Stress Reaction and Coping Strategies among Nursing Students in Delhi

Nirmala Singh¹, Charu Kohli²

¹Principal, College of Nursing, Dr RML Hospital, New Delhi

²Resident, Department of Community Medicine, Maulana Azad Medical College, New Delhi.

Corresponding Author Email: kohlicdoc17@gmail.com

ABSTRACT:

Background:

Professional education can be a very stressful experience which often affects the physical and mental health. It is important to assess the psychological well being of the nursing students. This study was planned with an objective to identify and analyze the stress, stress reactions and coping strategies among nursing students in response to the stress in a nursing college in Delhi.

Materials and Methods:

A cross sectional study was conducted among 139 students of a nursing college in Delhi selected from different batches by purposive sampling method. Data was collected using a self administered questionnaire consisted of items on socio-demographic profile, clinical stress, stress reactions and coping strategies after getting written informed consent. Data was analyzed using SPSS software (version 17). Coefficient of correlation between clinical stress and stress reaction; stress reaction and coping strategies; clinical stress and coping strategies was calculated and “p” value less than 0.05 was considered significant.

Results:

A majority (70.5%) of study subjects were in the age group of 20-22 years, educated upto post high school (83.4%) and belonged to nuclear families (86.3%). The mean clinical score for stress was 56.8 + 15.7. Maximum number of study subjects (76.97%) reported moderate degree of stress with a mean stress score of 60.18. Study subjects reported both psychological and physical stress reactions but physical reactions (average-160.2) were more evident. Study reveals that anticipated coping and seeking social support were the most common coping strategies.

Conclusions:

Effective intervention strategies should be taken for reducing stress among nursing students.

KEYWORDS: Nursing students, Stress, Delhi

INTRODUCTION:

Professional education can be a very stressful experience which often affects the physical and mental health. Distress in the educational years may lead to impairments in the practicing years of a professional.¹ Academic stress among college students, especially fresher who are particularly prone to stress due to the transitional nature of college life is an area of interest. Students may need to develop entirely new social contacts and are expected to take responsibility for their own needs. They may have difficulty adjusting to more rigorous academic expectations and the need to learn to deal with individuals of different cultures and beliefs.² Tests, grades, competition, time demands, professors, class environment and concern about future careers are major sources of academic stress.³ If stress is not dealt with effectively, feelings of loneliness and nervousness, as well as sleeplessness and excessive worrying may result. Student perception of high stress levels can lead to poor academic performance, depression and serious health problems. Methods to reduce student stress often include effective time management, social support, positive appraisal, and engagement in leisure pursuits.⁴ The stress reported among nursing students have been categorized as academic, clinical and personal sources of stress.⁵Coping has been viewed as a stabilizing factor that may assist individuals in maintaining psychosocial adaptation during stressful events. It can be positive or negative depending upon situation and content.²

AIM:

Keeping the above aspect in view, it is important to assess the psychological well being of the nursing students so that effective intervention strategies can be made. This study was planned with an objective to identify and analyze the stress, stress reactions and coping strategies among nursing students in response to the stress in a nursing college in Delhi.

MATERIALS AND METHODS:

Study settings and population

A cross sectional study was conducted among students of a nursing college in Delhi. B.Sc nursing students studying in the institution constituted the study population. A total of 139 nursing students were selected from different batches by purposive sampling method.

METHODOLOGY:

A nominal roll of all nursing students studying in a batch was prepared. 139 students were selected randomly from batches in population proportionate to size sampling. Purpose of the study was explained to the study subjects and confidentiality was assured. Data was collected using a self administered questionnaire after getting written informed consent. The schedule consisted of four parts; I – socio-demographic details like age, education, type of family and family income; part II – clinical stress; part III – stress reactions; and part IV – coping strategies. In part II, items pertaining to clinical stress which were placed in seven stressor areas. For each question there was provision for selecting one out of four possible responses and weights were given as: severe stress (3), moderate stress (2), mild stress (1) and no stress (0). Total scores were summed up for the individual and categorized the degree of stress as “mild”, “moderate” and “severe”. The mild stress was with score 1-44, moderate stress with score 45-88 and severe stress having score of 89-132.

In part III, items pertaining to stress reaction which was categorized into physical and psychological reactions. The stress reaction questionnaire consists of 26 items related to physiological and psychological reactions. It is a four point scale with the responses and assigned weights accordingly: frequently (3), occasionally (2), rarely (1) and never (0). As per frequency of stress reaction, the total responses were categorized as rarely with stress reaction score of 1-26, occasionally with stress reaction score of 27-52 and frequently with score of 53-78.

Part IV had coping strategy items which were divided into eight categories of coping styles of seeking relaxation, venting, escaping, accepting responsibility, seeking social support, problem solving, anticipated coping and wishful thinking. The coping strategies questionnaire consisted of 35 items. It was a three point scale with the responses assigned weights as ‘ Always’ (2), ‘Sometimes’ (1), ‘Never’ (0). Here also, it was classified as “sometimes” with coping strategies when total scores were ranged between 1 and 35 and “always” with total scores were ranged between 36 and70.

Study tool validity and reliability analysis:

The content validity of the tool was established by giving it to ten experts in the fields of clinical psychology, psychiatric nursing, psychiatrist educationist, and administrator. Most of the experts agreed on most of the items and necessary modifications were made as per their suggestions. Pilot testing was done on adequate sample of nursing students of another nursing college. The reliability of the tool was established using Cronbach’s alpha method. The reliability of the clinical stress was 0.99 and for stress reaction it was 0.84 and 0.75 for coping strategies.

Data analysis

Data was analyzed using SPSS software (version 17). Results were presented in proportion, mean (M) and standard deviation (SD) wherever applicable. Coefficient of correlation between clinical stress and stress reaction; stress reaction and coping strategies; clinical stress and coping strategies was calculated and “p” value less than 0.05 was considered significant. Ethical clearance was taken from institutional ethical committee.

RESULTS:

Table 1 shows socio-demographic characteristics of the study subjects. 98 (70.5%) were in the age group of 20-22 years. 116 (83.4%) of the nursing student nurses had education up to post high school. The family-wise classification showed that majority of the student nurses; 120 (86.3%) belonged to nuclear families whereas only 19 (13.7%) belonged to joint family. Majority of the nursing students (30.9%) had a family income above Indian National Rupee (INR) twenty thousand.

Table 1: Socio demographic characteristics of nursing students

Characteristics	Frequency	Percentage (%)
Age
17-19 years	40	28.8
20-22 years	98	70.5
23-25 and above	1	0.7
Education
Till post high school	116	83.5
Graduate	22	15.8
Post graduate	1	0.7
Type of Family
Nuclear	120	86.3
Joint	19	13.7
Monthly Family Income (INR):
< 10000	31	22.4
10001-15000	32	23.0
15001-20000	33	23.7
20001 and above	43	30.9
Number of Family Members:
1-4	104	74.8
5-10	32	23.0
11-15	3	2.2

The mean clinical score for stress was 56.8 + 15.7. To identify the highest and least clinical stress area of nursing students, an area wise computation of mean score was done. Mean score calculated by adding up the scores of each item of one area and dividing it by the number of items as represented in Table 2. Data shows that the highest mean stress score was in the area of “Interaction with clinical faculty” (µ = 207.71) followed by “Interaction with health team members” (µ = 203.6). The least stress scores were in the area of “Interaction with patients and relatives” (µ = 134.5).

To assess the degree of stress in nursing students, scores were categorized into ‘mild’, ‘moderate’, and ‘severe’ as shown in Table 3. The maximum number of student nurses; 107 (76.97%) had moderate degree of stress with a mean stress score of 60.18. Five student nurses (3.59%) experienced severe stress with a mean score of 100.2 and 27 students (19.42%) experienced only mild stress with a mean of 35.33.

Table 2: Mean score of areas of clinical stress among nursing students

Clinical Stress area	Mean score (µ)
Interaction with clinical faculty	207.7
Interaction with health team members	203.6
Clinical rotation and assignments	184.5
Nursing procedures	181.7
Interaction with peer group/senior students	169.8
Patients’ disease condition	164.8
Interaction with patients and relatives	134.5

Table 3: Degree of stress among nursing students

Degree of Stress	Frequency (Percentage)	Mean score
Mild Stress (1-44)	27 (19.4)	35.3
Moderate Stress (45-88)	107 (76.9)	60.2
Severe Stress (89-132)	5 (3.6)	100.2

Mean stress score of second year student was 44.8 with S.D of 6.9 whereas third year student’s mean score was 40.8 with S.D. of 9.5 and fourth year students had a mean clinical stress score of 56.8 and S.D. of 12.2, although the students of all the years experienced clinical stress, however fourth year students experienced maximum stress and third year students had least clinical stress scores. Mean stress reaction score was 29.4 with standard deviation of 13.1. The stress reactions were divided into two areas-physical (10) and psychological reactions (16). Item wise mean score of physical and psychological stress reaction were computed to identify the most frequent and least frequent stress reactions as shown in Table 4. Although students experience both psychological and physical reactions but physical reactions (average-160.2) were more evident among students than psychological stress reactions (average-155.25).

Table 4: Stress reaction score for physical and psychological stress reactions among nursing students

Physical Stress Reactions	Stress reaction score	Psychological Stress Reactions	Stress reaction score
Do you suffer from headaches?	179	Do you feel depressed?	196
Do you have disturbed sleep?	178	Do you experience restlessness?	192
Do you experience palpitation?	169	Do you find it difficulty in concentration?	188
Do you feel lethargic?	166	Do you feel nervous while speaking and doing procedures?	183
Are you troubled by indigestion?	162	Do you experience mood change?	182
Do you experience muscular tensions and pains?	159	Do you feel irritated easily?	176
Do you over eat?	155	Do you find difficulty in taking decisions?	159
Do you suffer from Diarrhea?	148	Do you want to be left alone?	152
Do you feel thirsty frequently?	145	Do you get panicky in emergency situations?	151
Do you experience increased perspiration?	141	Do you perceive unknown fears?	139
Average	160.2	Do you get tried easily?	138
		Do you experience inferiority feelings?	134
		Do you feel threatened in the Clinical setting?	134
		Do you lose your self- control?	131
		Do you find yourself disorganized and disoriented?	128
		Do you feel like harming who disturb you?	101
		Average	155.2

When inquired about frequency of stress reactions, 57 (41%) reported rarely, 77 (55.39%) as occasionally and frequently was reported by 5 (3.6%). Mean coping strategy score was 42.5 + 7.9.

Figure 1 shows that the highest coping scores were in the area of “anticipated coping” (µ = 202.3) followed by “seeking social support” (µ = 197.8). The lowest score was in the area of “seeking relaxation” (µ =148.6) preceded by “escaping” (µ = 152.8). It suggests that “anticipated coping and seeking social support” were the most common coping strategies while “seeking relaxation and escaping” were least common. Most of the student nurses; 112 (80.5%) reported using coping strategies “always” with a mean score of 45.4, whereas 27 (19.4%) of them reported use of coping strategies “sometimes” with a mean score of 30.6.

Coefficient of correlation between clinical stress and stress reaction was 0.96 which was statistically significant (p value = 0.03). Similarly, coefficient of correlation between stress reaction and coping strategies was 0.98 (p value = 0.02). Coefficient of correlation between clinical stress reaction and coping strategies was also 0.98 (p value = 0.03).

DISCUSSION:

It was observed in the present study that stress levels were high among nursing students. Moderate stress levels were present in majority of nursing students. The findings are consistent with a study conducted by Singh A et al in a nursing college where mean perceived stress score of students was 28.67 (SD = 5.32) with least stress levels in third year students.⁶Other studies also indicated higher levels of stress and physiological and psychological symptoms among nursing students.⁷ Interaction with faculty, nursing procedures were main sources of stress. Nolan G et al also found that main sources of stress were associated with relationships in the clinical environment; clinical workload; matching competence and responsibility; and simultaneous clinical and academic demands.⁸

A number of physical and psychological symptoms were perceived by students like headaches, lethargy, disturbed sleep, palpitations, depressed mood etc. This is consistent with the study carried out by Sheu S et al which revealed that stress for students came mainly from the lack of professional knowledge and skills as well as caring of patients. The most common response to stress was social behavioral symptoms.⁹

Regarding coping strategies, anticipated coping, problem solving and seeking social support were most frequent responses. Similar findings were reported by SeyedfatemiN et al who conducted study among Iranian nursing students. The study revealed that problem solving strategies, trying to reason with parents and compromise were common coping strategies.¹⁰ Other studies also stated that nursing students used to cope up by using both problem-focused and emotion-focused coping skills as found in present study.¹¹

The significant correlation were found between stress reactions and coping strategies. Similarly significant correlation (P < 0.01) was found with avoidance coping behaviors and negative self-esteem. Positive self-esteem was significantly correlated (P < 0.01) with proactive coping behaviors in study conducted by Lo R.¹¹ The possible limitations of the study are sampling method which may lead to selection bias.

CONCLUSION AND RECOMMENDATIONS:

It is concluded that educators must take a close look at the clinical education process which encompasses the methods of teaching and evaluation choice of clinical faculty and the attitudes towards clinical expectations. Effective measures should be taken for reducing stress among students.

CONFLICT OF INTEREST:

None declared.

ACKNOWLEDGMENT:

The authors are grateful to study participants for their contribution.

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