Similar to other adult learners, registered nurses returning to school for the baccalaureate degree in nursing are often excited, enthusiastic, and eager at the prospect of being challenged by new ideas and experiences. However, in reality, they are often frustrated, confused, and overwhelmed by the educational experience. The stress experienced by these re-entry students is a significant deterrent to their success in school. While some of the problems of these students are similar to other mature students in higher education with similar adjustments and role transitions, in general, these returning nurses are older with previous education and experience. Many are married and have children (Muzio & Ohashi, 1979). Most of these students continue to work full time for financial reasons and are often overwhelmed with combined responsibilities of work, family, and school.
To teach registered nurses in a baccalaureate degree program effectively, educators need to be knowledgeable of the various coping methods used by re-entry registered nurses in response to academic and clinical stress. Little research has documented either the stressors or the coping strategies RNs use to deal with the pressures of returning to school. This article describes a study designed to identify coping methods of registered nurses enrolled in baccalaureate degree nursing programs.
Review of the Literature
Very little research has investigated specific methods used by students to cope with stress. According to Katz, Weiner, Gallagher, and Hellman (1970), coping is an individual matter and is related to the person's perception and evaluation of the stressful event. The individual may choose to avoid the situation, confront it, or use defense mechanisms such as repression, denial, and rationalization (Hamburg, 1974). Earlier research on coping methods involved acute crises: severe burn victims (Hamburg, Hamburg, & DeGoza, 1953), grief (Lindemann, 1944), surgical patients ( Janis, 1958), and parents of children with cancer (Chodoff, Friedman, & Hamburg, 1964).
Menninger, Mayman, and Pruyser (1963) observed a variety of methods used by individuals to cope with stressful situations. These methods included eating, smoking, drinking alcoholic beverages, crying, cursing, sleeping, talking, daydreaming, and acting to change the situation.
Sidle, Moos, Adams, and Cody (1969) reported that college students used 10 strategies in coping with stressful situations. The 10 strategies included seeking additional information about the situation; discussing the problem with others (friend, relative); looking at the humorous aspects of the situation positively; understanding the situation; preparing for the worst; developing alternative plans for handling the situation; using one's past experiences in dealing with a similar situation; becoming involved in other activities to avoid thinking about the problem; and reducing stress by eating, smoking, or exercise.
The concept of coping has been developed by Lazarus (1966, 1976) at the University of California at Berkeley. He states that coping is a form of problem solving, and it refers to dealing with difficult situations that are perceived by the person as stressful. Direct action and palliation are two methods used in coping with stressful situations (Lazarus, 1966, 1976).
In direct action, the behavior is directed at changing the individual's relationship with the environment and can take the form of preparation against harm, avoidance, or aggression. In preparation against harm, the individual takes action in anticipation of danger. If the action is effective, then the signs of danger recede. If not, the danger becomes evident.
Cox (1978) offers the following example of preparation against harm and avoidance in students' reactions to examinations. The danger is that of failing examinations. Students attempt to cope with the stress of examinations in three different ways. To begin with, students believe studying will enable them to pass the examinations; however, should this attempt at coping fail to reduce danger, then students may deny the importance of the examinations. Lastly, if the two attempts at coping fail, students may become ill and withdraw from the examinations. Mechanic (1962) described some of these behaviors in his study of doctoral students preparing for examinations.
In avoidance, the student flees or escapes from the source of stress. In aggression, the individual attacks the source of the problem, which may be perceived as a specific individual or a group of people. The attack can be physical or verbal and subtle or obvious. It may be expressed in the form of anger and hostility. For example, students may vent anger and frustrations with the dean of the school, or they may give the faculty members a very harsh evaluation.
Palliation, the second method used in coping, is a matter of moderating the distress caused by the experience of stress. According to Lazarus (1976), this is accomplished through symptom-directed and intrapsychic modes. Symptom-directed modes include use of drugs, such as alcohol, and muscle relaxation techniques. Intrapsychic modes are defense mechanisms such as denial, repression, projection, reaction formation, and intellectualization.
This study sought answers to the following questions:
1) What methods are used by re-entry students to cope with stress?
2) What are the similarities and differences in coping methods among re-entry registered nurses in programs designed for beginning students in nursing (generic) and programs designed to build on prior nursing education (specifically designed program)?
Nursing programs selected for the study were of two types: 1) baccalaureate degree programs in nursing designed for beginning students in nursing that provide advanced placement in the program for registered nurses, hereafter called generic program; 2) baccalaureate degree programs in nursing that admit only licensed nurses, the curriculum of which is specifically designed to build on prior nursing education, hereafter called specifically designed program. For logistical reasons, only programs in Southern California could be studied. To identify schools with bachelor of science in nursing programs, the investigator utilized Nayer (1981) and the National League for Nursing (1981). A final sample of 10 schools was identified: four specifically designed and six generic programs. Of the specifically designed programs, two were public and two were private. Of the generic programs, four were public and two were private.
SELECTION OF SUBJECTS- At each school, all seniors were solicited to participate in the study and subjects were selected based on their willingness to volunteer for the study. At four schools, all seniors present at school on the day data were collected participated in the study. This meant that students absent that day did not participate. Only two senior students enrolled in the programs were absent. Thirty students were not included in the study as they received their basic nursing preparation from a diploma program. In all, 111 subjects out of 143 were included in the study: 71 students enrolled in specifically designed programs, and 40 students enrolled in generic nursing programs. All subjects were female re-entry registered nurses with basic preparation in nursing from an associate degree program. Over 50% of the subjects were married, and 32% were single. More than 13% were divorced. Respondents ranged in age from 22 to 57. The mean age was 33 years. The majority of subjects graduated from an associate degree program between 1970 and 1979. The mean year of graduation was 1976. The mean number of years of experience in nursing before enrolling in the baccalaureate degree program was five. Ninety-five percent of the respondents reported having prior work experience as a registered nurse before enrolling in the baccalaureate degree program.
DATA COLLECTION- The data collection instrument consisted of a demographic data questionnaire that included a check list of background information such as age, marital status, and basic nursing preparation. In addition, students were requested to describe how they coped with an identified stressful situation that occurred in the classroom or clinical setting during the past school year. The questionnaire and critical incident technique were administered in a classroom setting, and the length of time to complete the instruments averaged 30 minutes.
The critical incident technique, a data-gathering procedure originally developed by Flanagan (1954) and modified by Fox, Diamond, Walsh, and Knophf (1965), was selected over other measurement methods because it allows the subjects to describe in their own words how they coped with stressful incidents. Students were requested to state how they coped with an identified stressful incident.
DATA ANALYSIS- Guided by the coping patterns identified by Lazarus (1976), the coping methods observed by Sidle et al (1969), and the psychological defenses identified by Hamburg ( 1974), coping categories were adopted for use in this study as follows.
SUBCATEGORIES WITHIN EACH MAJOR CATEGORY OF COPING METHODS
1) DIRECTACTION. The person takes steps to prevent, avoid, or conquer the problem that initially generated the threat. This category has six subcategories: verbal response, and social networking, preparation against harm, avoidance, attack, and inaction.
a) Verbal Response. This subcategory includes laughing, crying, and praying.
b) Social Networking. This subcategory includes being able to talk about what is on one's mind to friends, spouse, family, peers, instructor, and special support groups.
c) Preparation Against Harm. The person takes action to conquer the problem.
d) Avoidance. The person physically escapes the source of stress.
e) Attack. The person exhibits verbal and nonverbal anger and hostility.
f) Inaction. The person tolerates or "puts up with" threat without hindrance.
2) PALLIATION. The person takes action to relieve the emotional impact of stress. These actions make the person feel better but do not alter the threatening problem. Palliation has two subcategories: intrapsychic and somatic interventions.
a) Intrapsychic Coping. This subcategory includes use of psychological defense mechanisms (denial), mental withdrawal from the source of stress, attention deployment (thinking about a summer vacation rather than studying for an examination), and wishfulfilling fantasy (creating an emotional state of joy without connection with reality),
b) Somatic coping. This subcategory includes use of interventions such as eating, exercise, and meditation.
In coding all the coping methods, the investigator used only the first response that subjects wrote. A summary of the codes is provided in Table 1. These codes are in fact a way of achieving content validity. The rationale for the content of the code is derived from the literature on coping and stress. Three coders were used in the development of content analysis codes. Two coders were nurse educators and the third coder was a nurse researcher. Reliability of the code was established through computing the percent of time two independent coders agreed when they each coded the same materials. There was 93% agreement on the major categories for coping method. For the subcategories there was 88% agreement. When the two independent raters disagreed on a category, the third coder assigned the response to the most suitable category.
The study revealed that all subjects identified more than one method of coping with stress. Over half (82%) of the respondents used direct action, and 58% of the responses involved preparation against harm and social networking. Attack as a method of coping was described in 8% of the responses; avoidance, 5%; and verbal response, such as crying, in 6%. The remaining 5% of responses were categorized as inaction. The majority of respondents clearly used direct action, which includes preparation against harm and social networking. Some examples of the respondents' descriptions of direct coping methods are as follows:
"I just jumped into the experience and kept going. I realized it was my first day to see in-home patients and things were bound to go wrong." (Preparation Against Harm)
"I would study and prepare for class more than I usually do." (Preparation Against Harm)
"I cried." (Verbal Response)
"I cried for several hours." (Verbal Response)
"I discussed my anxiety with the instructor and my peers." (Social Networking)
"I vented my anger and frustration with other students." (Attack)
"I vented my feelings of hostility toward the instructor." (Attack)
"I wrote my feelings (in red ink) at the bottom of the teacher's evaluation form." (Attack)
"I voiced my anger in class to the instructor without support from my classmates." (Attack)
"I coped by utilizing my own resources." (Preparation Against Harm)
FREQUENCY AND PERCENT FOR SUBCATEGORIES OF COPING
"I coped by talking to some one who had a similar experience and knew the instructor." (Social Networking)
"I coped by sharing my feelings with fellow students and my family." (Social Networking)
Palliation as a method of coping accounted for only 18% of the responses. The subcategories, intrapsychic and somatic, accounted for 10% and 8%, respectively. Some examples of respondents' descriptions of palliation as a coping method are as follows:
"I took a deep breath to calm myself down." (Somatic)
"I attempted to place the incident in the back of my mind or out of mind entirely." (Intrapsychic)
"I tried to cope using repression." (Intrapsychic)
"I coped by drinking alcohol and coffee." (Somatic)
Summary of Findings
The majority of re-entry students (82%) in the study used direct action as a coping method in dealing with stressful incidents. Of the direct action coping methods, the majority of students in specifically designed programs used preparation against harm and social networking. The majority of students enrolled in generic programs also used preparation against harm and social networking in coping with stress. Attack as a form of coping was used only by some students enrolled in specifically designed programs.
The coping methods of re-entry registered nurses in generic and specifically designed programs were similar. Those in specifically designed programs used social networking as a coping method more frequently than those in generic programs. This finding suggests that students in specifically designed programs turned more often to peers because of shared interests and values.
Conclusions and Implications
Since the majority of students reported using direct action as a coping method, it can be concluded that registered nurses are not passive or submissive; they take action and deal directly with stressful situations. Since the majority of students used social networking in coping with stress, it can be concluded that family, friends, peers, and faculty support are important in managing stress. Perhaps the relationship between the faculty member and the reentry student should be more that of an advisor or consultant rather than an authority figure.
An advisor or consultant provides warmth and empathy and focuses more on support and problem-solving skills and less on grades, criticism, and control. A major implication of this study is the need to teach students how to use the palliation methods since these strategies are underused.
LIMITATIONS OF THE STUDY- The major limitation of the study is the sample selection bias in that it used a convenience rather than a random sample. The generalization of the findings is limited. Replications of the study should be conducted using random selection and examining all coping methods described by students to enhance the reliability of findings.
- Chodoff, P., Friedman, S., & Hamburg, D. (1964). Stress defenses and coping behavior: Observations in parents of children with malignant disease. American Journal of Psychiatry, 120, 743-749.
- Cox, T. (1978). Stress. Baltimore: University Park Press.
- Flanagan, J. (1954). The critical incident technique. Psychological Bulletin, 31, 327-358.
- Fox, D., Diamond, L., Walsh, R., & Knophf, L. (1965). Satisfying and stressful situations in basic programs in nursing education. New York: Bureau of publications, Teachers College, Columbia University.
- Hamburg, D. (1974). Coping behavior in life threatening circumstances. Psychotherapy Psychosomatics, 23, 13-15.
- Hamburg, D., Hamburg, B., & DeGoza, S. (1953). Adaptive problems and mechanisms in severely burned patients. Psychiatry, 16, 1-20.
- Hillsmith, K. (1978). From RN to BSN: Student perceptions. Nursing Outlook, 26, 98-102.
- Janis, I. (1958). Psychological stress: Psychoanalytic and behavioral studies of surgical patients. New York: John Wiley and Sons.
- Katz, J., Weiner, H., Gallagher, T., & Hellman, L. (1970). Stress, distress, and ego defenses. Archives of General Psychiatry, 23, 131-142.
- Lazarus, R. (1966). Psychological stress and the coping process. New York: McGraw-Hill.
- Lazarus, R. (1976). Patterns of adjustment. New York: McGrawHill.
- Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141-148.
- Mechanic, D. (1962). Students under stress. New York: Free Press.
- Menninger, K., Mayman, M., & Pruyser, P. (1963). The vital balance. New York: Viking Press.
- Muzio, L., & Ohashi, J. (1979). The R.N. student unique characteristics; unique needs. Nursing Outlook, 27, 528-532.
- National League for Nursing, Research Division ( 1981 ). NLN data book. (Publication No. 19-1852) New York: The National League for Nursing.
- Nayer, D. (1981). BSN doors are opening for RN students. American Journal of Nursing, 81, 2056-2064.
- Shane, D. (1980). The returning-to-school-syndrome. Nursing '80, 10, 86-87.
- Sidle, A., Moos, R, Adams, J., & Cody, P. (1969). Development of a coping scale. Archives of General Psychiatry, 20, 226-232.
- Wooley, A. (1978). From RN to BSN: Faculty perceptions. Nursing Outlook, 26, 103-108.
SUBCATEGORIES WITHIN EACH MAJOR CATEGORY OF COPING METHODS
FREQUENCY AND PERCENT FOR SUBCATEGORIES OF COPING