Nursing programs strive to prepare students with the knowledge and technological skills for practice in multiple settings. Clinical experiences provide the means through which students develop an understanding of patient problems and nursing management, psychomotor and technological skills, and values important in caring for others (Reilly & Oermann, 1992).
Clinical practice is inherently stressful for students. The environment cannot be fully controlled, and the student is faced with unexpected events and uncertainties associated with patient care and the environment in which that care is provided. Student learning occurs in public under the watchful eye of the teacher, patient, and others present during performance and care delivery. The student may be unfamiliar with the clinical setting, client population, staff, and even teacher, creating additional anxiety for them (Reilly & Oermann, 1992, p. 148). As more clinical experiences occur in homes and community agencies, there are even greater uncertainties associated with practice and less control and structure of the clinical environment. Beck and Srivastava (1991), in their study on the perceptions and sources of stress among baccalaureate nursing students, found that a high level of stress was experienced by nursing students. A curvilinear relationship exists between stress and learning (Spielberger, 1966). A high level of stress in clinical practice, therefore, may influence student learning and achievement.
Individual students may derive different meanings from their clinical experiences. While some students may find the clinical environment supportive of their learning, for others this same environment may inhibit learning and a sense of well-being. The teacher needs to be aware of individual differences among students in their perceptions of the learning environment and stresses experienced in clinical practice.
Lazarus and Folkman (1984) suggest that although certain environmental demands may create stress, there are differences in the degree of stress experienced by individuals and their reactions to it. An environment considered stressful by the student may be evaluated as a challenge, threat, or harm. Challenge is the potential for mastery and growth, and threat is the potential for harm. Both of these appraisals are anticipatory and concerned, therefore, with future events. An appraisal of a stressful situation as harm refers to an injury, such as a loss of self-esteem and confidence, that has already occurred (Lazarus & Folkman, 1984). The assessment by students of the clinical environment and their experiences may represent any of these appraisals and may differ with varying clinical courses and settings. Prior research has suggested that the teacher also may influence the student's stress in clinical (Kleehammer, Hart, & Keck, 1990; Pagana, 1988).
While research is available on the learning needs of students and their perceptions of selected clinical experiences, few studies have examined students' clinical practice across the curriculum, in various courses and clinical settings. This study assessed differences in perceived stress, degree of challenge, and threat associated with clinical practice experiences among nursing students enrolled in different clinical courses and settings. The research also was significant in that both ADN and BSN students described their clinical experiences in those courses. An understanding of the stress experienced by students in the clinical setting enables faculty to assist students in managing some of their stress and to provide a supportive learning environment for them.
A number of researchers have examined the stresses experienced by nursing students (Beck & Srivastava, 1991; Clarke & Ruffin, 1992; Jones, 1988; Kleehammer, Hart, & Keck, 1990; Loving, 1993; Pagana, 1988, 1989, 1990; Russler, 1991; Wilson, 1994). Their findings suggest that students experience varying degrees of stress in clinical practice and the nursing education program in general.
Jones (1988) conducted a study in which students reported that their health problems developed mainly from anxiety and inability to cope with stress while enrolled in the baccalaureate nursing program. Beck and Srivastava (1991) concluded from their research that the higher level of stress experienced by baccalaureate nursing students was associated with more psychiatric symptoms than noted in the general population.
Sources of students' stress were examined in a study by Clarke and Ruffin (1992). Stresses, ranked from highest to lowest, were study demands, emotional demands, fear of making mistakes, interactions with hospital staff, and personal factors such as limited time for friends and family. Pagana (1988, 1989, 1990) examined stresses and threats experienced by baccalaureate students in an initial clinical experience in a medical-surgical nursing course. The results of the study indicated that students were significantly more challenged than threatened by the clinical experience. In Russler's (1991) research, students with low self-esteem tended to experience higher levels of anxiety as well as negative emotions of threat and harm. They also appraised the environment as more harmful and threatening and less challenging and beneficial to their learning.
In another study, student-instructor interactions were described in adversarial terms, with evaluations by instructors rarely viewed as a formative process that would assist students in improving their nursing practice (Wilson, 1994). Loving (1993) also reported that the evaluation process was perceived by students as stressful. Students reported a reluctance to become actively involved in patient care for fear of making a mistake and receiving an unfavorable evaluation from the instructor.
Although previous research has suggested that clinical experience is stressful for students, there have been no studies on students' perceptions of stress, challenge, and threat as they relate to different clinical courses and settings among both ADN and BSN students.
1. Are there differences in the perceived amount of stress, degree of challenge, threat, and emotions experienced by nursing students across clinical courses?
2. Are there differences in stress, challenge, threat, and emotions based on the type of clinical setting and whether the clinical teacher is faculty from the nursing program or a preceptor from the clinical setting?
A descriptive exploratory design was used for the study. The independent variables were the clinical course, setting, and type of clinical teacher (faculty from the academic program or preceptor from the clinical agency). The dependent variables were the degrees of stress, challenge, and threat and emotions associated with the clinical experience.
Data were collected by administering a modified Pagana Clinical Stress Questionnaire (PCSQ) to nursing students (iV=416) in 10 randomly selected ADN and BSN programs accredited by the National League for Nursing in the midwest. The participants included both ADN and BSN students enrolled in different clinical courses, foundations (n=34), medical/surgical nursing (n=226), maternity nursing (n=69), care of children (n=33), psychiatric/mental health nursing (n=21) and community health (n=33). Students were enrolled in only one of these clinical courses during the time of the study.
The PCSQ assesses the stresses, challenges and threats of the clinical experience (Pagana, 1988). The questionnaire was modified with permission to examine student perceptions of clinical experiences in different courses and settings. In the first part of the instrument, a series of Likert scales ranging from 0 (none) to 4 (a great deal) were used to determine the degree of stress, challenge, and threat experienced in the clinical area, followed by openended questions to enable the participants to describe their responses to the clinical experience. Responses by students to items in the instrument related only to the clinical course in which they were currently enrolled.
In the second part of the instrument, a 20-item inventory of emotions that might be experienced in the clinical setting was ranked by subjects using the same Likert scale. These items were designed to measure challenge, threat, and harm emotions consistent with Lazarus and Folkman's (1984) theory of cognitive appraisal of stress. Pagana (1989) identified the 20 emotions for this part of the instrument from a stress interview described by Lazarus and Folkman, a literature review, interviews with nursing students, and a pilot study. A factor analysis by Pagana (1989) provided the basis for revisions of her original challenge, threat, and harm scales.
In the present study principal components factor analysis with varimax rotation was completed on the 20 emotions in the instrument. The four factors which resulted were consistent with Pagana's findings. The challenge scale included seven emotions: stimulated, exhilarated, excited, eager, happy, pleased, and hopeful. The threat scale consisted of six emotions: worried, anxious, fearful, apprehensive, intimidated, and overwhelmed. The harm scale included five emotions: disgusted, angry, disappointed, sad, and guilty. Two remaining emotions, confident and relieved, were originally in Pagana's (1989) challenge scale. The results of her factor analysis, however, indicated that these emotions were not part of the challenge scale, and they were dropped in the revised scale. In the present study the emotions of confident and relieved emerged as a separate factor. These four factors were used for subsequent data analysis.
Concurrent validity was established in the original study (Pagana, 1989) by comparing the scores on the threat and challenge scales with the coding of open-ended questions. Inter-rater reliability for the coding of the responses was .89. Cronbach's alpha was used to assess the internal consistency of the instrument scales. An alpha coefficient of .85 was obtained for the overall instrument. The alpha coefficients for the individual scales were: challenge .87, threat .89, harm .80, and confidence .28. Although the alpha coefficient for the confidence scale was low, as a result of only two items in the scale and an intercorrelation of .27, this scale emerged as a factor with an eigenvalue greater than one.
Questionnaires were mailed to contact faculty in each of the randomly selected nursing programs who explained the research to subjects and distributed the questionnaires to students willing to participate. The nursing students, therefore, represented a convenience sample across these programs. The investigators were unable to control the specific point in time within the clinical rotation when students completed the instrument, although completion dates indicated it was near the end of the semester. Data were analyzed with descriptive and inferential statistics.
The students' mean age was 30.2 years (SD=7.6). The mean number of clinical courses taken prior to the study was four. Respondents were fairly evenly divided between ADN (N=211) and BSN (N=205) programs. All levels of the curriculum were represented in the research. In the ADN program nearly half of the subjects were first year nursing students (n=105) and the other half were second year (n=106). Among the BSN students, 72 were seniors, 94 were juniors, and the remaining subjects were sophomores (n=33) and freshmen (n=6).
The first research question addressed differences in the perceived amount of stress, degree of challenge, threat, and emotions experienced by nursing students across clinical courses. Students perceived their clinical courses to be more challenging than stressful or threatening. There were significant differences across the clinical courses in terms of student stress, challenge, and threat.
On the scale of 0 (none) to 4 (a great deal), the mean stress score for all subjects was 2.34 although different levels of stress were experienced by students in each of the clinical courses (Table 1). ANOVA indicated significant differences across the groups on the stress variable (iT5,399]=9.58,p<.0001). The Multiple Range Test indicated that the stress experienced by students in care of children courses (M=2.9) was significantly higher than other clinical courses. Similarly, the stress experienced in foundations of nursing courses (M=1.33) was significantly lower.
When examining the challenge experienced by students, the mean score for all courses was 2.66, indicating a moderate amount of challenge. There were significant differences across the groups in the degree of challenge experienced in clinical CF[5,402]=9.58, p<.0001). The Multiple Range Test showed that students in care of children courses were significantly more challenged by thenclinical experiences than other courses (M=2.9). Foundations of nursing was the least challenging of the courses with a mean challenge score of 1.82. Challenge scores for these two types of clinical courses differed significantly from the other courses.
The mean score for threat (M=.98) was low reflecting minimal, if any, threat associated with clinical practice. ANOVA showed a significant difference across groups on the threat variable (F(5,402]=8.45, p<.0001). Students in care of children courses experienced the most threat (M= 1.81); foundations of nursing was least threatening (M= .35).
The research also sought to determine if there were differences in emotions experienced by nursing students across clinical courses. Overall, the challenge scale was ranked highest by students while harm was ranked lowest. The mean score for the challenge factor was 2.41, confidence factor 2.01, threat factor 1.62, and harm factor .71. Significant differences were found in each of these factors across the clinical courses (Table 2).
Stress, Challenge and Threat Moan Scores by Course
Emotion Scales by Course
While the degree of challenge was highest in pediatric nursing courses, when students rated the emotions experienced in clinical practice, ones associated with the challenge scale, such as stimulated, excited, and pleased, were described most frequently by students in maternity courses. Students in maternity courses reported significantly more emotions associated with the challenge scale (M=2.72) than other courses; fewer students found psychiatric/mental health (M= 1.78) and community health (M=1.82) nursing courses to be challenging (F[5,407]=5.54, p<.0001).
The mean score for the confidence factor was 2.01. ANOVA showed once again significant differences across groups on this factor (F[5,407]=3.90, p=.001). Students developed more confidence in clinical practice in foundations of nursing courses (M=2.38) than other clinical experiences. Students in psychiatric/mental health nursing courses developed the least amount of confidence from their clinical practice (M= 1.42), significantly lower than the other courses.
Emotions associated with threat were minimal, although there were differences across the courses (F(5,407]=5.33, p=>.0001). The Multiple Range Test indicated that in care of children courses students experienced more emotions associated with threat, such as anxiety, worry, fear, and feeling overwhelmed, than other courses. Students were not disappointed by their clinical practice experiences nor did they report other emotions associated with the harm scale (Table 2).
The second research question examined differences in stress, challenge, threat and emotions based on the type of clinical setting. Most students (iV=326) had clinical experience in hospitals; 37 were in community health and public health agencies; and 26 were in clinics and long-term care settings. The mean stress score for hospital-based courses was 2.4, 2.49 in community health and public health agencies, and 1.8 for clinics and long-term care settings. ANOVA indicated significant differences across these clinical settings (F[2,386]=4.63, p=.01). Students in clinics and long-term care had lower stress in clinical than other settings.
For the challenge variable, students with clinical experiences in the hospitals were more challenged (M=2.8) than in other clinical settings CF[2,388]=10.89, p<.0001). Similarly, on the emotions inventory, students were most challenged in courses in hospitals. There was minimal threat experienced by students in any of the settings. Similarly, the mean harm factor was low overall and in each setting with minimal or no harm experienced.
Lastly, t-test was used to determine if there were differences in stress, challenge, threat, and emotions experienced by students taught by faculty from the nursing program and preceptors from the clinical setting. There were no significant differences in any of these variables for students who had clinical faculty from the nursing program and those who had a preceptor from the clinical agency.
Preparing nursing students for entry into professional practice includes both learning in the classroom and experiential learning in the clinical setting. It is the clinical experience, however, that is of most concern to students (Pagana, 1988). The stressful nature of the clinical environment along with concern about own well-being elicits an appraisal by the student which may result in challenge or threat. It is important that the teacher understand the student's appraisal process in the clinical learning situation. While some students might find a particular clinical experience and setting to be challenging, the same clinical situation might evoke fear, anxiety, and related emotions for others. An awareness of student responses is important to provide necessary support for learners and challenging learning experiences for them.
Students were moderately stressed by their clinical experiences particularly in pediatric nursing courses. Students experienced moderate levels of stress in other clinical courses except for foundations of nursing. Clinical faculty should recognize the inherently stressful nature of clinical practice for students. A trusting and caring relationship with the teacher is critical for effective learning to occur and for the student to be willing to try out new ideas and approaches (Reilly & Oermann, 1992).
While the responses of challenge and threat are divergent emotions, they can occur simultaneously. The findings from this study suggest that while there were differences in appraisals of stress, challenge, threat and emotions based on the type of clinical course and setting, there are commonalities among student perceptions in certain clinical experiences. The predominant appraisal of stress, challenge, and threat by students in the care of children courses suggests that caring for children is a stressful experience and is likely to evoke a high degree of response and emotion from students. It is important to note that while emotions most often associated with threat appraisals were highest in care of children courses, overall students found their clinical experiences to be challenging. These findings are important for clinical faculty in pediatric nursing courses. Such experiences may be inherently stressful, particularly for students who are parents themselves, and may evoke a high degree of response from learners.
In contrast to care of children courses, students in foundations of nursing courses found their experiences to be the least stressful, challenging and threatening. Students in this beginning course, however, developed more confidence about nursing practice than other courses in the curriculum. Even though students expressed fewer emotions associated with a challenging experience, their development of self-confidence is an important outcome of the clinical practicum.
The clinical setting and interactions which occur during the clinical experience are the basis for meaning assigned by students to the learning experience (Wilson, 1994). Students were not as challenged by their clinical experience in community health and public health agencies as they were in other settings. As nursing curricula at both the ADN and BSN levels shift toward the community, faculty need to be creative in developing stimulating experiences for students as they care for patients in their homes, at their workplaces, in schools, and through varying community agencies. As students are introduced to nursing within a community context, it is incumbent upon faculty to design clinical experiences in which students are actively involved in providing care and have an opportunity to evaluate the impact of their care on the individual client and community as a whole (Oermann, 1994a, 1994b).
One limitation of the study was that the subjects may have had additional clinical experiences in roles such as nursing assistants and technicians which may have influenced their perceptions of the clinical experience. In addition, while the programs were selected randomly, students who participated were a convenience sample. One other limitation was the inability to control the setting and time at which subjects completed the instrument although questionnaires were distributed to the schools at the same point in time.
Despite these limitations, the findings provide instructors with important insights into the stressful nature of clinical practice particularly in pediatric nursing courses. The results also have important implications for teachers to develop supportive learning environments for students recognizing the stress they encounter in clinical practice.
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Stress, Challenge and Threat Moan Scores by Course
Emotion Scales by Course