn to manage stress if the overall nursing curriculum was designed in a way that students perceived as being overly stressful or was in conflict with their external responsibilities.

The finding of such high stress levels in students leaves in question whether these students felt being stressed was just a natural part of a nurse’s identity. Pryjmachuk and Richards (2007) thought that work–life balances must be central to nurs-ing curricula, but the role faculty play in perpetuating or miti-gating student stress is difficult to assess. In the face of a nurs-ing shortage, partially due to a faculty shortage, faculty with high workloads may manifest signs of stress and not role model successful management strategies to students. Further, Pryjma-chuk and Richards (2007) thought that faculty may also not be aware of the true stress levels of their students. Although accus-tomed to intervene when academic failure is seen, faculty may be unaware that self-reports of pressure and personal concerns, not academic problems, predict stress.

Students have reported feeling inadequately prepared to cope with the strain of professional nursing (Rella et al., 2008). The implication of this study for nursing education is that because nursing can be a stressful profession and stress contributes to burnout and attrition, nurse educators have a responsibility to prepare graduates to successfully manage stress just as they pre-

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pare their graduates to provide high quality, safe patient care. Educators should not assume students are incorporating stress management practices into their lives simply because they re-ceive information on the topic. More studies are needed to de-termine the best way to teach students to manage their stress and best design nursing curricula to reduce unnecessary stressors.

ReferencesArthur, D., Pang, S., Wong, T., Alexander, M.F., Drury, J., Eastwood, H., et

al. (1999). Caring attributes, professional self concept and technological influences in a sample of registered nurses in eleven countries. Interna-tional Journal of Nursing Studies, 36, 387-396.

Arthur, D., & Randle, J. (2007). The professional self-concept of nurses: A review of the literature from 1992-2006. Australian Journal of Ad-vanced Nursing, 24(3), 60-64.

Benson, H., & Stuart, E.M. (1992). The wellness book the comprehensive guide to maintaining health and treating stress related illness. New York, NY: Simon & Schuster.

Benson-Henry Institute for Mind Body Medicine. (2010). Stress warn-ings signals. Retrieved from http://www.massgeneral.org/bhi/basics/managing/warning_signs.aspx

Billingsley, S.K., Collins, A.M., & Miller, M. (2007). Healthy student, healthy nurse: A stress management workshop. Nurse Educator, 32, 49-51. doi:10.1097/01.NNE.0000264333.42577.c6

Casey, A., & Benson, H. (2004). Mind your heart: A mind/body approach to stress management, exercise, and nutrition for heart health. New York, NY: Free Press.

Chiauzzi, E., Brevard, J., Thurn, C., Decembrele, S., & Lord, S. (2008). MyStudentBody-Stress: An online stress management intervention for college students. Journal of Health Communications, 13, 555-572. doi: 10.1080/10810730802281668

Cowin, L. (2001). Measuring nurses’ self-concept. Western Journal of Nurs-ing Research, 23, 313-325. doi:10.1177/01939450122045177

Cowin, L.S., & Hengstberger-Sims, C. (2006). New graduate nurse self-concept and retention: A longitudinal survey. International Journal of Nursing Studies, 43, 59-70. doi:10.1016/j.ijnurstu.2005.03.004

Cowin, L.S., Johnson, M., Craven, R.G., & Marsh, H.W. (2008). Causal modeling of self-concept, job satisfaction, and retention of nurses. In-ternational Journal of Nursing Studies, 45, 1449-1459. doi:10.1016/j.ijnurstu.2007.10.009

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitch-

ell, P., et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122-131. doi:10.1016/j.outlook.2007.02.006

Downey, M. (2007). Effects of holistic nursing course. Journal of Holistic Nursing, 25, 119-125. doi:10.1177/0898010107301616

Edwards, D., Burnard, P., Bennett, K., & Hebden, U. (2009). A longitudinal study of stress and self-esteem in student nurses. Nurse Education To-day, 30, 78-84. doi:10.1016/j.nedt.2009.06.008

Gardner, E.A., Deloney, L.A., & Grando, V.T. (2007). Nursing student de-scriptions that suggest changes for the classroom and reveal improve-ments needed in study skills and self-care. Journal of Professional Nursing, 23, 98-104. doi:10.1016/j.profnurs.2006.07.006

Hensel, D. (2008). The relationships among health status, healthy lifestyles, and nursing self-concept among Midwestern nurses (Doctoral disserta-tion). Available from ProQuest Dissertation and Thesis database. (AAT 3342474)

Kand, Y.S., Choi, S.Y., & Ryu, E. (2009). The effectiveness of a stress cop-ing program based on mindfulness meditation on stress, anxiety, and depression experienced by nursing students in Korea. Nursing Educa-tion Today, 29, 538-543. doi:10.1016/j.nedt.2008.12.003

McElligott, D., Siemers, S., Thomas, L., & Kohn, N. (2009). Health promo-tion in nurses: Is there a healthy nurse in the house? Applied Nursing Research, 22, 211-215. doi:10.1016/j.apnr.2007.07.005

Pryjmachuk, S., & Richards, D.A. (2007). Predicting stress in preregistra-tion nursing students. British Journal of Heath Psychology, 12(1), 125-144. doi:10.1348/135910706X98524

Randle, J. (2003). Changes in self-esteem during a 3-year pre-registration diploma in higher education (nursing) programme. Journal of Clinical Nursing, 12, 142-143.

Rella, S., Winwood, P.C., & Lushington, K. (2008). When does nursing burnout begin? An investigation of the fatigue experience of Australian nursing students. Journal of Nursing Management, 17, 886-897.

Shavelson, R.J., Hubner, J.J., & Stanton, G.C. (1976). Self-concept: Valida-tion of constructs and interpretations. Review of Educational Research, 46, 407-441.

Siebens, K., Casterle, B.D., Abraham, I., Dierckx, K., Braes, T., Darras, E., et al. (2006). The professional self-image of nurses in Belgian hospitals: A cross-sectional questionnaire survey. International Journal of Nurs-ing Studies, 43, 71-82. doi:10.1016/j.ijnurstu.2005.04.004

Stark, M.A., Manning-Walsh, J., & Vliem, S. (2005). Caring for self while learning to care for others: A challenge for nursing students. Journal of Nursing Education, 44, 266-270.

Ware, S.M. (2008). Developing a self-concept of nurse in baccalaureate nursing students. International Journal of Nursing Education Scholar-ship, 5(1), Article 5. doi:10.2202/1548-923X.1500

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