MEDICAL COLLEGES OF NORTHERN PHILIPPINESAlimannao Hills, Peñablanca, Cagayan

STRESSORS AND STRESS MANAGEMENT IN THE CLINICAL SETTING IDENTIFIED BY

LEVEL III BACHELOR OF SCIENCE IN NURSING STUDENTS

A Research Presented To The

Faculty and Staff Of The

Medical Colleges of Northern Philippines

In Partial Fulfilment of the Requirements in Nursing Research

By:

Sheena Mae B. Acoba

Roberto V. Alonzo

Riva Tiara Clarisse T. Aranas

Philip D. Simangan

William P. Apostol

Maryrose R. Vinarao

Margie G. Cunanan

Jolly Dave M. Ancheta

Denice Fayne A. Tahiyam

Daphne Kae B. Madriaga

Catherine U. Mendoza

Caroline D. Uy

Carmen Agnes G. Miguel

CHAPTER I:

INTRODUCTION

All human beings are part of a greater whole. When one person is

affected, all of humanity is affected. These effects can be either

positive or negative. Nursing is a profession that understands holism

and looks at individuals holistically. As caregivers, it is essential

for nurses to care for themselves in order to give fully to those they

serve. Unmanaged stress can adversely affect the caring process.

Students of nursing appear to experience an increased level of stress.

Management of stress is a tool that is invaluable to the profession of

nursing. According to Pryjmachuk (as cited in American Holistic Nurses

Association [AHNA], “one third of nursing students experience stress

severe enough to induce mental health problems such as anxiety and

depression.” Although this has been the trend, it does not need to

continue.

In a more specific perspective of stress and stressors, Hamaideh

noted that university students are prone to stressors due tithe

transitional nature of university life. Based on a national study of

more than 300,000 freshmen at more than 500 colleges and universities

in the America by Santrock, today’s college students experience more

stress and are more depressed than in the past because of the growing

expectations from them such as the pressure to succeed, finding

employment after graduation and achieving a sense of financial

stability. Universities offer numerous programs to study and one of

the most stressful programs offered is the nursing course as stated by

Comeau. In the nursing curriculum according to Snell, students invest

longer hours and have greater emotional demands than most other

students. Other than the usual stress, such as paper works, tests,

exams, final grades, class environment, professors and competition,

nursing students experience clinical-related stress such as constantly

having to deal with patient’s pain, anxiety and death, as well as

giving emotional support to patient’s families and even the disruption

of the circadian rhythms in effect of shift work (Gross, 2007). High

levels of stress are believed to affect student’s health as well as

their academic performance that is why issues on stress should be

managed. Generally, people handle stress through coping as constantly

changing cognitive and behavioural efforts to manage external and/or

internal demands that are appraised as taxing or exceeding the

resources of the person. Comeau suggested that to achieve an effective

nursing program, stress management workshops should be provided during

the academic year, adding that implementing techniques to cope with

stress in a nursing program has an effect on retention and

performance. Key benefits of learning stress coping techniques as

nursing students include the promotion of these tools among clients

during hospital exposure as well as in the future practice of the

profession thus contributing to the care of their clients.

Because nursing students experience much stress, an ever growing

body of literature regarding the stresses of nursing supports the need

to include stress management education in curricula, Nursing curricula

is filled with the necessary elements of preparing competent nurses.

This presents the challenge of including yet another component into

nursing curriculum. Although this is a challenge, over-coming this

challenge is a must. The need for stress management techniques for

nursing students is necessary to prevent burnout and also to prevent

nurses from leaving the profession. The stress that nursing students

carry can only be of harm to the profession in the long-term.

Being part of the population of modern nursing students and

recognizing the prevalence of stressors in the nursing program, the

researchers, through this study, aim to identify the stressors that

significantly affect the third year nursing students of Medical

colleges of Northern Philippines in the clinical setting. Furthermore,

the study seeks to determine if these stressors have a positive or

negative effect in the academic pursuit of the respondents in the

nursing course. With the identification of the stressors that are

taxing to the nursing students, administrators may be given insight to

the plight of the students. Appropriate interventions or modifications

may then be done to address the issue thus promoting a better learning

environment, an essential factor for improvement in the students’

learning and performance.

STATEMENT OF THE PROBLEM

Nursing students experience different levels of stress. According

to Beddoe & Murphy, nursing students report very high stress levels

that are at times higher than those of students in other health

professions. Nursing students have attributed stress to academic and

interpersonal circumstances. This stress may affect performance and

ability to care for patients and self.

This study sought to identify the stressors and how they manage

such perceived by the Level III Bachelor of Science in Nursing (BSN)

Students in the clinical setting; specifically it pursued the

following objectives:

1. To determine the profile of the respondents in terms of age and

gender;

2. To determine and rank the identified stressors in the clinical

setting;

3. To identify the stress management utilized by the respondents to

stressors;

4. To determine whether the stressors are perceived by the respondents

as challenges or threats; and

4. To determine if there is a significant difference on the identified

stressors and stress management by the respondents when grouped

according to their profile.

HYPOTHESIS

There is no significant difference on the identified stressors

and stress management by the respondents when grouped according to

their profile.

SIGNIFICANCE OF THE STUDY

The findings of the investigation would be beneficial to the

following:

The researchers, conducting this kind of study will bring a learning

experience for them. It will hand them the pulse of the Level III

nursing students when it comes to managing their stress during their

clinical exposures, which was hardly known without survey.

The nursing students, who may acquire greater insights of the

stressors and challenges they may encounter during exposure on

clinical areas. This knowledge will give them better and wider

perspective about their profession and aid them in enhancing

their coping abilities and self-confidence.

The Clinical Instructors, the findings may provide them understanding

why nursing students behave like they do. This study will also provide

them hints of what remedial measures they need to institute to lessen

the learning difficulties of their students while undergoing clinical

exposure. Furthermore, it will eventually help them to build a better

relationship with the students, promote educational growth and improve

human and public relations with the identified clinical area of

operation.

With the result of the study, the The School Administrators and

Faculty will become more aware of the sources of stress of the

students in the clinical setting and thereby have a significant basis

to come up with appropriate interventions to properly manage the

stress experienced by the students thus promoting better performance.

It also gives them the chance to improve the quality of nursing

education for the benefit of the students and the institution as well.

The parents: this study will give insights to the parents about the

stressors encountered by their child and to prepare them or strengthen

them by providing emotional and moral support or in any ways that will

help them to cope.

The study will provide the future researchers baseline data as they

conduct further investigations on the stressors that nursing students

encounter.

SCOPE AND LIMITATION OF THE STUDY

This study is entitled “Stressors and Stress Management in the

Clinical Setting Identified by Level III Bachelor of Science in

Nursing Students”. The study focuses on stressors as perceived by

nursing students in the clinical setting. Stressors from other aspects

such as from the academic/classroom setting or from interpersonal

relationships (family or peer-related) were not considered in the

study. The respondents are the third year or Level III nursing

students officially enrolled in the second semester of school year

2012-2013 at the Medical Colleges of Northern Philippines.

DEFINITION OF TERMS

To convey clearly the meaning of the words used in the study, the

researchers defined the terms used operationally, as follows:

Clinical Setting- pertains to the hospital setting wherein

students apply and practice what they have learned in terms of

rendering nursing services and focusing on the holistic being of

the patient.

Clinical Instructors- refer to the person who impart knowledge

and skills to students

Related Learning Experience- refers to exposure of the nursing

students in different hospital wards or areas as well as in

different types of hospital services in order to broaden learning

while undergoing Related Learning Experience program by the

institution

Coping Mechanism- refers to the adaptation to stress events during and

Stress Management- refers to the act or art of managing the whole

system of care and treatment of the respondents during and after stress

Nursing Students- refer to the students enrolled in nursing

course

Medical Colleges of Northern Philippines – is a college that

provides instructional training in some health allied courses

like Bachelor of Science in Nursing in Peñablanca, Cagayan.

Stressors- pertains to factors affecting the performances of the

nursing students

CHAPTER II

REVIEW OF RELATED LITERATURE

Significant information on previous research related to the

stress in clinical setting is included in the review of the

literature. Within the context of the clinical learning environment,

what is known about stress, stressors and stress management in

relation to clinical setting from research studies is discussed and

analyzed. Related research on the variables of age and gender is

presented. As a result of this study on how nursing students manage

their stress in the clinical setting, unique insights into the

dynamics of this relationship may be gained.

FOREIGN LITERATURE AND STUDIES

Stress is a disruptive condition that occurs in response

to adverse influences from the internal or external

environments. (p. 78). It is a state produced by a change in

the environment that is perceived as challenging, threatening

or damaging to a person’s dynamic balance or equilibrium. The

change or stimulus that evokes this state is a stressor. The

nature of stressor is variable; an event or change that is

stressful for one person may not be stressful for another, and

an event that produces stress at one time and place may not do

so at another time or place. A person appraises and copes with

changing situations. The desired goal is adaptation or

adjustment to the change so that the person is again in

equilibrium and has the energy and ability to meet new demands.

This is the process of coping with the stress, a compensatory

process that has physiologic and psychological components.

(p.79)

Anxiety, frustration, anger and feelings of inadequacy,

helplessness or powerlessness are emotions often associated

with stress (p.91). After recognizing a stressor, a person

consciously or unconsciously reacts to manage a situation. The

physiologic response to a stressor, whether physical or

psychological, is a protective and adaptive mechanism to

maintain homeostatic balance of the body. When stress response

occurs, it activates a series of neurologic and hormonal

processes within the brain and the body systems. The duration

and intensity of the stress can cause both short-term and long-

term effects. A stressor can disrupt homeostasis to the point

where adaptation to the stressor fails and a disease process

results (p.81). (Smeltzer,S.C.,et.al.2010)

Kozier, B., et. al.(2008) defined Stress as a condition in

which the person experiences changes in the normal balanced

state. A Stressor is any event or stimulus that causes an

individual to experience stress. When a person faces stressors,

responses are referred to as coping strategies, coping

responses or coping mechanisms. There are many sources of

stressors: internal Stressors (originate within a person such

as infection or feelings of depression), External Stressors

(from outside the individual such as death in the family or

pressure from peers), Developmental Stressors (occur at a

predictable time throughout an individual’s life like

retirement or reduced income in older adults) and Situational

Stressors (unpredictable and may occur at any time during life

like marriage or illness). Stress can have physical, emotional,

intellectual, social and spiritual consequences. Usually the

effects are mixed, because stress affects the whole person.

Physically, stress can threaten a person’s physiologic

homeostasis. Emotionally, it can produce negative or

nonconstructive feelings about the self. Intellectually, stress

can influence a person’s perceptual and problem-solving

abilities. Socially, stress can alter a person’s relationships

with others. Spiritually, stress can challenge one’s belief and

values.

Rebecca J. Frey (2009) said that the stress in humans

result from interactions between persons and their environment

that are perceives ad straining or exceeding their adaptive

capacities and threatening their well-being. The element of

perception indicates that human Stress Response reflects

differences in personality, as well as differences in physical

strength or general health. Risk factors for stress-related

illnesses are a mix of personal, interpersonal and social

variables. These factors include lack or loss of control over

one’s physical environment and lack or loss of social support

networks. People who are dependent on others (e.g. children or

the elderly) or who are socially disadvantaged (because of

race, gender, and educational level or similar factors) are at

greater risk of developing stress-related illnesses. Other risk

factors include feeling of helplessness, hopelessness, extreme

fear, anger, and cynicism or distrust of others.

Walter Canon (2009) said that the human body reacts either

positively or negatively to as stress facto producing two kinds of

possible reactions. When the human body tries to flee from stressful

situation, negative reaction is exhibited. Positive reaction comes

about when the body makes the principle of homeostasis apply to

overcome stressful situation which is known as Adaptation or Coping.

He advocated that while the concepts of stress are absolute fact, its

presence and intensely receptions are relative in accordance with the

physical and psychological make-up of the individual. All people,

therefore, experience stress but the way stress is present and is

handles by each individual is unique for each other. A little

difficulty is hardly felt by another.

Stress can be defined as the brain’s response to any demand. Many

things can trigger this response, including change. Changes can be

positive or negative, as well as real or perceived. They may be

recurring, short-term, or long-term and may include things like

commuting to and from school or work every day, travelling for a

yearly vacation, or moving to another home. Changes can be mild and

relatively harmless, such as winning a race, watching a scary movie,

or riding a rollercoaster. Not all stress is bad. All animals have a

stress response, which can be life-saving in some situations. When you

face a dangerous situation, the pulse quickens, a person breathes

faster, muscles tense, the brain uses more oxygen and increases

activity—all functions aimed at survival. In the short term, it can

even boost the immune system. However, with chronic stress, those same

nerve chemicals that are life-saving in short bursts can suppress

functions that aren’t needed for immediate survival. The immunity is

lowered and the digestive, excretory, and reproductive systems stop

working normally. Once the threat has passed, other body systems act

to restore normal functioning. Problems occur if the stress response

goes on too long, such as when the source of stress is constant, or if

the response continues after the danger has subsided.

(http://www.nimh.nih.gov, 2012)

Stressors in Clinical Settings

A multitude of factors has been linked to students’ experiences

of stress and anxiety in a clinical setting. Themes that emerged from

a review of the literature include: a) interpersonal relationships

with nursing staff and the socialization process; b) relationships

with medical staff, c) relationships with clinical teachers; d)

feelings of incompetence and inadequacy; e) a lack of knowledge needed

to perform clinical procedures; and e) the fear of making mistakes and

possibly harming patients. Besides the stressors related directly to

the clinical setting, students are often dealing with life events

outside nursing which may lead to psychological stress (Watson,

Gardiner, Hogston, Gibson, Stimpson, Wrate and Deary, 2008). In

addition, as theories discussed above suggest, personal traits also

influence how the person perceives stressful situations and how they

cope with it.

Relationships with nursing staff and socialization process

Development of professional relations with staff members is part

of the socialization process. In the literature review, students

identified interpersonal encounters as a source of stress, especially

when students did not feel welcomed or supported by nursing staff.

This in turn often led to poor learning outcomes.

Nursing students evaluated their clinical experience as negative

when nursing staff was not interested in mentoring (Papp, Markkanen

and Von Bonsdorffif ; 2009). Other research studies found that nursing

students often had difficulty coping with unhelpful staff and being

ignored by them (Melincavage, 2008). Melincavage discovered that

students felt anxious when staff nurses were inconsiderate of

students’ inexperience, which in turn influenced students feeling of

incompetence. In LaFauci’s (2009) study, nursing students reported

that being treated as a nuisance by cranky and non-responsive staff

nurses hindered their learning experiences. In a qualitative study by

Shipton (2010), nursing students described some of the actions and

attitudes of nursing staff as stressful, and nurses were described as

“nasty”, “not wanting to be bothered” or “demeaning” (p. 246). The

nursing students in one study (Levett-Jones, Lathlea, Higgins &

McMillan; 2009) described nursing staff as unfriendly, hostile,

indifferent, unreceptive, and unapproachable. Their feelings of

inclusion/exclusion affected directly their sense of belongingness and

subsequently increased their anxiety, capacity and motivation to

learn.

In a qualitative research study by Gibbons, Dempster and Moutray

(2007), many nursing students had “a feeling of being criticized

rather than supported” by nurses on the unit (p. 286). They felt that

nurses focused more on students‟ weaknesses (or what they did not do)

rather than on their strengths. In some studies, students felt

stressed when nurses had unrealistic expectations of their clinical

abilities ( Melincavage, 2008).

As students often change their clinical settings, many find that

the unfamiliarity of clinical setting is stressful (Kim, 2008). It

stressed the importance of fitting in and learning the rules of the

wards. They identified the transient nature of their experiences as a

source of stress.

There are numerous studies which report positive outcomes when

students develop good relationships with nursing staff. Chesser-Smyth

(2007) reported factors identified by students which contributed to

their increased confidence level, increased self esteem, and decreased

anxiety which subsequently facilitated their learning. These were:

acquisition of knowledge; receptive, respectful and supportive staff;

and feeling as part of the team which all gave indication that

successful socialization process facilitated learning in clinical. In

the study by Levett-Jones et al. (2009) nursing students reported that

when they felt welcomed by nursing staff it motivated them to learn.

In the study by Papp et al. (2010) nursing students felt appreciated

when students felt to be a part of the nursing care team.

In addition to contending with exams, grades, long hours of

studying, work, family and other personal commitments you are also

faced with the challenges of clinical practice. 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 patients the wrong information or medication 

and concern about possibly harming a patient are just a few of the

stressors for the beginning student nurse. (Sharif & Masoumi, 2007).

Relationships with Medical Staff

The literature review revealed many research studies reporting

that nursing students find communication with medical staff stressful.

Many participants recalled that the interactions with physicians were

often unpleasant and anxiety provoking.

Several studies (Kim, 2008) identified talking with physicians as

anxiety-producing. In a study by Clarke and Ruffin (1992) when

students were asked to rate the interpersonal interactions on a stress

scale, the interaction with medical staff was rated highest.

Relationships and Interactions with Teachers

Clark (2008) conducted a qualitative research study on students’

perceptions of faculty incivility. Students in the study gave examples

of teachers treating students unfairly; teachers behaving in demeaning

and belittling ways towards students; and students being pressured by

teachers to conform to unreasonable demands. These teacher behaviours

made students feel powerless, helpless, traumatized, angry, and upset.

Similarly in LaFauci’s (2009) study, nursing students felt that being

exposed to clinical instructors who instilled fear and intimidation in

them hindered their learning.

In the research study by Shipton (2010), nursing students

appraised as stressful the following actions of the clinical faculty:

clinical evaluations, waiting on clinical instructor, being observed

by a clinical instructor. In the study by Tiwari, Lam, Yuen, Chan,

Fung and Chan (2007), nursing students described their clinical

assessment as very stressful. Clinical teachers in this study were

concerned about the student anxiety they witnessed during their

assessments. A majority of students and clinical teachers agreed that

the assessments influenced student learning and students spent all of

their energy on passing assessments at the expense of learning other

things.

Feelings of Inadequacy and Lack of Knowledge

The lack of clinical knowledge or skills to accomplish a task or

to perform clinical procedures has been linked to stress and anxiety

in many studies. Chesser-Smythe (2008) found students felt

particularly vulnerable at the beginning of each rotation when they

described themselves as “knowing little and feeling useless” (p. 323).

Kim (2008) found that 77% of nursing students in their last

semester of the program reported uncertainty about their clinical

skills and “doubts about personal adequacy as beginning staff nurses’

(p. 150). These feelings of inadequacy and uncertainty about their own

clinical skills were associated with high anxiety. Nursing students in

Magnussen’s and Amundson’s (2007) study reported feelings of

inadequacy and unpreparedness for clinical experience. Their teachers,

they reported, often “put them on the spot” and expected them to have

knowledge about “all aspects of care” (p. 265). Many students had “the

sense of knowing so little, when the professional demands would be so

great” even at the end of the program (p. 264.

Patients

The literature review shows that nursing students often get a

sense of satisfaction from interactions with patients. Although

interactions with patients are not often reported in studies as

anxiety provoking, nursing students identify a few situations which

are quite stressful. The identified situations are mainly dealing with

terminally ill and dying patients and handling emergencies and

situations in which there is a possibility change in the patient’s

condition. In Cook’ s study, situations perceived by nursing students

as challenging were dealing with very ill patients and having to deal

with emergencies such as cardiac arrests. Similar findings were

reported where nursing students identified fear of making a mistake or

harming a patient as a source of stress in clinical (Kim 2008).

Effects of Stress on Clinical Learning

Given the review of the literature on sources of stress and

anxiety experienced by nursing students during their clinical

rotations, and the theoretical review of the effects of high emotional

states on learning, one can expect that the learning process would be

negatively influenced under excessive amounts of stress and anxiety in

nursing students. A few studies below provide examples of the effects

of stress and anxiety on learning in clinical rotations.

Many studies identify difficult relations with staff as

influencing stress on student learning or performance. Anxiety related

to work overload, both in academics and clinical led to great stress,

fatigue and lack of sleep (Elgicil & Yildirim Sari, 2007). Hamill

(2010) studied stressors and coping methods used by 2nd year nursing

students. She described the use of mainly problem-focused coping

methods and 29 attributed it to students being more assertive and more

confident at the end of the 2nd year of the program. Besides problem-

focused coping, students also reported using emotion-focused coping

methods such as: binge eating; sitting in a bath and having a good

cry; being irritable; discussing stressors with peers; socializing;

resorting to alcohol. One of the common coping mechanisms which all of

the students in this study used was physical exercise.

Wang Letzkus (2007) reported qualitative findings which included

the following:

(a) Students interpreted flexibility on the part of their clinical

instructors to be a caring act;

(b) Junior nursing students perceived a broader range of the types of

caring behaviors than did seniors; and

(c) Nursing students found that working with uncaring RN staff members

to be stressful.

Clawson Roe (2009) reported data on research with baccalaureate

junior and senior nursing students and clinical faculty as it related

to stress and caring in the clinical setting. According to Clawson

Roe, baccalaureate nursing students perceived stressors as a challenge

in the presence of a caring instructor. Conversely, when clinical

instructors’ demonstrated caring behaviors less frequently, nursing

students perceived stressors as a threat or as harm (Clawson Roe,

2009). In the studies conducted by Wade (2007), Wang Letzkus (2005),

and Clawson Roe (2009), age and gender were not included as variables.

Sources of student stressors identified by Clawson Roe were as follow:

(a) coursework, (b) time, (c) being unsure, (d) fear, (e) educator,

and (f) clinical environment. Clawson Roe (2009) reported the

perception of stressors as a threat or challenge was highest in

beginning level students. According to Clawson Roe, stress perceived

as a threat related to a fear of failure. Conversely, stressors

perceived as a challenge related to managing the coursework and time

management (Clawson Roe,2009). According to Clawson Roe, beginning

nursing students perceived their clinical educator as less of a

stressor than their “fear of failing, harming a patient or meeting

their own expectations” (p. 227).

Moscaritolo (2009) reviewed qualitative studies on undergraduate

diploma, associate and baccalaureate programs and identified factors

associated with stress and anxiety in the clinical learning

environment. According to Moscaritolo, the following were the most

common factors contributing to stress and anxiety for nursing

students: (a)their first clinical experience, (b) fear of making

mistakes, (c) performing clinical skills,(d) faculty evaluation, (e)

lack of support by nursing personnel, and (f) connecting theory with

practice. Moscaritolo reported high levels of anxiety in nursing

students led to interference with learning. On the other hand, some

anxiety was inevitable and facilitated motivation and improved

performance (Moscaritolo, 2009). Kube’s (2010) study found that

“caring, nurturing teaching behaviors had a significant influence on

learning” (p.85).Kube reported that nursing students stress and

anxiety in a clinical setting was reduced by the caring actions of

their clinical instructors.

Gender and Stress

While both men and women recognize the impact stress can have on

physical health, men appear to be somewhat more reluctant to believe

that it’s having an impact on their own health. Likewise, men put less

emphasis on the need to manage their stress than women do. Yet men are

more likely than women to report being diagnosed with the types of

chronic physical illnesses that are often linked to high stress levels

and unhealthy lifestyles and behaviors, signalling that there may be

some important gender differences when it comes to stress management.

(American Psychological Association, 2010).

There was a paucity of research on whether age plays a role in

student perception (Langford, 2007). Age as a variable was included in

light of the increasing entry of older age students into second degree

nursing programs. Gender was included based on the growing number of

males entering nursing programs and gender differences cited in the

literature (Smith, 2009). Gender may influence nursing students’

management with stress.

Nursing evolved as a female dominated field of practice with a

small number of nurses reported as male. Historically, the majority of

men entered nursing as a second career (Smith, 2009). Some nursing

schools targeted the male population starting at the grade school

level to change the image of nursing as a female profession and to

address the nursing shortage of males in nursing (Burton, 2011). Some

studies addressed the need for recruitment and retention of male

nursing students and exploration of factors which influenced male

attrition (Brady & Sherrod, 2008). According to Anthony (2008) the

attrition rate for male nursing students in a large mid-Western

nursing program, ranged between four percent and seven percent. To

date, national statistics on male attrition were not published.

Several studies also addressed the perceptions of male nursing

students. Identification of influencing life stressors to success

within a nursing program was one if the identified perception. (Bell-

Scriber, 2008).

According to Ann Marriner Tomey et. al,(2009),stress is a part of

every student’s daily life. Leaving home, daily managing finances,

living with roommates and juggling work, classes and relationships all

contribute to the normal stress of being a student. In addition, it is

not uncommon for students to feel stressed and anxious about wasting

time, meeting high standards or being lonely. Stress can come from

exciting or positive events. Falling in love, preparing to study

abroad or buying a car can be a stressful as fewer happy events. One

of the most important things you can do is to recognize when stress

levels are building. The amount of stress that you can tolerate before

you become distressed varies with your life situation and your age. A

critical first step in coping with stress is taking stock of stressors

in life. Whenever stress is present, your body reacts. It acts like an

alarm system that prepares your body to defend yourself. A little

stress is good. It helps you to think faster and harder and makes you

put that extra bit of effort to meet the challenges of life.

Carson et al. believed that nurses with high self-esteem will

have lower levels of stress and burnout and better coping skills than

those with low self-esteem (cited in Gross and Kinnison, 2007).Since

nursing is a stressful program to study. Comeau (2009) suggested

coping techniques such as time management, better sleeping habits,

general health improvement, and support system with family and

friends, and stress management within the nursing curriculum. Academic

institutions can institute stress management techniques like massage

therapy, meditation, yoga, dance and art therapy activities within

their orientation program.

Local Literature and Studies

According to Calderon, people who experience a high level of

stress for a long time and who cope poorly with this stress may become

irritable, socially withdrawn and emotionally unstable. They may also

have difficulty concentrating and solving problems. Some people under

intense and prolonged stress may start to suffer from extreme anxiety,

depression or other severe emotional problems.

Odrigo G. Ancheta stated “Stress gives us energy to cope with the

demanding activity of life. It is true that stress is a normal

constant part of life because it involves changes, challenges and

emotions. Try to imagine life without stress; you would not have any

challenges to affect your emotions and anything new and exciting. It

gives us energy because it involves physical and emotional activities.

Stress might be considered as a problem because we often bear about

stress in negative light that people may also associate bad

experiences with stress.

According to Cuevas,P.F., et. Al., (2007), stress is not

only inevitable and essential but also normal part of life.

However, normal does not mean necessarily mean healthy. It

triggers hormones that change the way body works and feels.

These changes are nature’s way of helping the person cope with

perceived threats. Some cope with stress by behaving in a way

that is unhealthy like drinking, smoking or overeating. This is

the reason why it is important to manage stress appropriately

in order to avoid the unhealthy effects of inappropriate coping

mechanisms.

Fortunately, stress management is largely a learnable

skill. It is not possible to live without stress but one can

learn ways to handle the stress of daily life efficiently. It

is also important to remain attentive to negative stress

symptoms and to learn to identify the situations that evoke

them. When these symptoms persist, the risk for serious health

problems is greater because stress can exhaust the immune

system. Recent research demonstrates that 90% of illness is

stress-related. Meditation, self awareness, time management,

siesta (taking a nap or short rest), stretching, sensation

technique (touch therapy), sports, socials, music, talking to

someone, stress debriefing and smile were identified as stress

management techniques.

Bersabe (2008) recommended stress management to resist and cope

with stress as follows: satisfying relationships/ social network,

humor, hobbies, strong sense of self and optimism, consulting a

specialist (psychiatrist, support group), and physical health and good

health habits.

Another local study in relation to stress was done by Bayogos, S.

et.al. (2007) which was on the level of stress experienced by third

year student nurses on their first clinical exposure, it was found

that the respondents during their first clinical exposure seldom

experienced personal-related, hospital facilities- related, peer-

related and family-related stresses.

THEORETICAL/CONCEPTUAL FRAMEWORK

This study is anchored on Betty Neuman’s Systems Model, a model

based on the concept of stress and reaction to stress. This nursing

theory views nursing as being responsible for developing interventions

to prevent or reduce stressors on the client or to make them more

bearable for the client. Neuman believes that every person develops

set of responses to stress that constitute the normal line of defense.

This line of defense helps to maintain health and wellness. However,

when physiological, psychological, socio-cultural, developmental, or

spiritual influences are unable to buffer stress, the normal line of

defense is broken, and disease can result. (Perry, 2009).The model

emphasizes the importance of accuracy in assessment and interventions

that promote optimal wellness using primary, secondary, and tertiary

prevention strategies. According to Neuman’stheory, the goal of

primary prevention is to promote client wellness by stress prevention

and risk factors reduction. Secondary prevention occurs after symptoms

appear. The nurse determines the meaning of the illness and stress to

the client and the client’s needs and resources for meeting them.

Tertiary prevention begins when the client system becomes more stable

and recovers. At the tertiary level of prevention the nurse supports

rehabilitation processes involved in healing, moving the client back

to wellness and the primary level of disease prevention(Perry, 2009).

Basing on Neuman’s goal of primary prevention, the study on the

stressors in the clinical setting as identified by third year nursing

students will be conducted. It is perceived to promote wellness among

the students when the stressors that significantly affect them are

identified thus foundation for stress prevention and management is

established.

The research paradigm is shown in Figure 1. This included the

input, the process and the output. The input contains the profile of

the Level III BSN students, the different stressors they encountered

and the different management they perform to alleviate them. In the

process, questionnaires will be distributed and observations were

conducted to gather pertinent information. It also includes the

analysis and evaluation of the gathered data and information from

respondents using statistical treatment such as getting the mode,

average mean, weighted mean, percentage, and t-test. The output

consists of the findings about the stressors, perception of the

stressors and stress management and in relation to age and gender.

Figure 1. Paradigm of the study. Stressors and stress management in

the clinical setting identified by Level III Bachelor of Science in

Nursing Students.

Respondent’s Profile The Different Stressors Encountered By the respondents in the Clinical Setting

Perception of Stressors (challenging or Threatening)

Different Stress Management Performed By the respondents

Significant difference on the identified stress management by the respondents when grouped according to their profile

DISTRIBUTION OF QUESTIONNAIRES

OBSERVATION

ANALYSIS AND EVALUATION USING STATISTICAL TREATMENT

- PERCENTAGE

- AVERAGE MEAN

- WEIGHTED MEAN

- T-TEST

- ANOVA

Determination of the following:

stressors in the clinical setting

stress management utilized

whether the stressors as challenges or threats

if there is a significant difference on the identified stress management by the respondents when grouped according to their profile.

INPUT PROCESS OUTPUT

Chapter III

RESEARCH METHODOLOGY

This chapter presents the method of research used, instruments,

the sources of data and the procedures used in gathering of data

employed by the researchers.

RESEARCH DESIGN

A descriptive quantitative research design is used to explore

stressors, perception of the stressors whether challenging or

threatening, and stress management in the clinical setting identified

by the respondents. Descriptive research “examines a situation as it

is ”and “does not involve changing or modifying the situation under

investigation nor is it intended to determine cause and affect

relationships” .Leedy and Omrod state that “surveys are used to

describe the incidence, frequency, and distribution of certain

characteristics in a population” (p. 108). According to Leedy and

Ormrod, the design of the survey involves the provision of questions

to “willing participants, summarizes their responses with percentages,

frequency counts, or more sophisticated statistical indexes; and then

draws inferences about a particular population from the responses of

the sample” (p. 184).

This study identifies, describes and explores nursing students’

stressors and stress management on their clinical exposure or Related

learning Experience which included gender and age as variables. Two

instruments and a demographic data form will be administered by pen

and paper to a sample of willing participants in Alimannao Hills,

Peñablanca, Cagayan. Results are to be analyzed statistically and

report in narrative or table format. Researchers may also deal with

comparison and contrast or the discovery of existing relationships

between events and groups.

This quantitative method describes and explores nursing students

stressors encountered how they manage stress in their clinical

exposure and their relationship with age and gender in an objective

empirical-based way. However, the survey instruments originate from a

naturalistic paradigm. A naturalistic paradigm, according to Polit and

Beck, produced findings based on the individuals involved in the

phenomenon of interest. The phenomenon of interest is the nursing

students specified stressors and their behaviors on managing those

identified in the clinical setting.

The two survey instruments used in this study are based on

qualitative and quantitative studies. By using a survey instrument

developed from a naturalistic paradigm, the construct validity of the

instrument captures data reflective of the phenomenon of interest.

This may strengthen the content and construct validity of a

quantitative instrument. According to Creswell, quantitative research

problems are designed to describe trends by looking at the tendencies

and variations in tendencies in participant responses. Nursing

students’ answers may be influenced by the variables of age and

gender. In the research design of this study, the views of male and

female nursing students from different age groups are included. The

researchers use questionnaire as the primary tool in gathering data.

This is made from created materials and statements that could generate

the desired result when the respondents follow correctly the direction

given. The researchers formulate questions based on their readings

from books, manuals, journal and experiences as nursing students. The

questionnaires are first drafted for the approval of their adviser and

other members of the faculty knowledgeable to the topic.

SAMPLING DESIGN

The researchers use the Level III BSN nursing students of Medical

Colleges of Northern Philippines as their respondents who are

randomly selected from four sections. They are chosen using

single random sampling, each number of the population has an

equal chance to be included in the sample gathered. Their reactions,

opinions and answers are to be analyzed and reported.

SECTION POPULATION NUMBER OF RESPONDENTS

Gold 39 36

Silver 33 30

Bronze 41 37

Jade 37 34

Total 150 109

DATA GATHERING PROCEDURE

The researchers surfed through the internet to look for related

and relevant topics, to look for previous researches conducted by

experts or other person, be it local or worldwide. The researchers try

to look in some related literatures and studies. This is for the

researchers to reprove, look for new reasons and to understand stress

by nursing students in the clinical setting. The researchers conducted

an actual survey in a local college at Peñablanca, Cagayan. The target

population were the junior BSN students. The respondents must answer

given questionnaires honestly. After gathering data, the researchers

tallied and came up with results.

The researchers floated questionnaires for them to gain the

respondents perception and identification of the stressors and stress

management they utilize.

STATISTICAL TREATMENT OF DATA

After the distribution, collection and completion of

questionnaires, the researchers tally gathered data and 

use central tendency measures (average mean, weighted mean),

percentage, t-test and interpretation and ranking. The following

formulas are to be used:

For the percentage

(%) = rf x 100

Where:

% = percentage

rf = relative frequency

For the Average Mean

X = Σx

n

Where:

X = average mean

Σx = sum of scores or measures

n = Total number of respondents

For the Weighted Mean

Formula: WX = ∑fx

N

Where: WX---Weighted Mean

fX---Summation of Frequency

N----Total Population

For t-test

t = X1 – X2

The researchers used ranking to determine the position of each

variable.

Finally, the findings were summarized and compared with each

work; conclusions were drawn, and recommendations were formulated.

ANALYSIS OF VARIANCE

DATA ANALYSIS PLAN

In determining the profile of the respondents, frequency

distribution and percentage are used.

To describe and characterize the stressors, weighted mean is

used.

In determining the significant difference on the stress

management utilized by the respondents when grouped according to their

profile, T-test is used in gender and Analysis of variance is used for

Age.

NUMBER VALUE E (DoR) INTERPRETATION

4.20 TO 5.00 5 ALWAYS

3.40 TO 4.19 4 OFTEN

2.60 TO 3.39 3 SOMETIMES

1.80 TO 2.59 2 SELDOM

1.0 TO 1.79 1 NEVER

CHAPTER IV

PRESENTATION, ANALYSIS, AND INTERPRETATION OF DATA

This chapter presents the data gathered in this study which has

been carefully presented, analyzed, and interpreted. These data are

gathered by the researchers to 109 junior nursing students

enrolled at the Medical Colleges of Northern Philippines, second

semester, and school year 2012-2013.

Table 1.1

Distribution of Respondents According to Age

AGE (YEARS

OLD)

FREQUENCY PERCENTAGE Rank

18 8 7.34 4

19 63 57.80 1

20 22 20.18 2

21 16 14.68 3

Total 109 100.00

Mean=19.43

Table 1.1 shows the profile of the 109 respondents in terms of their

age. There are 8 or 7.34% of the respondents who are 18 years old

which ranked as number fourth; 63 or 57.80% of the respondents were 19

years old which ranked first; 22 or 20.18 % were aged 20 years which

ranked second, and 16 or 14.68%of the respondents were 21 years old

and ranked third.

The data indicate that the respondents are at the right age to

consider them as mature individuals capable of identifying and

managing stress. It also shows that the majority of the respondents

are 19 years old.

TABLE 1.2 1Distribution of Respondents According to GENDER

GENDER FREQUENCY PERCENTAGE RANK

MALE 29 26.31 2

FEMALE 80 73.39 1

Total 109 100.00

Table 1.2 presents the data of the 109 respondents in terms of their

gender. There were 29 or 26.31% of the respondents were male while 80

or 73.39% of the respondents were female.

This indicates that majority of the students enrolled in

BSN are female.

Table 1.3 Weighted Mean and Descriptive Values of Stressors

STRESSORS Weighted

mean

Rank Descriptive

Interpretation

1.uninterested/unapproachable/unreceptive

staff nurse

3.53 24 Often

2. unrealistic expectation of clinical

abilities

3.80 23 Often

3. fear of making mistakes 4.34 4 Always

4.being treated as nuisance in the area 4.21 8 Always

5. unfamiliarity of the clinical area 4.67 1 Always

6. uncertainty on own clinical skills and

knowledge

4.40 3 Always

7. lack of clinical knowledge or skills to

accomplish a task or perform procedures

4.28 5 Always

8. assigned to two or more patients 4.24 6 Always

9. bedside conference 4.17 9 Often

10. charting 4.06 12.5 Often

11. standing for long hours 4.43 2 Always

12. difficult patient (very ill,

emergencies, disbelief, etc.)

4.06 12.5 Often

13. significant others of the patient 3.86 21 Often

14. interaction with the physician/intern 3.91 18 Often

15. clinical instructor treating students

unfairly.

3.81 22 Often

16. clinical instructor behaving in

demeaning and belittling ways toward

students.

3.90 19.5 Often

17. being pressured by clinical

instructor/staff nurse/physician/intern

4.22 7 Always

18. waiting on clinical instructor. 3.95 14 Often

19. being observed by staff nurse or

clinical instructor.

3.99 13 Often

20. relationship with duty mate. 3.92 17 Often

21. uncaring and/or moody clinical

instructor.

3.87 20 Often

22. connecting theory with practice (i.e.

ideal procedures are not observed in the

area)

3.90 19.5 often

23. rotation examination. 3.94 15 Often

24. oral report or oral revalida in the

area.

4.08 10 often

25. preparing for case presentation. 3.93 16 often

26. on the spot making of requirements

(NPC, DAR, LFD, Case Analysis, etc)

4.07 11 Often

Table 1.3 The stressors in the clinical setting identified by the

respondents are reflected in table 1.3 with their corresponding

weighted mean and descriptive interpretation, points garnered and

overall rank.

The individual rankings done by each respondent were then subjected to

a point system established by the researchers. Unfamiliarity of the

clinical area ranked first with a weighted mean of 4.67 , standing for

long hours with 4.43 weighted mean, . uncertainty on own clinical

skills and knowledge with 4.40 ranked third, fear of making mistake

with 4.34 ranked fourth, lack of clinical knowledge or skills to

accomplish a task or perform procedures with 4.28 as fifth, assigned

to two or more patients with 4.24 ranked sixth, being treated as

nuisance in the area with 4.21 and being pressured by clinical

instructor/staff nurse/physician/intern with 4.22 ranked 7th and

interpreted as always.

This indicates that majority of the study participants felt that

in terms of knowledge they were not prepared to deal with complex

patient cases in clinical setting. Many doubted themselves and many

were overwhelmed by the amount of knowledge that one needed in order

to work safely with patients. Physically, majority of the respondents

find it difficult to care while standing for too long hours and have

to take care to different patients at the same time. Respondents were

negatively affected by the environment they practiced in, which

affects their learning outcomes.

Bedside conference got a weighted mean of 4.17 and ranked as 9th most

stressful, oral report or oral revalida in the area with 4.08 ranked

10th, on the spot making of requirements (NPC, DAR, LFD, Case

Analysis, etc)with 4.07 as eleventh, charting and difficult patients

(very ill, emergencies, disbelief, etc.) with 4.06 as twelfth, being

observed by staff nurse or clinical instructor with 3.99 as 13th,

waiting on clinical instructor with 3.95 as 14th, rotation examination

with 3.94 as 15th, preparing for case presentation with 3.93 as 16th,

relationship with duty mate with 3.92 as 17th, with 3.91 as 18th,

clinical instructor behaving in demeaning and belittling ways toward

students and connecting theory with practice (i.e. ideal procedures

are not observed in the area) with 3.90 as 19th, uncaring and/or moody

clinical instructor with 3.87 as 20th, significant others of the

patient with 3.86 as 21st , clinical instructor treating students

unfairly with 3.81 as 22nd, unrealistic expectation of clinical

abilities with 3.80 as 23rd,and uninterested/unapproachable/unreceptive

staff nurse ranked last with 3.53. All of them were interpreted as

often. This indicates that majority of the respondents are still

having difficult time in socializing and establish harmonious

relationship with other members of the health care team, dutymates,

patients and their significant others and as well as with the Clinical

Instructors. Activities and requirements during the exposure were also

found stressful.

The interpersonal relationship with healthcare professionals was a

source of stress among the participants. The process of socialization

into the unit and into the team of nurses was difficult for many and

it depended in large part on the behaviors and on the professionalism

of individual nurses and doctors/interns. Some students experienced

unwelcoming environments in which the nurses were not interested in

teaching and helping them. Some clinical instructor’s way of approach

and inappropriate communication style was a source of stress. Constant

evaluation process in clinical made the respondents feel stressed. A

majority of the respondents may feel that the responsibility placed on

them was overwhelming and that teachers had unrealistic expectations

of them. They might feel like they were not given opportunity to be

students as they believed teachers expected them to be perfect.

Activities to be accomplished on time cause the respondents stress.

Patients and their significant others were considered as another

significant source of stress in the clinical setting because some of

them had a negative attitude, were uncooperative in their care, and

unapproachable. Also, the critical condition of some patients worried

and instilled fear in some respondents. Group mates were at times also

a source of stress because of the different personalities that

sometimes clashed

Table 1.3 Distribution of Perception of the Stressors

PERCEPTION FREQUENCY PERCENTAGE RANK

Challenging 88 80.73 1

Threatening 21 19.27 2

Total 109 100

Table 1.3 shows the Distribution of Perception of the Stressors .After

the identification of stressors in the clinical setting, the

respondents were then asked about their coping towards their

stressors. They were asked to identify whether they see their

stressors as challenges or threats. The respondents see the stressors

identified in a positive way.

Table 1.4 Weighted Mean and Descriptive Values of Stress Management

STRESS MANAGEMENT WEIGHTED

MEAN

Rank Descriptive

Interpretation

1. I adjust to the environment or situation. 4.02 7 Often

2. I allot ample time to prepare. 3.81 11 Often

3. I confront the patient. 2.80 27 Sometimes

4. I study and read to be more knowledgeable. 3.76 12 Often

5. I manage my time. 4.09 5 Always

6. I accept the situation. 4.19 3 Often

7. I take a shower to feel good. 3.93 8 Often

8. I do household chores. 3.11 19 Sometimes

9. I eat my favorite food. 3.55 16 Often

10. I take a nap/sleep. 4.39 2 Always

11. I express my feelings. 3.83 10.5 Often

12. I go out to the mall. 2.07 36 Seldom

13. I go out to park. 2.13 35.5 Seldom

14. I go to spa and get a massage. 1.46 38 Never

15. I surf the internet. 2.93 24 Sometimes

16. I simply smile. 3.68 15 Often

17. I laugh at it. 3.73 13 Often

18. I listen to music. 4.15 4 Often

19. I just think positively. 4.59 1 Always

20. I read magazines, newspapers and the like. 3.29 18 Sometimes

21. I reflect on what happened. 3.70 14 Often

22. I just relax. 3.07 20 Sometimes

23. I go shopping. 3.02 21 Sometimes

24. I enjoy pleasurable activities like drawing,

playing instruments, etc.

2.99 22 Sometimes

25. I engage myself in sport. 2.49 31 Seldom

26. I curse. 2.36 33 Seldom

27. I do physical exercises (jogging, aerobics,

etc.)

3.83 10.5 Often

28. I turn to my friends. 3.90 9 Often

29. I watch the television or listening to the

radio.

3.49 17 Often

30. I write it down on my journal/ LFD. 2.92 25 Sometimes

31. I drink alcoholic beverages. 2.91 26 Sometimes

32. i smoke. 2.51 30 Seldom

33. I pity myself. 2.44 32 Seldom

34. I ignore it. 2.55 29 Sometimes

35. I consult a specialist. 2.96 23 Sometimes

36. I pray to God. 4.08 6 Often

37. I would get angry/frustrated/depressed. 2.68 38 Sometimes

38. I reason out and answer back to defend myself. 2.28 34 Seldom

39. I take medication for relief. 2.13 35.5 Seldom

40. I simply stay at the corner of my room and

cry.

1.92 37 Seldom

Table 1.4 presents the stress management performed by the

r e s p o n d e n t s   t o   h a n d l e   a n d   a l l e v i a t e   t h e i r   s t r e s s .

a significant difference on the identified stressors and stress

management by the respondents when grouped according to their profile.

Table 1.5

Analysis Of Variance on the Significant Difference the Identified Stressors and Stress Management by the Respondents

when Grouped According to their Profile

Sources SUM OF

SQUARES

Df MEAN

SQUARE

F P DECISION

Between

Groups

22833.435 40 570.836 338.894 .oooE+00 Accept

Ho at .05

levelWithin

Groups

7458.569 4428 1.684

Total 30292.004 4468

The table above shows that the probability between and

within groups is 0.00E+00, hence the Ho is accepted: “There is no

significant difference on the identified stressors and stress

management by the respondents when grouped according to their

profile.”

Chapter V

This chapter presents the conclusion and the recommendations made

by the researchers based on the analysis of gathered and collated

data.

Conclusion

The null hypothesis: “There is no significant difference on the

identified stressors and stress management by the respondents when

grouped according to their profile” is accepted.

It was evident from the data gathered that when grouped according

to age group, the respondents have similar coping

strategies/mechanisms to address stress. Although each of the

respondents may have different tolerance threshold levels, they

address similar stressors almost the same way.

The top stressor among students is “the fear of committing

errors;” most of those who have this first on their list use “positive

thinking” as a coping mechanism or as a stress management.

Majority of the respondents take the stressors as mere

challenges. Therefore, these stressors may be positively contributing

to their successes at achieving their goals; albeit it may also be

negative once their maximum tolerance is broken. Say for instance

fear, it may induce anxiety. Anxiety when unmanaged/mismanaged may

cause debilitating effect to the individual.

Recommendations:

Stress management is essential in maintaining balance. Stressors

when become compounded may cause burn out and eventually psychological

disturbance that may lead to the alteration on the normal

functioning/role performance of the individual. It is recommended

therefore that each individual adapts appropriate stress management

techniques each time they feel stressed. It is important that the

management to be employed should post minimal risk; i.e. the benefits

must outweigh the risks involved. Ultimately, the end goal of stress

management is to promote relaxation of the different faculties of the

human being, thereby maintaining homeostasis in both internal and

external milieu. The most important consideration when choosing stress

management technique is safety.

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