Int. J. Nurs. Educ. Scholarsh. 2015; 12(1): 1–8

Linda Wallace*, Mary P. Bourke, Lucy J. Tormoehlen and Marlene V. Poe-Greskamp

Perceptions of Clinical Stress in Baccalaureate Nursing Students DOI 10.1515/ijnes-2014-0056

Abstract: The Nursing Students’ Clinical Stress Scale, a Likert-type survey by Whang (2002), translated from Korean into English, was used to identify perceptions of stress in baccalaureate nursing students. Data was collected from a convenience sample of baccalaureate nursing students at a Midwestern university. Students ranked their perceived stress level from clinical situations. One open-ended item asked students to describe their most stressful clinical experience. Rasch Model analysis/diagnostics were used to check the instrument for validity and reliability. Quantitative data were analyzed for descriptive statistics (means). Information from open-ended question was analyzed for themes. Qualitative themes were consistent with results from quantitative analysis and well-aligned with the literature. Students were stressed by incivility by healthcare staff and instructors, inconsistencies and time constraints. Research shows that stress can interfere with learning. It is imperative to determine causes of stress so educators can help decrease stress and improve student learning. Keywords: clinical student stress, fear, incivility, time constraints, inconsistencies

The preparation of future nurses requires classroom and “hands on” practice education. Nursing students must perform patient care in clinical settings while being observed, coached, and evaluated by an instructor. Aspects of the clinical setting may cause varying degrees of stress in nursing students. This study was designed to measure dimensions of stress in the context of the clinical experience. Dimensions of stress within the context of clinical experience as articulated in the survey included: fear, incivility, inconsistencies, and time constraints. Dimensions were studied in relationship to being unprepared/doing something new or unfamiliar/making

*Corresponding author: Linda Wallace, School of Nursing, Indiana University Kokomo, East Building 220, 2300 South Washington Street, Kokomo, IN 46902, USA, E-mail: [email protected] Mary P. Bourke, Lucy J. Tormoehlen, Marlene V. Poe-Greskamp, School of Nursing, Indiana University Kokomo, East Building 220, 2300 South Washington Street, Kokomo, IN 46902, USA

a mistake, and behaviors of healthcare staff and instructors/teachers toward students.

Review of literature Nursing students worldwide have articulated various causes for stress throughout their education. Ratanasiripong, Ratanasiripong, and Kathalae (2012) in their study on biofeedback as an intervention note, “It has been well documented that nursing students across the world experience stress and anxiety throughout their education and training” (para 1). Stress is defined as “A physical or psychological stimulus that can produce mental tension or physiological reactions that may lead to illness.” (“Stress”, n.d., para. 8). Stress can lead to anxiety, a sense of uneasiness or uncertainty. While some anxiety is needed for its motivational effect, higher levels of anxiety can have “the opposite effect” (Vannaja, 2005, p. 6). Consequences of anxiety can be observed as cognitive deficits, inability to concentrate, lack of memory or recall, and even misinterpretation of what is being said. Stress in students may cause feelings of self-deprecation, low self-esteem, and a loss of confidence in their ability to perform assigned tasks. Although anxiety-causing stimuli varies from student to student, too much is a barrier to learning (Vannaja, 2005). In a longitudinal study (Edwards, Burnard, Bennett, & Hebden, 2010), students articulated increased levels of stress when instructors emphasized negative aspects of their work, and perceptions of inadequate support from their instructors. Increased stress from conflict and from criticism from supervisors were also identified. Jimenez, Navia-Osorio, and Diaz (2009) surveyed 357 nursing students and found that participants experienced moderate to severe stress from the following; their performance did not meet teachers’ expectations; teachers’ instructions were different from their expectations; they lacked guidance from teachers; and they felt that teachers did not evaluate students fairly. Additionally, in a review of quantitative studies related to stress in nursing students, Pulido-Martos, Augusto-Landa, and Lopez-Zafra (2012) noted, “Clinical sources that were identified as most stressful include dealing with unfamiliar situations, making errors with patients, learning to apply clinical

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procedures and managing technical instruments, among others.” (p. 23).

of faculty incivility. Not surprisingly, students who were targets of this interpersonal mistreatment were dissatisfied with their nursing programs.

Fear Inconsistency In a study by Oermann and Lukomski (2001), students articulated that one of the major goals of clinical was to “do no harm to the patient” and as a result, the fear of making a mistake and causing harm increased student stress. Hegge and Larson (2008) stated that in a study of 75 nursing students, fear of medication errors was one of the major themes identified by students as a source of stress. Jones and Johnston (1997) reported in their study of nursing students that fear of failing was a major contributor to stress. Similarly, Sharif and Masoumi (2005) found that fear of making a mistake (fear of failure), was a stressor for nursing students and compromised student performance.

Incivility Teacher incivility (teacher behaviors that were perceived as being authoritarian and intimidating), was also identified as causing stress that interfered with learning (Marchiondo, Marchiondo, & Lasiter, 2010). Clark (2008) studied students’ perception of uncivil faculty behaviors and consequently defined academic incivility in nursing education as “any speech or action that disrupts the harmony of the teaching-learning environment” (p. 284). The dominant theme identified by students was faculty making belittling and demeaning remarks, often “publicly” or at least in front of colleagues. These students felt traumatized, helpless, and powerless. They perceived that they had too much to lose if they confronted faculty or took their complaint to a higher level. They feared being expelled from the nursing program. Benner, Sutphen, Leonard, and Day (2010) wrote, “When most students enter a clinical setting, it is often unfamiliar territory to them as a place to learn. They may meet nurses who accept them wholeheartedly and see them as future colleagues or others who express outright hostility” (p. 62). Marchiondo et al. (2010) articulated that the clinical setting is an environment that involves regular interaction between instructors/faculty and students, and therefore includes the elements of feedback and criticism. “Under these conditions, the opportunity for incivility can be high.” (p. 612). Students were resistant to exposing these abusive behaviors and reported feeling anxious, nervous, or depressed following an experience

When students perceive inconsistencies between expectations delineated in the syllabus, how the instructor assigns grades, and what is actually rewarded/punished by instructors and staff in clinical, their trust is shaken, leading to increased uncertainty and stress. In contrast, students are more likely to trust faculty who were organized and reliable in terms of responses to students. “The instructor [who is] trusted by the students recognized the student’s need for clear guidelines and expectations for the clinical rotation” (Stowe, 2003, p. 154).) According to Berg & Lindseth (2004) communications, specifically in relationship to course information and expectations, was one of the top five characteristics cited when students described effective and ineffective instructors. The effective instructor “reviews expectations clearly” (p. 567), whereas the ineffective instructor does not, and this leads to inconsistency. In a qualitative study of nursing students in Iran, inconsistency between theory and practice, and between demands of nursing staff and instructors led to student anxiety (Sharif & Masoumi, 2005). In relation to the differences between theory and practice, best practices and clinical practice, Levett-Jones and Lathlean (2008) discovered, “There were also claims in the nursing literature that some students conform to clinical practices, irrespective of whether they are ‘best practice’, so as to be accepted into the nursing team and to belong.” (p. 105). Therefore, when faced with inconsistencies, students took the path of least resistance in order to decrease their stress. One of the most powerful lessons students may learn in school is to “fit in” at whatever cost. Ultimately, this is not desirable for patients, practice, or academia.

Time constraints While there are gaps in the literature related to the lack of, and demands on, instructor time as perceived by the student, a National League of Nursing (NLN) Think Tank on Transforming Clinical Education (2008) charged with the task of examining clinical education stated, We need to be asking what students are really doing while they are in the clinical setting and how they are spending their time. Is their time always focused on learning? How much time do

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L. Wallace et al.: Perceptions of Clinical Stress

they spend finding information, waiting for the instructor, or other activities that take them away from patients? Do we keep students too safe? Are activities always focused on patientcentered care? (p. 8)

It is common for students to wait for an instructor to watch them give medications or to perform treatments and other procedures; therefore, an instructor has to balance and prioritize time necessary to meet student and patient needs. This wait, although understandable, is perceived as stressful to students.

Purpose The Institute of Medicine (2011) recommended that nurses should be more educated, should practice to the “full extent of their education and training” and should be full partners in “redesigning healthcare in the United States” (p. 5). While a certain amount of stress and anxiety can lead to enhanced attention and focus, too much can, as noted earlier, lead to cognitive deficits, inability to concentrate, lack of memory or recall, and even misinterpretation of what is said. Nurse educators need to be aware of what causes unnecessary stress and anxiety in clinical nursing education and find ways to help minimize it. In order to understand what causes nursing student stress in the clinical setting, a survey was used which focused on the clinical experience, addressing the following dimensions of stress: fear, incivility, inconsistency, and time constraints. The purpose of this research was to answer the following questions: 1. What situations are perceived by students as causing the most stress related to being unprepared/doing something new or unfamiliar/making a mistake? 2. What behaviors of healthcare staff toward students are perceived by students as causing the most stress? 3. What instructor behaviors and supposed meanings of such behaviors are perceived by students as causing the most stress?

Procedure The need to assess clinical stress in pre-licensure baccalaureate students was based on the potential deleterious effects of stress on student performance in clinical courses. The Nursing Students’ Clinical Stress Scale, a Likert-type instrument developed by Whang (2002), was selected because it focused on stress in the clinical setting more

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so than stress in general. The original survey had a Cronbach Coefficient of 0.60 and this reliability was increased to 0.94 on the refined tool used for this study. Whang (2002) translated the original work from Korean to English upon request from one of this study’s authors. The same author refined the language of the instrument so that it flowed easily for English-speaking students, while retaining the substance of each survey item. This English translation of the instrument was used for this study in the USA. The survey was placed online utilizing FlashLight survey technology. FlashLight Online is a tool to distribute simple questionnaires, surveys, etc., and to gather statistics on responses, utilizing a web based interface (MacPhee, n.d.). The use of FlashLight allowed individual student data to be collected anonymously and in a format necessary for analysis. Survey items were based on 59 aspects of student clinical experiences and response categories measured an associated level of perceived stress. For example, “How much stress do the following situations cause you in clinical?” was followed by examples of typical clinical situations that nursing students could encounter. Response categories for each item were stated as 1 ¼ Very Much, 2 ¼ Much, 3 ¼ Some, 4 ¼ Not Much or 5 ¼ None. Additional survey items included demographics, level of satisfaction with clinical experiences while in school, level of satisfaction with the nursing major, and the primary reason for choosing nursing. One open-ended item asked students to describe their most stressful clinical experience. This provided an opportunity for triangulation of data aimed at garnering a deeper understanding of students’ perceptions of stressful clinical experiences. Descriptive statistics (means) and Rasch Model diagnostic data were analyzed along with themes identified by qualitative data collected from the open-ended item. Following approval by the University’s Institutional Review Board/Human Subjects Committee, a convenience sample of all junior (46) and senior (64) nursing students was invited to take the FlashLight survey using the University’s on-line course management system. Responding to the survey was voluntary and not associated with any course work or grade. Students were provided the link to the on-line Flashlight survey in an e-mail message and had 6 weeks to respond. The survey was estimated to take 10–15 minutes to complete.

Analysis Of the 110 students invited to participate in the study, 65 students completed the survey (59% response rate);

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58.5% were between the ages of 18 and 30. Of the respondents, 93.8% were female. Only 35.4% of respondents had more than 1 year of hospital experience. Fifty-four percent (54.6%) of respondents were satisfied with their clinical experience, and 65.1% were satisfied having a nursing major. Although 33% stated they chose nursing as a future career because of salaries, the remaining 67% elected not to share why they had chosen nursing as a profession. After participants submitted their responses, researchers identified the constructs of stress that were evident in the question construction from the original survey. Research questions were analyzed based on the identified constructs. Rasch Model diagnostics were performed on survey responses in order to assess the instrument’s validity, reliability and item functioning, particularly as it relates to objective measurement. In addition, diagnostic tests within Rasch Model analysis provided valuable information about item and category functioning (response categories on a Likert scale) as well as, reliability and validity of the instrument. The Statistical Package for the Social Sciences (PASW Statistics 18) was used for descriptive analysis. Rasch Model analysis found that all items except 54 and 59 measured the constructs of stress as they relate to the clinical experience of nursing students. Responses to the open-ended item which asked students to describe their most stressful clinical experience were organized according to the most closely related construct of stress. This provided a well-organized system to articulate the student’s perspective of perceived clinical stress within the framework of identified constructs of stress.

Results Rasch diagnostics and analysis allows the empirical evidence to demonstrate that the survey items did, in fact, measure the latent variable “stress”. The empirical definition of a variable is the content of the items and that each item contributed to the measurement of the latent variable. However, although it was determined that the instrument is valid and reliable, diagnostics identified a need to redefine the categories for better differentiation by the respondents. All items except 54 and 59 measured the dimensions of the construct stress as they relate to the clinical experience of nursing students. As a result of the analysis it was determined by the researchers that a revised future instrument will contain the following

categories: (1) “No Stress” (2) “Mild Stress” (3) “Moderate Stress” and (4) “Severe Stress” and that items 54 and 59 will be deleted. Results are reported using a mixed method approach. The significant findings are organized and reported for each research question.

Stress related to doing something new or unfamiliar or making a mistake What situations are perceived by students as causing the most stress related to being unprepared, doing something new or unfamiliar or making a mistake? Table 1 lists the survey item means related to this research question in rank order, starting with the most stressful (lowest mean) to the least stressful (highest mean). Not surprisingly “seeing a patient die” caused them the most stress followed by “afraid of making a mistake”. These two items articulate an understanding of the seriousness of working with patients. The third most stressful item in this section, “being afraid of failing in the nursing major,” addresses student concerns about their future career plans.

Table 1: Mean scores for items Rasch person item map indicated as most stressful related to being unprepared, doing something new or making an error. Item Seeing a patient die Afraid of making a mistake Being afraid of failing in nursing major Fear of making errors in clinical Performing certain nursing procedure for the first time Watching client’s distress, like death and dying Difficulty in application from nursing theory and knowledge in clinical Feeling helpless in clinical situations Not feeling confident in nursing knowledge Feeling pressure from preparation for/presentation in clinical conference

Mean . . . . . . . . . .

Note: 1 ¼ Very Much, 2 ¼ Much, 3 ¼ Some, 4 ¼ Not Much or 5 ¼ None, N ¼ 65.

Similar themes identified from qualitative findings were fear of being unprepared, doing something new or unfamiliar (such as caring for more than one patient or doing a procedure for the first time) or making a mistake (such as in medication administration). One student commented that she had “fear and anxiety’ because she was afraid something would go wrong. Another verbalized

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L. Wallace et al.: Perceptions of Clinical Stress

“fear of IV push medications that could kill the patient if the wrong dose were given too fast.” One respondent reflected on the experience of having a patient on a balloon pump, and “…worried that the pump would fail.” Another described the most stressful clinical situation as “…the first time I had to administer medication. Making sure it was the right patient, right drug, right dose, right time, and right route.” Not surprisingly, “participated[ing] in a code situation” was reported as being stressful. New experiences cause fear such as the first time a student was assigned more than one patient, the fear of “forgetting something or not being organized enough.”

Behaviors of healthcare staff perceived by students as causing the most stress The most stressful situation for students related to healthcare staff was when the “staff was at odds with the nursing faculty/students”. Students were concerned about being caught in the middle and being used as a scapegoat when something went wrong on the unit, as evidenced by the second most stressful situation, “nurse blames student for nurse’s error”. Table 2 lists behaviors of healthcare staff perceived as most stress-producing for students. Respondents described several stressful situations encountered during their clinical experiences that were the direct result of uncivil behaviors from other healthcare workers, including nurses and physicians. Students were blamed for many things. One student described how

Table 2: Mean scores for items Rasch person item map indicated as most stressful related to the behaviors of healthcare staff toward students. Item

Mean

Hospital staff is at odds with nursing faculty/students Nurse blames student for nurse’s error Nurse is angry with or scolds students in front of client Medical doctors and nurses ignore students Medical teams are not cooperative Appropriate treatment or care is not given to client Nurses are not kind enough to clients Nurses who are not attentive to students Nurse does not follow nursing principles Physicians and nurses are not polite to students There’s no place for students in the clinical area

. . . . . . . . . . .

Note: 1 ¼ Very Much, 2 ¼ Much, 3 ¼ Some, 4 ¼ Not Much or 5 ¼ None, N ¼ 65.

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the clinical group was “verbally assaulted” in post conference over a “bag of chips” left sitting on the table and from which a few students had taken a few chips. A staff nurse came into the room and “spoke to us as though we were dogs, and this was not the first time…even the instructor was taken aback by it.” Students were made to feel unwelcome by the staff working on the unit. In one instance, “one staff nurse made it clear that she did not want us there” and “it’s sad when you walk into report and the nurses start complaining because students are there that day.” Another stated, “My most stressful clinical situation was when I was yelled at by a physician.” Afterward, the student was told “to get thick skin”; and “if you can’t take being yelled at, I should get out now.” “In one facility, the nurses took a hands-off approach. They only communicated with us when we went to them.” It is not known if the staff was trying not to interfere or otherwise, but this is how one student perceived this behavior. Students cannot help feeling unsupported in an environment where they do not feel included or respected; essentially when they have “no voice” (Steele, 2009). More so, the student pointed out that the nurses documented care and assessments when “I didn’t even know they had gone in to see my patient.” Students also witnessed the proverbial “things we’ve been taught not to do” and of course, the student “didn’t feel it was my place to correct them.” Another student, in the first clinical experience at a new hospital, felt the report given by the nurse about the assigned patient was seriously lacking, placing the student in an emergent situation. The nurse stated that the patient’s “thumb was somewhat blue and the (new dialysis) shunt might be occluded.” The student found that the patient’s entire lower arm was blue and could tell that this needed to be addressed quickly. Fortunately, the instructor quickly assessed the patient and took action. One student found that the patient did not have an elevated toilet seat that had been ordered. The student spoke to the charge nurse who said to go ahead and get the seat and attach it to the patient’s toilet. When the student did so, a physical therapist working at the bedside suggested that a bedside commode would be more appropriate for the patient’s level of mobility. The charge nurse overhearing this conversation “loudly chided” the student for an inadequate assessment in front of the patient and the therapist. After being told by a nurse to give the patient an injection of Demerol, a student envisioned “my nursing career going down the drain” because that same nurse said that the student “gave too much.” The student and

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instructor worked out the problem but it was “horrifying.” Another student concluded, “I want to be with a helpful nurse so I can actually learn something and not with one who gets snappy when I ask a question.”

Instructor behaviors perceived by students as causing the most stress Some experiences perceived as stressful resulted from uncivil behaviors by the nursing instructor. An example was, “being confronted by my clinical instructor in front of my patient.” Another participant provided the following example, where the student felt the instructor “had it out for me”: She follow[ed] me around throughout each day at the clinical site and literally questioned and almost argue[d] with me regarding my every action. I received my lowest grade ever in a clinical that year and I feel I did not learn anything.

Another’s most stressful clinical situation: The most stressful clinical situation I had was when giving an IM shot to a new mother. I accidently triggered the safety latch so that the needle was not exposed and my clinical instructor blew it out of proportion. She took it from me and then dropped it on the floor. And with me holding the end of the syringe, she tried to pull back the safety latch with her bare hands, instead of just going to get a new needle. All of this was witnessed by the new mother and her husband. …I was stressed because I was angry that my clinical instructor did this in front of them when she should have obtained a new syringe!

Had these actions taken place in other settings, they would be identified as abusive but are often tolerated in clinical settings, perhaps because instructors believe they are making their students stronger. Inconsistencies related to expectations were articulated by students as stressful: “going into a clinical setting without a good understanding of what to expect and what is expected of you.” Other students experienced stress from “being asked to document when their [the hospital’s] documentation is completely different than what we learned in school” and “each clinical instructor wanting a care plan done a different way.” Time constraints related to instructors in the clinical setting also caused participant stress. Clinical rosters often consist of ten students per one instructor. This high number of students caused stress for students and faculty alike. The high student-to-instructor ratio contributes to excessive waiting periods that were expressed to be stressful. One student described the stress of waiting:

When you are constantly waiting for your instructor to get done with 9 other students, it can be stressful. Many times meds were an hour late because I had to wait on my clinical instructor. I wouldn’t get other tasks done, because if I wasn’t there to remind her that my client needed meds. Since then, I had a different instructor, who assigned only 5–6 students to the floor per week. This was much easier and my stress level went down.

Another participant wrote, “Having a patient that required many medications that I needed to have the clinical instructor present to give which made me feel behind.” In addition to feeling rushed due to the instructor’s lack of availability, some students also felt that they were in hurry-up-and-wait situations, rushing to do some tasks then waiting and wasting time while the instructor was doing something else. As one student illustrated, “Every time I am at clinical, I will need the instructor for something and won’t be able to find her…sometimes we are doing NOTHING.” One participant expressed dissatisfaction with clinical as: It is stressful to me to just feel like I am in the way. I don’t like just watching, because I feel like an extra wheel in the way, wasting eight hours of time. If I had never worked in a healthcare setting before, I would be so overwhelmed with everything – from the sights, sounds on the unit to knowing who is who. I am disappointed in clinical. I thought I would do more, learn more, and have more hands-on opportunities. I would love to go 2–3 times per week if only I didn’t have so much busy work to complete for assignments.

Other students complained about assignments encroaching on their time, restricting their focus on clinical. For example, “Having a paper due that takes days to type and two exams in the same week, or near to each other. I feel clinical should not have so much homework”.

Discussion The Nursing Students’ Clinical Stress Scale by Whang (2002) has now been used in two languages, Korean (original) and English and can be used in other languages. While Rasch Model analysis indicated that the instrument was reliable and valid, it was discovered that respondents had difficulty making a distinction between “some” and “not much” Likert-type categories. In this situation, it is advised to re-label these categories for clarification. This is explained in more detail in another article by the researchers, Bourke, Wallace, PoeGreskamp, and Tormoehlen (2015). The analysis from this study illustrates clearly that clinical experiences can be very stressful for students. The

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L. Wallace et al.: Perceptions of Clinical Stress

qualitative data clarified quantitative results. What was not well known from the literature review was the intensity of fear experienced by nursing students; fear of making a mistake, fear of harming a patient and fear of failure. If student fears are not effectively managed they may be manifested as floundering efforts when trying to perform skills or other nursing tasks, or as acting out behaviors. Discourteous behaviors of those who surround the student in clinical are regarded as incivility in this study. This maltreatment can also result in fear and hence are perceived as stressful for nursing students. Another source of stress was the time “wasted” while waiting for the nursing instructor when clinical groups are of maximum size. Even though students may appear to be idly waiting, they are stressed because other patient care tasks were not being completed or were being delayed because of the wait. Nursing is perceived as a caring, healing profession therefore students expect that nurses (staff and instructors especially) will nurture and support their efforts to become nurses. Staff and instructors often see their role as preparing students for the realities of real life nursing, which includes stress and sadness at times. Additionally, staff and instructors may be unaware of the vulnerability students feel in unfamiliar territory of clinical nursing and the amount of support and interpretation students need in order to be successful. When students are confronted with inconsistencies and discourteous behaviors they experience dissonance and confusion which exacerbate their fear of failure. Quantitative findings in this study give insight into the experiences which cause the most stress to students, such as “seeing a patient die” or “fear of making a mistake”. Instructors should anticipate these experiences and specifically prepare students in advance to deal effectively and compassionately with their patients and their families, and even themselves when death is imminent. Faculty are responsible to ensure that students are well-prepared and supported, especially during new experiences, in order to safeguard the patient and the student. And they can meet this responsibility in part through anticipatory guidance. Similarly faculty should role model effective, courteous communications with staff, not leaving students to fend for themselves or to be used as scapegoats when things do not go well. If student stress is allowed to escalate, they are more prone to make mistakes, lose their confidence, and fail. Or they may be successful, in spite of the stress, but learn behaviors to keep themselves emotionally safe and which perpetuate the same troublesome behaviors of some nurses.

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This research studied student perceptions of clinical stress. Further research needs to consider student clinical stress from the instructors’ and staff nurses’ points of view. All parties involved in nursing clinical education need to actively dialogue on issues of controlling clinical stress.

Limitations One study limitation is the relatively small size (n ¼ 65) of the sample. The risk here is that students might have used the survey as an opportunity to vent about what annoyed them. For example, they may have viewed instructors as unfair, when, in fact, the instructors may have been attempting to give constructive criticism. Another limiting factor may be that the instrument has only been used once in the USA and further refinement may be appropriate. This can occur only with repeated use and subsequent analysis.

Conclusion Survey responses and narratives provide rich insight into causes of nursing student stress in clinical education settings. They document the need for a thorough and clear orientation, clear expectations, and courteous interactions. Students should be told why certain things, which frustrate students but may be mandated by either the clinical facility or the education program, are in place. These may include student to faculty ratios. Fewer students per faculty in clinical would be more costly and most education programs have limits as to how much of this cost can be passed on to students. Alternately, clinical facilities and education programs should continue to explore equally, or more, effective ways to provide hands-on experiences, such as enhanced simulations, precepted clinicals, and dedicated education units. Students need to know what is expected of them from the beginning of a clinical rotation and if any changes are absolutely necessary they should be thoroughly and respectfully explained to students. This requires faculty to think ahead and to anticipate the effect of changes on students. Dialog and shared problem solving can help to minimize the negative effect of necessary changes while helping students hone these important skills. Instructors, as guides and translators in the unfamiliar territory of clinical, should anticipate and prepare

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students to face and overcome stressful situations. Instructors should provide as safe an environment as possible for patients and students. Students should always be treated respectfully. Instructors should be role models of respectful, effective communications with staff and students. They should demonstrate the clinical reasoning and conflict resolution skills they expect in their graduates. Reflecting openly about their feelings of inadequacy and vulnerability as students may also help students relax and to relate better to them. Being transparent, sharing experiences about when they failed and recovered or how they took a difficult situation and grew from it will help students realize that their experience is not unique and is most likely something from which they can recover and learn. The future of nursing is being crafted in our students by nursing instructors and clinical nursing staff. With the privilege of educating future nurses comes great responsibility.

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Perceptions of Clinical Stress in Baccalaureate Nursing Students.

The Nursing Students' Clinical Stress Scale, a Likert-type survey by Whang (2002), translated from Korean into English, was used to identify perceptio...
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