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International Journal of Mental Health Nursing (2013) ••, ••–••
doi: 10.1111/inm.12054
Feature Article
Perceived stress and coping strategies among Jordanian nursing students during clinical practice in psychiatric/mental health courses Abdulkarim Subhi Al-Zayyat and Ekhlas Al-Gamal Department of Community Health Nursing, The University of Jordan, Amman, Jordan
ABSTRACT: Clinical practice in the psychiatric/mental health nursing (PMHN) field is considered a highly-stressful experience for nursing students. The purpose of the present study was to identify the degrees of stress, the types of stressors, and coping strategies perceived by undergraduate nursing students during their clinical practice in PMHN courses. A descriptive, longitudinal design was used. Sixty-five students registered in PMHN clinical courses were recruited from five Jordanian universities using a systematic random-sampling method. Data collection was conducted in the second semester of the 2012–2013 academic year at two points of time: pre-PMHN clinical training and post-PMHN training. The Basic Information Questionnaire, Perceived Stress Scale, and Coping Behavior Inventory were administered. Students’ ages ranged from 20 to 25 years. The findings illustrate that the highest reported types of stressors at both data-collection times were taking care of patients, stress related to teachers and nursing staff, and from assignments and workloads. The most utilized coping strategy at both data-collection times was problem solving. The findings of the present study are useful for clinical educators in identifying nursing students’ stressors, easing their learning in the clinical setting, and establishing an efficient PMHN course programme. KEY WORDS: clinical practice, coping, nursing student, psychiatric/mental health nursing, stress.
INTRODUCTION Overview Stress among university students has been extensively investigated by several researchers (Chou et al. 2011; Hamaideh 2012; Hamdan-Mansour et al. 2009; Pillay & Ngcobo 2010). Stress is defined as a relationship involving an individual and the environment, which is evaluated by the individual as demanding or beyond his or her available resources (Lazarus & Folkman 1984). A stressor is a stimulus or an event that causes the individual to suffer stress (Basavanthappa 2004). Correspondence: Abdulkarim Subhi Al-Zayyat, Department of Community Health Nursing, Faculty of Nursing-The University of Jordan, Amman 11942, Jordan. Email: [email protected] Abdulkarim Subhi Al-Zayyat, RN, MSC. Ekhlas Al-Gamal, RN, MSC, PhD. Accepted October 2013.
© 2013 Australian College of Mental Health Nurses Inc.
Nursing students experience unique stressors. For example, clinical practice, an essential element in nursing education, can be stressful for nursing students (Chan et al. 2009). Some of the clinical stressors that are reported by nursing students include initial clinical experience, clinical procedures, assignments and workloads, clinical evaluations, and relationships with clinical staff, peers, and patients (Nelwati et al. 2013). Other stressors include lack of capability, powerlessness, uncertainty, and linkage with clients (Gorostidi et al. 2007). Clinical stressors could be more complicated in psychiatric settings (Ewashen & Lane 2007; Melrose 2002). The purpose of the present study was to determine the degrees of stress, the types of stressors, and coping strategies perceived by nursing students during pre- and post-clinical periods in psychiatric/mental health nursing (PMHN) courses.
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PMHN in Jordan Nursing students in Jordan have to enrol in the theoretical and practical parts of the PMHN course during their undergraduate programmes. There are similarities between Jordanian universities in terms of training objectives, training areas, and training duration for the practical part of the PMHN course. Training usually lasts 14 weeks, two of which the students spend in the university laboratories (for the orientation programme). During the orientation programme, the clinical teachers discuss the fundamentals of PMHN and therapeutic communication techniques with the students. In the remaining 12 weeks, the students train for 2 days per week in the National Mental Health Center. The focus of students’ training includes utilizing the nursing process for patients with different mental illnesses. Other training activities include daily clinical conferences, attending medical and nursing rounds and diagnostic treatment procedures, and keeping diaries and logs about patients’ conditions. The students are evaluated using evaluation sheets addressing their performance in the clinical area. Furthermore, the paperwork (i.e. clinical logs, daily assignments, and written case studies) is used as part of the students’ evaluation. The World Health Organization and the Ministry of Health (MOH) in Jordan published a report about the Jordanian mental health system (WHO & MOH 2011). In terms of mental health services, the report revealed that those services were provided by the MOH (government), Royal Medical Services (military), the private sector, and universities. There was a total of 64 outpatient psychiatric/mental health clinics in Jordan; 37 (58%) are governmental services, 18 (28%) are private services, seven (11%) are military services, and two (3%) are university services (hospitals). Psychiatric beds were situated in the four psychiatric hospitals, and the total number was 8.27 beds per 100 000 people. It is important to note that the most frequently-allocated diagnosis at both psychiatric hospitals and outpatient services is schizophrenia. In relation to mental health professionals, the report revealed that 203 nurses work in the psychiatric hospitals, and only 13 nurses work in the outpatient psychiatric clinics. The most reported stressors among Jordanian mental health nurses are problematic relations with other health professionals, poor staffing, inadequate equipment, and insufficient financial support (HamdanMansour et al. 2011). Nurses have low organizational support to overcome these stressors.
Stress It has been reported that nursing students who enrol in PMHN courses can be susceptible to emotional distress
A. S. AL-ZAYYAT AND E. AL-GAMAL
because of their inexperience, the intrinsic demands of psychiatric nursing education, and the challenges of everyday living (McGann & Thompson 2008). This could be due to the stigma and negative stereotypes that are connected to individuals who have mental illnesses (Happell & Gough 2007; Stuart 2009; Surgenor et al. 2005). This negative attitude can hinder students’ learning, have a negative impact on their development of therapeutic relationships with patients, and create emotional distress (Fisher 2002). Consequently, the international literature indicates that a small percentage of student nurses choose this area as a future career option after graduation (Gough & Happell 2009; Happell 2008a; Happell & Gough 2007; Spence et al. 2012). Nolan and Ryan (2008) found that nearly 48% of nursing students in PMHN courses have degrees of stress greater than the threshold score reported by Goldberg (1978), signifying levels of distress that are unlikely to be alleviated without intervention. Karimollahi (2011) reported that nursing students who enrol in PMHN training courses usually face stressors of fear of violence, fear of the unknown, erroneous beliefs concerning patients, peer effect, and media effect. Therefore, the present study was conducted to provide an understanding of the stressors among nursing students during their clinical periods in PMHN courses in Jordan.
Coping ability Nursing students cannot avoid stressors; however, their coping ability is vital in determining the outcomes of these stressors (Seyedfatemi et al. 2007). Coping refers to the dynamic cognitive and behavioural attempts to handle external and/or internal stressors (Lazarus & Folkman 1984). Tully (2004) investigated the impacts of the utilized coping techniques on the degrees of distress perceived by nursing students during their psychiatric training. The findings of Tully’s study showed that students who employed ineffective coping techniques (i.e. wishing things were different, taking medications, or attempting to forget the stress) reported having high degrees of distress. Conversely, students who employed effective coping techniques, such as problem solving, reported having low degrees of distress. To the best of our knowledge, there has only been one recently-published Jordanian study about stress and coping among nursing students who had their initial training in a general hospital (Shaban et al. 2012). Therefore, the present study is considered important in its focus on PMHN clinical stress in Jordan. Moreover, the present study will add to the breadth of understanding of the problems in the international literature from a Jordanian perspective. © 2013 Australian College of Mental Health Nurses Inc.
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The findings of the present study might have important implications for both research and practice: (i) it will offer information that can be used by teachers to increase their understanding of the severity of the problem; and (ii) will help students manage and cope effectively with stress, and thus promote quality of care for psychiatric patients.
Aim of the study and research questions The purpose of the present study was to determine the degrees of stress, the types of stressors, and the coping strategies perceived by nursing students during pre- and post-clinical periods in PMHN courses. The specific research questions were: 1. What are the degrees of stress, the types of stressors, and the coping strategies that are perceived by nursing students enrolled in PMHN clinical course at each of the data-collection times? 2. Do the degrees of stress, types of stressors, and coping strategies experienced by nursing students differ significantly between the two data-collection times?
METHOD Design A descriptive, longitudinal design was used to answer the research questions. There were two data-collection times: the pre-PMHN and the post-PMHN clinical periods.
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cal parts); (ii) could speak Arabic (in Jordan, Arabic is considered to be the first spoken language); and (iii) agreed to participate in the study. Exclusion criteria were students who: (i) have been working with patients with mental illnesses; (ii) have a family member with a mental illness; and (iii) have previously taken any mental health course. Eligible students were selected by the systematic random-sampling method. A power analysis was conducted to determine the appropriate sample size using the G*Power computer software programme (Faul et al. 2009). In the present study, paired t-test was used; a medium effect size of 0.50 was determined, as it was used previously in similar literature (Shaban et al. 2012); a significance level of α = 0.05 was set, which is acceptable to control the risk of making a type 1 error; and a power of 80% was used to reduce the risk of a type II error (Munro 2005). Subsequently, the yielded sample size was 34. However, to overcome the problems of attrition and incomplete questionnaires, a larger sample of 72 students was planned as a precaution (Polit & Beck 2008). Ultimately, 65 of those students agreed to participate. The response rate was largely positive (90%). Attrition was not found in this study, given that all 65 students were attending their classes at the second data-collection time and filling the questionnaires.
MEASURE
Setting
Basic Information Questionnaire
This study was conducted at five universities situated in the middle part of Jordan. The students of these universities represent diverse economic and geographic backgrounds. The participating universities were selected from a list, which contains all of those universities that are located in the middle part of the Jordan, and have baccalaureate nursing programmes. Other universities were not chosen, as they did not offer PMHN clinical courses during the semester when the data were collected. The lecture theatres of these universities were the datacollection setting.
We designed the Basic Information Questionnaire (BIQ) to satisfy the purpose of this study. It includes information regarding the demographic characteristics of participants, including age, sex, religion, marital status, employment status, working hours, academic score, academic credit hours, current university year, and interest in psychiatric nursing. In addition to the BIQ, we used the Perceived Stress Scale (PSS) and Coping Behavior Inventory (CBI) after obtaining permission from the original authors.
Participants The target population of this study was undergraduate Jordanian nursing students who were studying at Jordanian universities and enrolled in PMHN clinical courses. The accessible population was undergraduate Jordanian nursing students who study at the previously-selected universities. The inclusion criteria were Jordanian nursing students who: (i) were registered in the second semester of the 2012–2013 academic year in a PMHN course (clini© 2013 Australian College of Mental Health Nurses Inc.
PSS The PSS was generated by Sheu et al. (1997) to measure the perceived stress of nursing students in clinical practice (types of stressors and stress degrees). It consists of 29 items, utilizing a five-point Likert-type scale classified into six factors. These six factors, encompassing stress, relate to patient care (8 items), stress related to teachers and nursing staff (6 items), stress related to assignments and workloads (5 items), stress related to peers and daily life (4 items), stress related to lack of professional knowledge and skills (3 items), and stress related to the clinical
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environment (3 items). Typically, total scores, as well as individual subscale scores, are considered. The total score ranges between 0 and 116. Elevated scores signal a higher degree of stress. Psychometric properties were reported in a pilot study of 150 nursing students (Sheu et al. 2002). This tool had satisfactory internal consistency reliability (Cronbach’s α: 0.89). Construct validity was confirmed using factor analysis (Sheu et al. 2002). In the present study, Cronbach’s alpha coefficient for the total scale was 0.89, indicating reasonable internal consistency reliability.
CBI The CBI was developed to determine nursing students’ coping strategies that were associated with clinical practice (Sheu et al. 2002). It consists of 19 items divided into four categories: avoidance behaviours (efforts to avoid the stressful situation; 6 items), problem-solving behaviours (efforts to manage or change the stress arising from a stressful situation; 6 items), optimistic coping behaviours (efforts to keep a positive attitude towards the stressful situation; 4 items), and transference behaviours (efforts to transfer one’s attention from the stressful situation to other things; 3 items). Each item uses a five-point Likerttype scale from 0 to 4. Higher scores for each factor represent more recurrent use of a certain type of coping behaviour. Cronbach’s alpha of 0.76 and the 1-week-apart test–retest reliability of 0.57, 0.57, 0.59, and 0.55 for the four categories, respectively (P < 0.001), illustrated the instrument’s reliability (Sheu et al. 2002). Construct validity was confirmed using factor analysis (Sheu et al. 2002). In the present study, Cronbach’s alpha coefficient for the total scale was 0.74, demonstrating adequate internal consistency reliability.
Translation process For the purpose of this study, all of the previouslymentioned instruments, with the exception of the BIQ, were translated from English to Arabic, and the translated versions were checked as equivalent to the originals, according to Brislin’s model of translation and back translation (Brislin 1970; 1986; Brislin et al. 1973).
Ethical considerations Ethical approval was obtained from the research ethics committee at the University of Jordan and all other targeted universities before data collection commenced. The voluntary nature of participation was emphasized in the information sheet and informed consent. Participants were assured of their right to privacy, and data were kept strictly confidential. No names or personal details were included, and each participant was given an identification
A. S. AL-ZAYYAT AND E. AL-GAMAL
code. The researcher informed the students to discontinue filling the questionnaires at any time if psychological stress became too intense, and the counsellor who was assigned at each of the previously-selected universities was available to speak to the students in private. None of the participants was found to be emotionally distressed during the course of the study.
Data-collection method The Ministry of Higher Education provided a list of all of the universities that are located in the middle part of Jordan and have baccalaureate nursing programmes for the purpose of this study. Five universities were selected from this list, as they offered PMHN clinical courses in the second semester of the 2012–2013 academic year. The admission and registration office at each participating university was contacted to obtain a list of all the PMHN course (theoretical part) sessions that were offered to undergraduate nursing students during the second semester of the 2012−2013 academic year, and to obtain a list of the registered students in each of these classes. We chose students who were registered for both the theoretical and clinical parts of the PMHN course in order to facilitate the data collection. Therefore, the data were collected in the theoretical classes. We then contacted the teacher/instructor of each selected session, explained the study purpose to them, and set a plan for data collection during/after their class sessions. Thirteen students from each university were selected using the systematic random-sampling method. Data were collected from the eligible students twice: at the beginning of their clinical training in the PMHN course (in the first week of the semester) and in the last week of the PMHN clinical course. The data collection took place over a period of 14 weeks.
Data analysis The Statistical Package for Social Science (SPSS version 16.0; SPSS, Chicago, IL, USA) was used for the data analysis. Descriptive and inferential statistical tests were used to satisfy the study aims. Descriptive statistics was utilized to describe the study sample and to answer research question one. The descriptive statistics used were mean, median, standard deviation, range, frequency, and percentage. The inferential test, paired sample t-test, was used to answer the second research question. The Shapiro–Wilk (SW) inferential measure was used to check the normality assumption. The SW test findings showed that all stress and coping variables were normally distributed (P > 0.05), with the exception of stress related to teachers and nursing staff, problem solving, and stay © 2013 Australian College of Mental Health Nurses Inc.
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optimistic variables, which violate the assumption of normality (P < 0.05). Accordingly, the square-root transformation was conducted to these variables to obtain more normally-distributed scores (Munro 2005).
RESULTS Characteristics/demographics of the study sample The demographic variables of the study sample are summarized in Table 1. The mean age of the students was 21.15 years (standard deviation (SD) = 1.42), with a range of 20–25 years. The majority of the students were female (n = 55, 84.6%), Muslim (n = 62, 95.4%), single (n = 58, 87.7%), and unemployed. Only two students worked full time for 40 hours per week (in jobs other than nursing), and two students work part time for 15 hours per week. All participating students had their PMHN training in the National Mental Health Center.
Degrees of perceived stress and types of stressors Pre-PMHN clinical training experience
The degrees of perceived stress encountered by nursing students in the pre-PMHN clinical training period ranged
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from 19 to 91 (mean = 56.37, SD = 16.97). Considering the subscales of the PSS, the results showed that the taking care of patients subscale (mean = 16.62, SD = 5.93), the stress related to teachers and nursing staff subscale (mean = 10.57, SD = 4.50), and the stress from assignments and workloads subscale (mean = 9.23, SD = 3.74) had the highest means among all perceived stress subscale scores. In contrast, the stress from lack of professional knowledge and skills subscale (mean = 7.15, SD = 2.74) and the stress from the clinical environment subscale (mean = 5.86, SD = 2.63) had the lowest means among all perceived stress subscale scores (Table 2). Post-PMHN clinical training experience
The nursing students reported that their degrees of perceived stress in the post-PMHN clinical training period ranged from 7 to 79 (mean = 43.05, SD = 15.69). For the PSS subscales, the results illustrated that the taking care of patients subscale (mean = 12.28, SD = 4.46), the stress from assignments and workloads subscale (mean = 8.06, SD = 3.88), and the stress from teachers and nursing staff subscale (mean = 7.98, SD = 4.45) had the highest means among all perceived stress subscale scores. Conversely, the stress from the clinical environment subscale (mean = 4.06, SD = 2.14), and the stress from lack of professional
TABLE 1: Characteristics/demographics of the study sample (n = 65) Variable Age Academic cumulative score average Academic credit hours Sex Female Male Religion Muslim Christian Marital status Single Married Divorced Employment status Full time Part time Unemployed Current university year 1st year 2nd year 3rd year 4th year Interest in studying psychiatric nursing Yes No
Frequency (%)
55 (84.6%) 10 (15.4%) 62 (95.4%) 2 (4.6%) 57 (87.7%) 7 (10.8%) 1 (1.5%) 2 (3.1%) 2 (3.1%) 61 (93.8%) 0 (0%) 0 (0%) 49 (75.4%) 14 (21.5%) 58 (89.2%) 7 (10.8%)
SD, standard deviation.
© 2013 Australian College of Mental Health Nurses Inc.
Mean (SD)
Median
Minimum
Maximum
21.15 (1.42) 2.97 (0.33) 16 (12)
21 3.00 17
20 2.26 12
25 3.65 20
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A. S. AL-ZAYYAT AND E. AL-GAMAL
TABLE 2: Perceived stress among nursing students during psychiatric/mental health nursing (PHMN) clinical training (n = 65) Pre-PMHN clinical period Subscale
Post-PMHN clinical period
Ranking
Mean
SD
Subscale
1 2 3 4 5 6
16.62 10.57 9.23 7.49 7.15 5.86
5.93 4.50 3.74 3.04 2.74 2.63
Taking care of patients Assignments and workloads Teachers and nursing staff Peers and daily life Clinical environment Lack of professional knowledge and skills
Taking care of patients Teachers and nursing staff Assignments and workloads Peers and daily life Lack of professional knowledge and skills Clinical environment
Ranking
Mean
SD
1 2 3 4 5 6
12.28 8.06 7.98 6.40 4.06 3.95
4.46 3.88 4.45 2.73 2.14 2.33
SD, standard deviation.
TABLE 3: Utilized coping strategies among nursing students during psychiatric/mental health nursing (PHMN) clinical training (n = 65) Pre-PMHN clinical period Subscale
Post-PMHN clinical period
Ranking
Mean
SD
Subscale
1 2 3 4
17.23 12.09 11.58 7.31
4.27 3.86 2.36 2.51
Problem solving Stay optimistic Avoidance Transference
Problem solving Avoidance Stay optimistic Transference
Ranking
Mean
SD
1 2 3 4
17.60 11.48 11.15 6.18
4.13 2.02 3.91 2.56
SD, standard deviation.
knowledge and skills subscale (mean = 3.95, SD = 2.33) had the lowest means among all perceived stress subscale scores (Table 2).
Coping strategies utilized by nursing students Pre-PMHN clinical training experience
The most utilized coping strategy (subscale) among nursing students in the pre-PMHN clinical training period was the problem-solving strategy (mean = 17.23, SD = 4.27), followed by the avoidance strategy (mean = 12.09, SD = 3.86). The transference strategy (mean = 7.31, SD = 2.51) was the least utilized coping strategy (Table 3). Post-PMHN clinical training experience
Nursing students in the post-PMHN clinical training period reported that the problem-solving strategy (mean = 17.60, SD = 4.13), followed by the stay optimistic strategy (mean = 11.48, SD = 2.02), were the most utilized coping strategies (subscale). The transference strategy (mean = 6.18, SD = 2.56) was the least utilized coping strategy (Table 3).
Changes in the degrees of perceived stress and types of stressors Using paired t-test analysis, the results revealed that the mean of the total perceived stress scale and the six perceived stress subscale scores were higher among students in pre-PMHN clinical training than in post-PMHN clini-
cal training. The results showed that there was a highly statistically-significant difference in the total PSS score and all subscales scores among students in pre- and postPMHN clinical periods. Statistical significance was set at P < 0.05, indicated that degrees of perceived stress decreased significantly during the post-PMHN training period (Table 4).
Changes in the types of coping strategies The results of the paired t-test showed that the types of utilized coping strategies among nursing students did not differ significantly between the two data-collection times (P > 0.05), except for transference subscale scores, which were statistically significant in the pre- and post-clinical training periods (t = 2.76, d.f. = 64, P = 0.01). The students reported lower transference scores in the posttraining period (mean = 6.18) than the pretraining period (mean = 7.31).
DISCUSSION Reported stressors In the present study, stress from taking care of patients, stress related to teachers and nursing staff, and assignments and workloads were the most prominent reported stressors among students at both data-collection times. These findings are consistent with previous research studies (Chen & Hung 2014; Nolan & Ryan 2008; Por © 2013 Australian College of Mental Health Nurses Inc.
PERCEIVED STRESS AND COPING STRATEGIES
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TABLE 4: Paired t-test statistics comparing students’ perceived stress scores in the total Perceived Stress Scale and the subscales at pre- and post- psychiatric/mental health nursing (PHMN) clinical periods (n = 65) Scale/Subscale Total Perceived Stress Scale Pre Post Taking care of patients subscale Pre Post Teachers and nursing staff subscale Pre Post Lack of professional knowledge and skills subscale Pre Post Clinical environment subscale Pre Post Assignments and workloads subscale Pre Post Peers and daily life subscale Pre Post
Mean (SD)
t
d.f.
P-value
5.77
64
0.001*
3.90
64
0.001*
4.49
64
0.001*
8.12
64
0.001*
4.99
64
0.001*
2.28
64
0.02*
3.62
64
0.001*
56.37 (16.97) 43.05 (15.69) 16.62 (5.93) 12.28 (4.46) 10.57 (4.50) 7.98 (4.45) 7.15 (2.74) 3.95 (2.33) 5.86 (2.63) 4.06 (2.14) 9.23 (3.74) 8.06 (3.88) 7.94 (3.04) 6.40 (2.73)
*Significant at α = 0.05 (2 tailed). SD, standard deviation.
2005; Tully 2004). A possible explanation for why taking care of patients was the highest-ranked stressor at both data-collection times is that students’ training in PMHN courses focuses on fundamental mental health nursing and therapeutic communication techniques. However, nursing students might meet a range of patients who have psychiatric conditions with complex bio–psycho–social problems and needs. This situation requires nursing students to be competent in developing and sustaining therapeutic relationships with their patients and their patients’ families. Moreover, those nursing students should have adequate knowledge and skills regarding providing nursing care, mental health interventions, and follow-up procedures for such patients. Consequently, nursing educators must be able to recognize the components essential for dealing with patients with mental illnesses and be able to provide this information to students. Simulation can be used to help in familiarizing students with the nature of mental illnesses and proper nursing managements for such conditions (Robinson-Smith et al. 2009). Negative attitudes towards patients with mental illnesses among nursing students might also contribute to stress (Hamdan-Mansour & Wardam 2009; Happell 2008a,b). Nevertheless, it is evident that students’ negative attitudes can be changed positively through learning experiences that aim to prepare them with proper knowl© 2013 Australian College of Mental Health Nurses Inc.
edge, skills, and attitudes towards patients with mental illnesses (Happell 2009; Happell et al. 2008a,b). Moreover, stress from teachers and nursing staff was among the highest-reported stressors in this study. Stress from relationships with teachers seems to be relatively widespread in health-related professions (Timmins & Kaliszer 2002). In the present study, the lack of the congruence between students’ and teachers’ expectations might explain the stress from teachers. Clinical teachers should communicate these expectations clearly to students through the discussion of the clinical objectives, which will give students clear expectations. In the present study, the students reported that medical personnel lack empathy and are not willing to help. Supportive professional relationships with healthcare staff need to reduce the effect of these stressful events and aid the students in better handling them (Penn 2008). It is vital that clinical teachers and clinical setting coordinators develop approaches to strengthen student– staff relations. This might incorporate the beginning or further expansion of preceptorship programmes, promoting communication channels between university staff and health-care staff (Timmins & Kaliszer 2002). Stress from assignments and workloads was identified as one of the most significant sources of stress in the present study, and for nursing students internationally
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(Evans et al. 2007; Lou et al. 2010; Nolan & Ryan 2008; Shirey 2007). Although clinical assignment preparation appears to catalyse the critical thinking skills of students, the students in the present study reported that the requirements of psychiatric clinical practice exceeded their physical and emotional endurance. Nursing students are overwhelmed by the academic demands of PMHN clinical courses in terms of case studies, clinical logs, projects, and examinations throughout clinical rotations. The results of the present study have significant implications for clinical teachers of PMHN courses. Clinical learning activities should support the acquisition of knowledge, clinical skills, values, and attitudes necessary for providing the nursing care to those patients who suffer from mental illnesses (Happell 2009; Happell et al. 2008a,b).
Degrees of perceived stress High levels of degrees of perceived stress among students have been found in many studies during the pre-PMHN training period (Karimollahi 2011; Szpak & Kameg 2011). The findings of the present study revealed that students in the pre-PMHN clinical period report more stress than in the post-PMHN clinical period. The degrees of perceived stress for the total PSS and all subscales decreased in the post-PMHN training period. This finding is supported by Karimollahi (2011), who found that the initial period of training at the psychiatric unit was very stressful for students; however, the students in Karimollahi’s (2011) study reported that, during their training, the level of stress diminished, and they overcame their fears. Our findings on Jordanian students’ perceived stress, as well as those of Karimollahi (2011), emphasize to clinical teachers the importance of finding appropriate measures to decrease students’ degrees of stress during the preclinical period of PHMN training. During the orientation period (which precedes the actual clinical training), a variety of training resources can be utilized to satisfy this purpose. These resources might include video simulations, role plays, an expert guest speaker, and field visits. The use of such measures might help students alleviate their degrees of stress (Penn 2008).
Most utilized coping strategy The findings of the present study indicated that the most the finding of utilized coping strategy at both data-collection times was problem solving. This finding lends support to those of Chen and Hung (2014), which revealed that problem solving was the most utilized coping strategy among Taiwanese nursing students during their clinical training. However, the present study’s finding is contrary to those of Shaban et al. (2012), Sheu
A. S. AL-ZAYYAT AND E. AL-GAMAL
et al. (2002), and Tully (2004), who found that the avoidance coping strategy was the most utilized. It is important to note that the differences in the methodological aspects, the composition of nursing educational programmes, and the studied nursing student populations in these studies should be taken into consideration. The domination of problem-solving strategies in the present study can be justified; throughout the nursing programme, the nursing students had previous various clinical learning opportunities. Those opportunities enabled nursing students to develop problem-solving skills with regards to stress associated with their clinical training situations (Chan et al. 2009). In the pre-PMHN clinical period of their training in psychiatric settings, the nursing students utilized the previously-learnt problem-solving strategies to deal with PMHN clinical stress. The more time the students spent during their practice in the psychiatric settings, the more they found that the problem-solving strategy was the most helpful strategy; therefore, it remained the most utilized. However, in Tully’s (2004) study, the nursing students were in their first and second years of study, as opposed to the students in the present study, who were in their third and fourth years. Therefore, the students in Tully’s study did not have enough learning opportunities to develop problemsolving skills, and as a result, they chose the avoidance coping strategy. Moreover, in the present study the utilization of the transference coping strategy decreased significantly at the end of nursing students’ PMHN clinical training. This could be because the transference coping strategy (i.e. watching TV or having a shower) provides quick relief of the transitory stress symptoms in the initial period of practice. When the psychiatric clinical training progressed, the students realized that the transference coping strategy was ineffective for handling long-term clinical stress. Consequently, the utilization of the transference coping strategy decreased at the end of PMHN training.
Limitations and future recommendations The present study has some limitations. First, in relation to the setting, data were collected from the available students in the lecture theatres, so students who were not present at those theatres might have had different responses with regards to the study instruments. Second, the structured questionnaire might have restricted the in-depth understanding of the students’ reactions to stress and the ability to identify other strategies of coping. The integration of a qualitative part (e.g. adding open-ended questions to the study tools) in further study designs © 2013 Australian College of Mental Health Nurses Inc.
PERCEIVED STRESS AND COPING STRATEGIES
might be helpful. Third, by employing the longitudinal design in the present study, we can detect changes in the degree of stress and coping abilities by tracking the same participants over time; however, students could be exposed to different sources of stress, other than being enrolled in clinical psychiatric nursing courses, which might affect students’ stress experiences. These other sources were not detected in the present study.
CONCLUSION The present study contributes to the knowledge of stress and coping among Jordanian nursing students during their PMHN clinical training. The study results revealed that the most reported stressors at both data-collection times were stress from taking care of patients, stress from teachers and nursing staff, and stress from assignments and workloads. Equipping students with essential clinical knowledge and skills, reviewing the clinical PMHN curriculum requirements, and preparing all professionals involved in training the nursing students adequately are imperative issues that might help students effectively deal with these clinical stressors. Further research should be conducted to examine the specific needs of students, either during pre-PMHN clinical training or post-PHMN clinical training, in order to develop appropriate interventions. Moreover, it is recommended that upcoming studies expand the scope of the present study by examining stressors and coping strategies among nursing students enrolled in other clinical courses, such as foundations, medical/surgical nursing, paediatrics, and maternity.
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10 Happell, B. (2009). Influencing undergraduate nursing students’ attitudes toward mental health nursing: Acknowledging the role of theory. Issues in Mental Health Nursing, 30 (1), 39–46. Happell, B. & Gough, K. (2007). Undergraduate nursing students’ attitudes towards mental health nursing: Determining the influencing factors. Contemporary Nurse, 25 (1–2), 72–81. Happell, B., Robins, A. & Gough, K. (2008a). Developing more positive attitudes towards mental health nursing in undergraduate students: Part 1––does more theory help? Journal of Psychiatric and Mental Health Nursing, 15 (6), 439–446. Happell, B., Robins, A. & Gough, K. (2008b). Developing more positive attitudes towards mental health nursing in undergraduate students: Part 2-the impact of theory and clinical experience. Journal of Psychiatric and Mental Health Nursing, 15 (7), 527–536. Karimollahi, M. (2011). An investigation of nursing students’ experiences in an Iranian psychiatric unit. Journal of Psychiatric and Mental Health Nursing, 19 (8), 738–745. Lazarus, R. S. & Folkman, S. (1984). Stress, Appraisal and Coping. New York: Springer. Lou, J. H., Chen, S. H., Yu, H. Y., Li, R. H., Yang, C. I. & Eng, C. J. (2010). The influence of personality traits and social support on male nursing student life stress: A cross-sectional research design. Journal of Nursing Research, 18 (2), 108–116. McGann, E. & Thompson, J. (2008). Factors related to academic success in at-risk senior nursing students. International Journal of Nursing Education Scholarship, 5 (1), 1–15. Melrose, S. (2002). A clinical teaching guide for psychiatric mental health nusing: A qualitative outcome analysis project. Journal of Psychiatric and Mental Health Nursing, 9 (4), 381–389. Munro, B. H. (2005). Statistical Methods for Health Care Research, 5th edn. Philadelphia, PA: Lippinicot Williams and Wilkins. Nelwati, McKenna, L. & Plummer, V. (2013). Indonesian student nurses’ perceptions of stress in clinical learning: A phenomenological study. Journal of Nursing Education and Practice, 3 (5), 56–65. Nolan, G. & Ryan, D. (2008). Experience of stress in psychiatric nursing students in Ireland. Nursing Standard, 22 (43), 35–43. Penn, T. D. (2008). Enhancing student comfort in psychiatric clinical settings. Teaching and Learning in Nursing, 3 (2), 53–55. Pillay, A. L. & Ngcobo, H. S. B. (2010). Sources of stress and support among rural-based first-year university students: An exploratory study. South African Journal of Psychology, 40 (3), 234–240. Polit, D. & Beck, C. (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice, 8th edn. Philadelphia, PA: Lippinicot Williams and Wilkins.
A. S. AL-ZAYYAT AND E. AL-GAMAL Por, J. (2005). A pilot data collecting exercise on stress and nursing students. British Journal of Nursing, 14 (22), 1180– 1184. Robinson-Smith, G., Bradley, P. & Meakim, C. (2009). Evaluating the use of standardized patients in undergraduate psychiatric nursing experiences. Clinical Simulation in Nursing, 5 (6), e203–e211. Seyedfatemi, N., Tafreshi, M. & Hagani, H. (2007). Experienced stressors and coping strategies among Iranian nursing students. BMC Nursing, 6 (1), 11. Shaban, I. A., Khater, W. A. & Akhu-Zaheya, L. M. (2012). Undergraduate nursing students’ stress sources and coping behaviours during their initial period of clinical training: A Jordanian perspective. Nurse Education in Practice, 12 (4), 204–209. Sheu, S., Lin, H.-S., Hwang, S.-L., Yu, P.-J., Hu, W.-Y. & Lou, M.-F. (1997). The development and testing of perceived stress scale of clinical practice. Nursing Research (Republic of China), 5 (4), 341–351 (in Chinese). Sheu, S., Lin, H.-S. & Hwang, S.-L. (2002). Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice: The effect of coping behaviors. International Journal of Nursing Studies, 39 (2), 165– 175. Shirey, M. R. (2007). An evidence-based solution for minimizing stress and anger in nursing students. The Journal of Nursing Education, 46 (12), 568–571. Spence, D., Garrick, H. & McKay, M. (2012). Rebuilding the foundations: Major renovations to the mental health component of an undergraduate nursing curriculum. International Journal of Mental Health Nursing, 21 (5), 409–418. Stuart, G. W. (2009). Principles and Practice of Psychiatric Nursing, 9th edn. St. Louis, MO: Mosby. Surgenor, L. J., Dunn, J. & Horn, J. (2005). Nursing student attitudes to psychiatric nursing and psychiatric disorders in New Zealand. International Journal of Mental Health Nursing, 14 (2), 103–108. Szpak, J. L. & Kameg, K. M. (2011). Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clinical Simulation in Nursing, 9 (1), e13–e19. Timmins, F. & Kaliszer, M. (2002). Aspects of nurse education programmes that frequently cause stress to nursing students––fact finding sample survey. Nurse Education Today, 22 (3), 3–11. Tully, A. (2004). Stress, sources of stress and ways of coping among psychiatric nursing students. Journal of Psychiatric and Mental Health Nursing, 11 (1), 43–47. World Health Organization, & Ministry of Health (2011). WHO-AIMS Report on Mental Health System in Jordan. [Cited 15 September 2012]. Available from: URL: http:// www.who.int/mental_health/evidence/mh_aims_report _jordan_jan_2011_en.pdf
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International Journal of Mental Health Nursing (2013) ••, ••–••
doi: 10.1111/inm.12054
Feature Article
Perceived stress and coping strategies among Jordanian nursing students during clinical practice in psychiatric/mental health courses Abdulkarim Subhi Al-Zayyat and Ekhlas Al-Gamal Department of Community Health Nursing, The University of Jordan, Amman, Jordan
ABSTRACT: Clinical practice in the psychiatric/mental health nursing (PMHN) field is considered a highly-stressful experience for nursing students. The purpose of the present study was to identify the degrees of stress, the types of stressors, and coping strategies perceived by undergraduate nursing students during their clinical practice in PMHN courses. A descriptive, longitudinal design was used. Sixty-five students registered in PMHN clinical courses were recruited from five Jordanian universities using a systematic random-sampling method. Data collection was conducted in the second semester of the 2012–2013 academic year at two points of time: pre-PMHN clinical training and post-PMHN training. The Basic Information Questionnaire, Perceived Stress Scale, and Coping Behavior Inventory were administered. Students’ ages ranged from 20 to 25 years. The findings illustrate that the highest reported types of stressors at both data-collection times were taking care of patients, stress related to teachers and nursing staff, and from assignments and workloads. The most utilized coping strategy at both data-collection times was problem solving. The findings of the present study are useful for clinical educators in identifying nursing students’ stressors, easing their learning in the clinical setting, and establishing an efficient PMHN course programme. KEY WORDS: clinical practice, coping, nursing student, psychiatric/mental health nursing, stress.
INTRODUCTION Overview Stress among university students has been extensively investigated by several researchers (Chou et al. 2011; Hamaideh 2012; Hamdan-Mansour et al. 2009; Pillay & Ngcobo 2010). Stress is defined as a relationship involving an individual and the environment, which is evaluated by the individual as demanding or beyond his or her available resources (Lazarus & Folkman 1984). A stressor is a stimulus or an event that causes the individual to suffer stress (Basavanthappa 2004). Correspondence: Abdulkarim Subhi Al-Zayyat, Department of Community Health Nursing, Faculty of Nursing-The University of Jordan, Amman 11942, Jordan. Email: [email protected] Abdulkarim Subhi Al-Zayyat, RN, MSC. Ekhlas Al-Gamal, RN, MSC, PhD. Accepted October 2013.
© 2013 Australian College of Mental Health Nurses Inc.
Nursing students experience unique stressors. For example, clinical practice, an essential element in nursing education, can be stressful for nursing students (Chan et al. 2009). Some of the clinical stressors that are reported by nursing students include initial clinical experience, clinical procedures, assignments and workloads, clinical evaluations, and relationships with clinical staff, peers, and patients (Nelwati et al. 2013). Other stressors include lack of capability, powerlessness, uncertainty, and linkage with clients (Gorostidi et al. 2007). Clinical stressors could be more complicated in psychiatric settings (Ewashen & Lane 2007; Melrose 2002). The purpose of the present study was to determine the degrees of stress, the types of stressors, and coping strategies perceived by nursing students during pre- and post-clinical periods in psychiatric/mental health nursing (PMHN) courses.
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PMHN in Jordan Nursing students in Jordan have to enrol in the theoretical and practical parts of the PMHN course during their undergraduate programmes. There are similarities between Jordanian universities in terms of training objectives, training areas, and training duration for the practical part of the PMHN course. Training usually lasts 14 weeks, two of which the students spend in the university laboratories (for the orientation programme). During the orientation programme, the clinical teachers discuss the fundamentals of PMHN and therapeutic communication techniques with the students. In the remaining 12 weeks, the students train for 2 days per week in the National Mental Health Center. The focus of students’ training includes utilizing the nursing process for patients with different mental illnesses. Other training activities include daily clinical conferences, attending medical and nursing rounds and diagnostic treatment procedures, and keeping diaries and logs about patients’ conditions. The students are evaluated using evaluation sheets addressing their performance in the clinical area. Furthermore, the paperwork (i.e. clinical logs, daily assignments, and written case studies) is used as part of the students’ evaluation. The World Health Organization and the Ministry of Health (MOH) in Jordan published a report about the Jordanian mental health system (WHO & MOH 2011). In terms of mental health services, the report revealed that those services were provided by the MOH (government), Royal Medical Services (military), the private sector, and universities. There was a total of 64 outpatient psychiatric/mental health clinics in Jordan; 37 (58%) are governmental services, 18 (28%) are private services, seven (11%) are military services, and two (3%) are university services (hospitals). Psychiatric beds were situated in the four psychiatric hospitals, and the total number was 8.27 beds per 100 000 people. It is important to note that the most frequently-allocated diagnosis at both psychiatric hospitals and outpatient services is schizophrenia. In relation to mental health professionals, the report revealed that 203 nurses work in the psychiatric hospitals, and only 13 nurses work in the outpatient psychiatric clinics. The most reported stressors among Jordanian mental health nurses are problematic relations with other health professionals, poor staffing, inadequate equipment, and insufficient financial support (HamdanMansour et al. 2011). Nurses have low organizational support to overcome these stressors.
Stress It has been reported that nursing students who enrol in PMHN courses can be susceptible to emotional distress
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because of their inexperience, the intrinsic demands of psychiatric nursing education, and the challenges of everyday living (McGann & Thompson 2008). This could be due to the stigma and negative stereotypes that are connected to individuals who have mental illnesses (Happell & Gough 2007; Stuart 2009; Surgenor et al. 2005). This negative attitude can hinder students’ learning, have a negative impact on their development of therapeutic relationships with patients, and create emotional distress (Fisher 2002). Consequently, the international literature indicates that a small percentage of student nurses choose this area as a future career option after graduation (Gough & Happell 2009; Happell 2008a; Happell & Gough 2007; Spence et al. 2012). Nolan and Ryan (2008) found that nearly 48% of nursing students in PMHN courses have degrees of stress greater than the threshold score reported by Goldberg (1978), signifying levels of distress that are unlikely to be alleviated without intervention. Karimollahi (2011) reported that nursing students who enrol in PMHN training courses usually face stressors of fear of violence, fear of the unknown, erroneous beliefs concerning patients, peer effect, and media effect. Therefore, the present study was conducted to provide an understanding of the stressors among nursing students during their clinical periods in PMHN courses in Jordan.
Coping ability Nursing students cannot avoid stressors; however, their coping ability is vital in determining the outcomes of these stressors (Seyedfatemi et al. 2007). Coping refers to the dynamic cognitive and behavioural attempts to handle external and/or internal stressors (Lazarus & Folkman 1984). Tully (2004) investigated the impacts of the utilized coping techniques on the degrees of distress perceived by nursing students during their psychiatric training. The findings of Tully’s study showed that students who employed ineffective coping techniques (i.e. wishing things were different, taking medications, or attempting to forget the stress) reported having high degrees of distress. Conversely, students who employed effective coping techniques, such as problem solving, reported having low degrees of distress. To the best of our knowledge, there has only been one recently-published Jordanian study about stress and coping among nursing students who had their initial training in a general hospital (Shaban et al. 2012). Therefore, the present study is considered important in its focus on PMHN clinical stress in Jordan. Moreover, the present study will add to the breadth of understanding of the problems in the international literature from a Jordanian perspective. © 2013 Australian College of Mental Health Nurses Inc.
PERCEIVED STRESS AND COPING STRATEGIES
The findings of the present study might have important implications for both research and practice: (i) it will offer information that can be used by teachers to increase their understanding of the severity of the problem; and (ii) will help students manage and cope effectively with stress, and thus promote quality of care for psychiatric patients.
Aim of the study and research questions The purpose of the present study was to determine the degrees of stress, the types of stressors, and the coping strategies perceived by nursing students during pre- and post-clinical periods in PMHN courses. The specific research questions were: 1. What are the degrees of stress, the types of stressors, and the coping strategies that are perceived by nursing students enrolled in PMHN clinical course at each of the data-collection times? 2. Do the degrees of stress, types of stressors, and coping strategies experienced by nursing students differ significantly between the two data-collection times?
METHOD Design A descriptive, longitudinal design was used to answer the research questions. There were two data-collection times: the pre-PMHN and the post-PMHN clinical periods.
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cal parts); (ii) could speak Arabic (in Jordan, Arabic is considered to be the first spoken language); and (iii) agreed to participate in the study. Exclusion criteria were students who: (i) have been working with patients with mental illnesses; (ii) have a family member with a mental illness; and (iii) have previously taken any mental health course. Eligible students were selected by the systematic random-sampling method. A power analysis was conducted to determine the appropriate sample size using the G*Power computer software programme (Faul et al. 2009). In the present study, paired t-test was used; a medium effect size of 0.50 was determined, as it was used previously in similar literature (Shaban et al. 2012); a significance level of α = 0.05 was set, which is acceptable to control the risk of making a type 1 error; and a power of 80% was used to reduce the risk of a type II error (Munro 2005). Subsequently, the yielded sample size was 34. However, to overcome the problems of attrition and incomplete questionnaires, a larger sample of 72 students was planned as a precaution (Polit & Beck 2008). Ultimately, 65 of those students agreed to participate. The response rate was largely positive (90%). Attrition was not found in this study, given that all 65 students were attending their classes at the second data-collection time and filling the questionnaires.
MEASURE
Setting
Basic Information Questionnaire
This study was conducted at five universities situated in the middle part of Jordan. The students of these universities represent diverse economic and geographic backgrounds. The participating universities were selected from a list, which contains all of those universities that are located in the middle part of the Jordan, and have baccalaureate nursing programmes. Other universities were not chosen, as they did not offer PMHN clinical courses during the semester when the data were collected. The lecture theatres of these universities were the datacollection setting.
We designed the Basic Information Questionnaire (BIQ) to satisfy the purpose of this study. It includes information regarding the demographic characteristics of participants, including age, sex, religion, marital status, employment status, working hours, academic score, academic credit hours, current university year, and interest in psychiatric nursing. In addition to the BIQ, we used the Perceived Stress Scale (PSS) and Coping Behavior Inventory (CBI) after obtaining permission from the original authors.
Participants The target population of this study was undergraduate Jordanian nursing students who were studying at Jordanian universities and enrolled in PMHN clinical courses. The accessible population was undergraduate Jordanian nursing students who study at the previously-selected universities. The inclusion criteria were Jordanian nursing students who: (i) were registered in the second semester of the 2012–2013 academic year in a PMHN course (clini© 2013 Australian College of Mental Health Nurses Inc.
PSS The PSS was generated by Sheu et al. (1997) to measure the perceived stress of nursing students in clinical practice (types of stressors and stress degrees). It consists of 29 items, utilizing a five-point Likert-type scale classified into six factors. These six factors, encompassing stress, relate to patient care (8 items), stress related to teachers and nursing staff (6 items), stress related to assignments and workloads (5 items), stress related to peers and daily life (4 items), stress related to lack of professional knowledge and skills (3 items), and stress related to the clinical
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environment (3 items). Typically, total scores, as well as individual subscale scores, are considered. The total score ranges between 0 and 116. Elevated scores signal a higher degree of stress. Psychometric properties were reported in a pilot study of 150 nursing students (Sheu et al. 2002). This tool had satisfactory internal consistency reliability (Cronbach’s α: 0.89). Construct validity was confirmed using factor analysis (Sheu et al. 2002). In the present study, Cronbach’s alpha coefficient for the total scale was 0.89, indicating reasonable internal consistency reliability.
CBI The CBI was developed to determine nursing students’ coping strategies that were associated with clinical practice (Sheu et al. 2002). It consists of 19 items divided into four categories: avoidance behaviours (efforts to avoid the stressful situation; 6 items), problem-solving behaviours (efforts to manage or change the stress arising from a stressful situation; 6 items), optimistic coping behaviours (efforts to keep a positive attitude towards the stressful situation; 4 items), and transference behaviours (efforts to transfer one’s attention from the stressful situation to other things; 3 items). Each item uses a five-point Likerttype scale from 0 to 4. Higher scores for each factor represent more recurrent use of a certain type of coping behaviour. Cronbach’s alpha of 0.76 and the 1-week-apart test–retest reliability of 0.57, 0.57, 0.59, and 0.55 for the four categories, respectively (P < 0.001), illustrated the instrument’s reliability (Sheu et al. 2002). Construct validity was confirmed using factor analysis (Sheu et al. 2002). In the present study, Cronbach’s alpha coefficient for the total scale was 0.74, demonstrating adequate internal consistency reliability.
Translation process For the purpose of this study, all of the previouslymentioned instruments, with the exception of the BIQ, were translated from English to Arabic, and the translated versions were checked as equivalent to the originals, according to Brislin’s model of translation and back translation (Brislin 1970; 1986; Brislin et al. 1973).
Ethical considerations Ethical approval was obtained from the research ethics committee at the University of Jordan and all other targeted universities before data collection commenced. The voluntary nature of participation was emphasized in the information sheet and informed consent. Participants were assured of their right to privacy, and data were kept strictly confidential. No names or personal details were included, and each participant was given an identification
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code. The researcher informed the students to discontinue filling the questionnaires at any time if psychological stress became too intense, and the counsellor who was assigned at each of the previously-selected universities was available to speak to the students in private. None of the participants was found to be emotionally distressed during the course of the study.
Data-collection method The Ministry of Higher Education provided a list of all of the universities that are located in the middle part of Jordan and have baccalaureate nursing programmes for the purpose of this study. Five universities were selected from this list, as they offered PMHN clinical courses in the second semester of the 2012–2013 academic year. The admission and registration office at each participating university was contacted to obtain a list of all the PMHN course (theoretical part) sessions that were offered to undergraduate nursing students during the second semester of the 2012−2013 academic year, and to obtain a list of the registered students in each of these classes. We chose students who were registered for both the theoretical and clinical parts of the PMHN course in order to facilitate the data collection. Therefore, the data were collected in the theoretical classes. We then contacted the teacher/instructor of each selected session, explained the study purpose to them, and set a plan for data collection during/after their class sessions. Thirteen students from each university were selected using the systematic random-sampling method. Data were collected from the eligible students twice: at the beginning of their clinical training in the PMHN course (in the first week of the semester) and in the last week of the PMHN clinical course. The data collection took place over a period of 14 weeks.
Data analysis The Statistical Package for Social Science (SPSS version 16.0; SPSS, Chicago, IL, USA) was used for the data analysis. Descriptive and inferential statistical tests were used to satisfy the study aims. Descriptive statistics was utilized to describe the study sample and to answer research question one. The descriptive statistics used were mean, median, standard deviation, range, frequency, and percentage. The inferential test, paired sample t-test, was used to answer the second research question. The Shapiro–Wilk (SW) inferential measure was used to check the normality assumption. The SW test findings showed that all stress and coping variables were normally distributed (P > 0.05), with the exception of stress related to teachers and nursing staff, problem solving, and stay © 2013 Australian College of Mental Health Nurses Inc.
PERCEIVED STRESS AND COPING STRATEGIES
optimistic variables, which violate the assumption of normality (P < 0.05). Accordingly, the square-root transformation was conducted to these variables to obtain more normally-distributed scores (Munro 2005).
RESULTS Characteristics/demographics of the study sample The demographic variables of the study sample are summarized in Table 1. The mean age of the students was 21.15 years (standard deviation (SD) = 1.42), with a range of 20–25 years. The majority of the students were female (n = 55, 84.6%), Muslim (n = 62, 95.4%), single (n = 58, 87.7%), and unemployed. Only two students worked full time for 40 hours per week (in jobs other than nursing), and two students work part time for 15 hours per week. All participating students had their PMHN training in the National Mental Health Center.
Degrees of perceived stress and types of stressors Pre-PMHN clinical training experience
The degrees of perceived stress encountered by nursing students in the pre-PMHN clinical training period ranged
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from 19 to 91 (mean = 56.37, SD = 16.97). Considering the subscales of the PSS, the results showed that the taking care of patients subscale (mean = 16.62, SD = 5.93), the stress related to teachers and nursing staff subscale (mean = 10.57, SD = 4.50), and the stress from assignments and workloads subscale (mean = 9.23, SD = 3.74) had the highest means among all perceived stress subscale scores. In contrast, the stress from lack of professional knowledge and skills subscale (mean = 7.15, SD = 2.74) and the stress from the clinical environment subscale (mean = 5.86, SD = 2.63) had the lowest means among all perceived stress subscale scores (Table 2). Post-PMHN clinical training experience
The nursing students reported that their degrees of perceived stress in the post-PMHN clinical training period ranged from 7 to 79 (mean = 43.05, SD = 15.69). For the PSS subscales, the results illustrated that the taking care of patients subscale (mean = 12.28, SD = 4.46), the stress from assignments and workloads subscale (mean = 8.06, SD = 3.88), and the stress from teachers and nursing staff subscale (mean = 7.98, SD = 4.45) had the highest means among all perceived stress subscale scores. Conversely, the stress from the clinical environment subscale (mean = 4.06, SD = 2.14), and the stress from lack of professional
TABLE 1: Characteristics/demographics of the study sample (n = 65) Variable Age Academic cumulative score average Academic credit hours Sex Female Male Religion Muslim Christian Marital status Single Married Divorced Employment status Full time Part time Unemployed Current university year 1st year 2nd year 3rd year 4th year Interest in studying psychiatric nursing Yes No
Frequency (%)
55 (84.6%) 10 (15.4%) 62 (95.4%) 2 (4.6%) 57 (87.7%) 7 (10.8%) 1 (1.5%) 2 (3.1%) 2 (3.1%) 61 (93.8%) 0 (0%) 0 (0%) 49 (75.4%) 14 (21.5%) 58 (89.2%) 7 (10.8%)
SD, standard deviation.
© 2013 Australian College of Mental Health Nurses Inc.
Mean (SD)
Median
Minimum
Maximum
21.15 (1.42) 2.97 (0.33) 16 (12)
21 3.00 17
20 2.26 12
25 3.65 20
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TABLE 2: Perceived stress among nursing students during psychiatric/mental health nursing (PHMN) clinical training (n = 65) Pre-PMHN clinical period Subscale
Post-PMHN clinical period
Ranking
Mean
SD
Subscale
1 2 3 4 5 6
16.62 10.57 9.23 7.49 7.15 5.86
5.93 4.50 3.74 3.04 2.74 2.63
Taking care of patients Assignments and workloads Teachers and nursing staff Peers and daily life Clinical environment Lack of professional knowledge and skills
Taking care of patients Teachers and nursing staff Assignments and workloads Peers and daily life Lack of professional knowledge and skills Clinical environment
Ranking
Mean
SD
1 2 3 4 5 6
12.28 8.06 7.98 6.40 4.06 3.95
4.46 3.88 4.45 2.73 2.14 2.33
SD, standard deviation.
TABLE 3: Utilized coping strategies among nursing students during psychiatric/mental health nursing (PHMN) clinical training (n = 65) Pre-PMHN clinical period Subscale
Post-PMHN clinical period
Ranking
Mean
SD
Subscale
1 2 3 4
17.23 12.09 11.58 7.31
4.27 3.86 2.36 2.51
Problem solving Stay optimistic Avoidance Transference
Problem solving Avoidance Stay optimistic Transference
Ranking
Mean
SD
1 2 3 4
17.60 11.48 11.15 6.18
4.13 2.02 3.91 2.56
SD, standard deviation.
knowledge and skills subscale (mean = 3.95, SD = 2.33) had the lowest means among all perceived stress subscale scores (Table 2).
Coping strategies utilized by nursing students Pre-PMHN clinical training experience
The most utilized coping strategy (subscale) among nursing students in the pre-PMHN clinical training period was the problem-solving strategy (mean = 17.23, SD = 4.27), followed by the avoidance strategy (mean = 12.09, SD = 3.86). The transference strategy (mean = 7.31, SD = 2.51) was the least utilized coping strategy (Table 3). Post-PMHN clinical training experience
Nursing students in the post-PMHN clinical training period reported that the problem-solving strategy (mean = 17.60, SD = 4.13), followed by the stay optimistic strategy (mean = 11.48, SD = 2.02), were the most utilized coping strategies (subscale). The transference strategy (mean = 6.18, SD = 2.56) was the least utilized coping strategy (Table 3).
Changes in the degrees of perceived stress and types of stressors Using paired t-test analysis, the results revealed that the mean of the total perceived stress scale and the six perceived stress subscale scores were higher among students in pre-PMHN clinical training than in post-PMHN clini-
cal training. The results showed that there was a highly statistically-significant difference in the total PSS score and all subscales scores among students in pre- and postPMHN clinical periods. Statistical significance was set at P < 0.05, indicated that degrees of perceived stress decreased significantly during the post-PMHN training period (Table 4).
Changes in the types of coping strategies The results of the paired t-test showed that the types of utilized coping strategies among nursing students did not differ significantly between the two data-collection times (P > 0.05), except for transference subscale scores, which were statistically significant in the pre- and post-clinical training periods (t = 2.76, d.f. = 64, P = 0.01). The students reported lower transference scores in the posttraining period (mean = 6.18) than the pretraining period (mean = 7.31).
DISCUSSION Reported stressors In the present study, stress from taking care of patients, stress related to teachers and nursing staff, and assignments and workloads were the most prominent reported stressors among students at both data-collection times. These findings are consistent with previous research studies (Chen & Hung 2014; Nolan & Ryan 2008; Por © 2013 Australian College of Mental Health Nurses Inc.
PERCEIVED STRESS AND COPING STRATEGIES
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TABLE 4: Paired t-test statistics comparing students’ perceived stress scores in the total Perceived Stress Scale and the subscales at pre- and post- psychiatric/mental health nursing (PHMN) clinical periods (n = 65) Scale/Subscale Total Perceived Stress Scale Pre Post Taking care of patients subscale Pre Post Teachers and nursing staff subscale Pre Post Lack of professional knowledge and skills subscale Pre Post Clinical environment subscale Pre Post Assignments and workloads subscale Pre Post Peers and daily life subscale Pre Post
Mean (SD)
t
d.f.
P-value
5.77
64
0.001*
3.90
64
0.001*
4.49
64
0.001*
8.12
64
0.001*
4.99
64
0.001*
2.28
64
0.02*
3.62
64
0.001*
56.37 (16.97) 43.05 (15.69) 16.62 (5.93) 12.28 (4.46) 10.57 (4.50) 7.98 (4.45) 7.15 (2.74) 3.95 (2.33) 5.86 (2.63) 4.06 (2.14) 9.23 (3.74) 8.06 (3.88) 7.94 (3.04) 6.40 (2.73)
*Significant at α = 0.05 (2 tailed). SD, standard deviation.
2005; Tully 2004). A possible explanation for why taking care of patients was the highest-ranked stressor at both data-collection times is that students’ training in PMHN courses focuses on fundamental mental health nursing and therapeutic communication techniques. However, nursing students might meet a range of patients who have psychiatric conditions with complex bio–psycho–social problems and needs. This situation requires nursing students to be competent in developing and sustaining therapeutic relationships with their patients and their patients’ families. Moreover, those nursing students should have adequate knowledge and skills regarding providing nursing care, mental health interventions, and follow-up procedures for such patients. Consequently, nursing educators must be able to recognize the components essential for dealing with patients with mental illnesses and be able to provide this information to students. Simulation can be used to help in familiarizing students with the nature of mental illnesses and proper nursing managements for such conditions (Robinson-Smith et al. 2009). Negative attitudes towards patients with mental illnesses among nursing students might also contribute to stress (Hamdan-Mansour & Wardam 2009; Happell 2008a,b). Nevertheless, it is evident that students’ negative attitudes can be changed positively through learning experiences that aim to prepare them with proper knowl© 2013 Australian College of Mental Health Nurses Inc.
edge, skills, and attitudes towards patients with mental illnesses (Happell 2009; Happell et al. 2008a,b). Moreover, stress from teachers and nursing staff was among the highest-reported stressors in this study. Stress from relationships with teachers seems to be relatively widespread in health-related professions (Timmins & Kaliszer 2002). In the present study, the lack of the congruence between students’ and teachers’ expectations might explain the stress from teachers. Clinical teachers should communicate these expectations clearly to students through the discussion of the clinical objectives, which will give students clear expectations. In the present study, the students reported that medical personnel lack empathy and are not willing to help. Supportive professional relationships with healthcare staff need to reduce the effect of these stressful events and aid the students in better handling them (Penn 2008). It is vital that clinical teachers and clinical setting coordinators develop approaches to strengthen student– staff relations. This might incorporate the beginning or further expansion of preceptorship programmes, promoting communication channels between university staff and health-care staff (Timmins & Kaliszer 2002). Stress from assignments and workloads was identified as one of the most significant sources of stress in the present study, and for nursing students internationally
8
(Evans et al. 2007; Lou et al. 2010; Nolan & Ryan 2008; Shirey 2007). Although clinical assignment preparation appears to catalyse the critical thinking skills of students, the students in the present study reported that the requirements of psychiatric clinical practice exceeded their physical and emotional endurance. Nursing students are overwhelmed by the academic demands of PMHN clinical courses in terms of case studies, clinical logs, projects, and examinations throughout clinical rotations. The results of the present study have significant implications for clinical teachers of PMHN courses. Clinical learning activities should support the acquisition of knowledge, clinical skills, values, and attitudes necessary for providing the nursing care to those patients who suffer from mental illnesses (Happell 2009; Happell et al. 2008a,b).
Degrees of perceived stress High levels of degrees of perceived stress among students have been found in many studies during the pre-PMHN training period (Karimollahi 2011; Szpak & Kameg 2011). The findings of the present study revealed that students in the pre-PMHN clinical period report more stress than in the post-PMHN clinical period. The degrees of perceived stress for the total PSS and all subscales decreased in the post-PMHN training period. This finding is supported by Karimollahi (2011), who found that the initial period of training at the psychiatric unit was very stressful for students; however, the students in Karimollahi’s (2011) study reported that, during their training, the level of stress diminished, and they overcame their fears. Our findings on Jordanian students’ perceived stress, as well as those of Karimollahi (2011), emphasize to clinical teachers the importance of finding appropriate measures to decrease students’ degrees of stress during the preclinical period of PHMN training. During the orientation period (which precedes the actual clinical training), a variety of training resources can be utilized to satisfy this purpose. These resources might include video simulations, role plays, an expert guest speaker, and field visits. The use of such measures might help students alleviate their degrees of stress (Penn 2008).
Most utilized coping strategy The findings of the present study indicated that the most the finding of utilized coping strategy at both data-collection times was problem solving. This finding lends support to those of Chen and Hung (2014), which revealed that problem solving was the most utilized coping strategy among Taiwanese nursing students during their clinical training. However, the present study’s finding is contrary to those of Shaban et al. (2012), Sheu
A. S. AL-ZAYYAT AND E. AL-GAMAL
et al. (2002), and Tully (2004), who found that the avoidance coping strategy was the most utilized. It is important to note that the differences in the methodological aspects, the composition of nursing educational programmes, and the studied nursing student populations in these studies should be taken into consideration. The domination of problem-solving strategies in the present study can be justified; throughout the nursing programme, the nursing students had previous various clinical learning opportunities. Those opportunities enabled nursing students to develop problem-solving skills with regards to stress associated with their clinical training situations (Chan et al. 2009). In the pre-PMHN clinical period of their training in psychiatric settings, the nursing students utilized the previously-learnt problem-solving strategies to deal with PMHN clinical stress. The more time the students spent during their practice in the psychiatric settings, the more they found that the problem-solving strategy was the most helpful strategy; therefore, it remained the most utilized. However, in Tully’s (2004) study, the nursing students were in their first and second years of study, as opposed to the students in the present study, who were in their third and fourth years. Therefore, the students in Tully’s study did not have enough learning opportunities to develop problemsolving skills, and as a result, they chose the avoidance coping strategy. Moreover, in the present study the utilization of the transference coping strategy decreased significantly at the end of nursing students’ PMHN clinical training. This could be because the transference coping strategy (i.e. watching TV or having a shower) provides quick relief of the transitory stress symptoms in the initial period of practice. When the psychiatric clinical training progressed, the students realized that the transference coping strategy was ineffective for handling long-term clinical stress. Consequently, the utilization of the transference coping strategy decreased at the end of PMHN training.
Limitations and future recommendations The present study has some limitations. First, in relation to the setting, data were collected from the available students in the lecture theatres, so students who were not present at those theatres might have had different responses with regards to the study instruments. Second, the structured questionnaire might have restricted the in-depth understanding of the students’ reactions to stress and the ability to identify other strategies of coping. The integration of a qualitative part (e.g. adding open-ended questions to the study tools) in further study designs © 2013 Australian College of Mental Health Nurses Inc.
PERCEIVED STRESS AND COPING STRATEGIES
might be helpful. Third, by employing the longitudinal design in the present study, we can detect changes in the degree of stress and coping abilities by tracking the same participants over time; however, students could be exposed to different sources of stress, other than being enrolled in clinical psychiatric nursing courses, which might affect students’ stress experiences. These other sources were not detected in the present study.
CONCLUSION The present study contributes to the knowledge of stress and coping among Jordanian nursing students during their PMHN clinical training. The study results revealed that the most reported stressors at both data-collection times were stress from taking care of patients, stress from teachers and nursing staff, and stress from assignments and workloads. Equipping students with essential clinical knowledge and skills, reviewing the clinical PMHN curriculum requirements, and preparing all professionals involved in training the nursing students adequately are imperative issues that might help students effectively deal with these clinical stressors. Further research should be conducted to examine the specific needs of students, either during pre-PMHN clinical training or post-PHMN clinical training, in order to develop appropriate interventions. Moreover, it is recommended that upcoming studies expand the scope of the present study by examining stressors and coping strategies among nursing students enrolled in other clinical courses, such as foundations, medical/surgical nursing, paediatrics, and maternity.
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