A lumber of nursing schools across he globe are engaged in curricuum innovation. Most important in any curriculum review is the structure of the envisioned program. Research has shown in moat caaes it is not the content of the curriculum that makes or breaks students but rather how the curriculum is organized Baker, 1969; Hawley, Rosenboltz, Goods tei n , & Hasselbring, 1983).
Traditional generic nursing degree programs in South Africa require students be placed in hospitals for clinical learning experiences as early as the first year of the program. Predictably, stress imposed by the demands of balancing clinical learning experiences with a new and often large academic course workload is not unusual among nursing students. Lazarus and Folkman (1934) define stress as
a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering hia or her well-being Ip. 19).
It is well known that, for most students, tertiary education in general is highly stressful (Haroill, 1995; Thyer & Bazeley, 1993). Hamill (1995) conducted a qualitative study involving 18 Project 2000 students to examine their perceptions of stress. Hamill found problems arising from adjusting to tertiary education as well as to the ward environment were the major sources of stress for participants in the study.
Traumatic experiences related to clinical learning stress were reported by a number of researchers (Beck & Srivastava, 1991; Kleehammer, Hart. & Keck; 1990; Lees & Ellis, 1990; Lindop, 1989; Mahat, 1996; Wood, 1992). Liudop (1989) conducted a study involving 23 past learners who left nurse training because of stress. Regarding students' experiences of stress in nursing education, Lindop cited physical exhaustion, interference with social life, and negative attitudes of fellow nurses. There seems to be no paucity of literature attesting to academic workload, heavy examination schedules, feelings of doubt about nursing as a career choice, and feelings of inadequacy and insecurity in the clinical setting as some of the common major stresses for nursing studente (Beck, 1993; Beck & Srivastava, 1991; Lees & Ellis, 1990).
Evidence exists that most attrition in nursing education occurs during the first 12 months, followed by 13 to 14 months of training (Lees & Ellis, 1990) and that traumatic experiences of being subjected to cases of death and dying as well as the responsibility entailed in taking care of a sick person so early in the students' educational careers are seen as the major stresses among students of nursing.
The issues raised in the reviewed literature were also causes for concern in the Department of Nursing at the University of Natal 6 years ago. A number of students in the "old" program were finding it difficult to balance the clinical learning requirements and a full academic courseload. Students were extremely busy, and they often complained they found it difficult to have a social life.
In 1994, a new baccalaureate nursing degree program was adopted. The "new" program departs from tradition because students are not placed in clinical settings until the second year. Even then, students are placed in community clinical settings only during university vacations. In the third year, students spend 3 of 5 weekdays in ward placements. Students in the old degree program were placed in hospital settings as early as the first year of their student careers. Clinical placements ran concurrently with university lectures, with students often spending the morning in class and the afternoon and early evening in the clinical setting.
The rationale for change was the new curriculum structure would reduce stress associated with the demands of concurrent clinical experiences and academic course workload. The plan was that all supporting social science and biomedicai science courses would be taken in the first 2 years of the degree program. Because only nursing courses would be taken in the third and fourth years of the degree, the Nursing Department could then control clinical and academic schedules for the third and fourth years.
The purposes of this study were to;
* Examine the differences in students' perceived levels of stress according to which program they had followed.
* Measure students' perceptions of their respective degree programs.
* Examine the differences in academic performance in the social and biomedical sciences between students in the two different programs.
Deaign, This was a comparative descriptive study involving studente in two different degree programs at a university nursing department. The targeted popula tien included Brat-year, secondyear, and third-year studente (N = 39) who were in the old program in 1992. For the new program, all students in the first year of the new program in 1994, as well the second-year· and third-year studente in 1996, were asked to participate in this study. In all, 62 students in the new program participated in the study. Because there were no fourth-year students in the new program at the time of data collection, fourth-year students in the ojd program were excluded from this study.
Data Collection and Instrumentation. The Perceived Stress Scale (PSS) designed by Cohen, Karmack, and Mennelstein (1983) was used to collect data on perceived stress. The PSS is a
14-item measure of the degree to which situations in one's life are appraised as stressful. [The] PSS items were designed to [identify] the degree to which respondents found their lives unpredictable, uncontrollable, and overloading (p. 387).
The basic assumption underlying the PSS is that stress is a subjective phenomenon. Such s view of stress has as its theoretical foundations, the work of Lazarus and Folkman (1984). Therefore, it is believed, although objective measurements of stress are important, they nevertheless overlook the subjective nature of stress. Response to a particular situation in the PSS sense is seen as determined not only by an inherent quality or intensity of the occurrence or event but also by the individual's appraisal of the situation. Furthermore, what makes the PSS relevant to the questions raised in this study is its ability to measure nonspecific situations in the individual's life in terms of whether they are perceived as stressful or not.
The PSS has been subjected to a variety of psychometric measurements involving college students and a smoking cessation group (Cohen et al., 1983). The results ranged between .84 and .86 for reliability. Correspondence between the PSS and Life Events scores for college students was reported at r = .65. For the present study, no testing of the instrument was conducted. However, concurrent use of the Clinical Stress Questionnaire (CSQ) with the PSS provided a measure of validity for the PSS.
The CSQ developed by Pagana (1989) was used to measure the extent to which emotions of challenge, threat, and harm were experienced by students in relation to their respective degree programs. This is an 18-item, five-point Likert-type scale. Respondents were required to rate the extent to which a particular emotive adjective described how they felt about their educational program (O - not at all to 4 = a great deal). The CSQ consists of challenge (n = T), threat (n = 6), and harm (n = 5) items. Among others, challenge items included adjectives such as happy, excited, and exhilarated. Threat was described as feelings such as apprehension, fearfulness, and being overwhelmed. Harm was described ae feelings such as anger, disappointment, and guilt. Pagana describes challenge and threat appraisals as anticipatory in nature, and thus they deal with an upcoming event. Pagana further states,
emclions indicative of threat and challenge are expected to be experienced moat intensely at the anticipatory stage of a stressful event (p. 170).
However, Pagana argues these emotions can also be experienced when people see possibilities, negative or positive, within an ambiguous situation. In the context of this study, such possibilities are assumed to be inherent in all educational programa to varying degrees. Harm, in the CSQ, is seen as an evaluation of a situation that has already occurred. In view of the fact that for both the old and new programs the CSQ data were collected during ongoing educational programs, perceived harm scores were expected to be low for both groups. Alpha coefficients of .85 and .84 for the challenge and threat scales, respectively, were reported. Pagana reported factor loadings ranging from .31 to .81 for the CSQ. The use of the CSQ was seen as a valuable measure in validating the findings of the PSS because no testing of either the CSQ or the PSS was conducted in the present study. It was expected the PSS scores would correlate positively with the harm and threat scores. However, a negative correlation between the PSS and challenge scores was expected.
The two questionnaires were distributed to students in class to be completed during regular class time. Academic performance data were collected using the university examination records. In the third month of the first academic year for each group, PSS data were collected. These data were supposed to provide information on whether or not there were any differences between groups on perceived level of stress on entry into the respective educational programs. Subsequent data were collected during the ninth and tenth months of the academic .year for first-year, second-year, and third-year students using both the PSS and the CSQ.
Participation in the study was voluntary for students, lîie researchers were not involved in any form of teaching either the old or new programs. Therefore, it was assumed the students would not feel pressure d to complete the questionnaires because they had no academic relationship with the researchers. Participants were assured anonymity and confidentiality of information. Students' names were not required on the questionnaires.
Results and Discussion
Sample Characteristics and Sample Realization. A total of IDI studente participated in the stress section of this study, 39 of whom were in the first 3 years of the nursing degree in 1992. The remaining 62 were registered in the new program from 1994 to 1996. The average age of participants was 22.06 (SD = 3.06) and 21.30 (SD = 3.30) for students in the new and old programs, respectively.
Educational background of the participants mirrored South Africa's political past. The students had been schooled in the country's racially segregated schools, which were in existence before the establishment of the 1994 democratically elected government. Quite a number of students (54%) were from the Department of Education and Training (African only), an education department notorious for its inadequacies in the quality of resources (both human and material). This group constitutes what is currently referred to as the educationally disadvantaged group. A few (4%) were either of non-South African origin or were educated in the country's private schools. The remaining respondents were from various racially segregated schools (e.g., Blacks, South African Indians, Whites).
Levele Stress. The ANOVA was used to test for differences between groups by program of study. In view of the fact that voluntary participation was used while aiming for population participation rather than sampling, normal distribution of scores could not be assumed. Therefore, tests for homogeneity of variance were performed. Bartlett'a and Cochran'e tests yielded alpha values greater than .05. It was then decided it was statistically sound to use parametric statistics for data analysis.
No significant differences on the PSS were found between groups by educational program on the ANOVA (F = .328, p = .577) in the third month of first year. However, subsequent data obtained from the PSS showed the students in the old program appraised their situations as more stressful compared ta those in the new program. The range of scores was between 21 and 35 for students in the new program; whereas scores ranged between 26 and 40 for students in the old program. These data were significantly different at p = .000.
Students in the new program rated their program as more challenging oil the CSQ, compared to students in the old program ratings of their program if = 28.70; p ~ .000). Challenge scores ranged from 14 to 22 (highest achievable score = 28) and 4 to 16 for the new and old programs, respectively. Furthermore, the PSS was negatively correlated with challenge scores (r = -.37; ? = .0003). That is, the higher the level of perceived stress, the less challenging the program was perceived to be.
For both perceived harm and perceived threat, students in the new program scored lower than those in the old program. Differences in threat scores between groups were significant at p = .001; whereas these differences were significant at p = .000 in harm scores. Students in the old program perceived their educational program a» more threatening and harmful, compared to those in the new program. The correlation between both harm and threat scores and perceived stress was positive (harm: r = .55,p = .000; threat: r = .52, p = .000). That is, the more stressed students felt, the more threatening and harmful they felt the educational program was.
For both groups, mean scores on academic performance were low, ranging from 50% to 59%. No significant diflerences by educational program were found in academic performance in both biomédical and social ßcienceß. Furthermore, no differences in university entrance scores were found between groups by program of study.
Discussion. The results of this study showed significant differences in perceived levels of stress as measured by both the PSS and the CSQ between students in the new and old programs. Students in the old program consistently scored higher in perceived stress, threat, and harm compared to those in the new program. Furthermore, students in the old program did not perceive their program as challenging compared to those in th« new program. These findings supported the researchers' expectations. It stands to reason that decreased demand on students' time (i.e., no clinical placements in the Erst year), addressing one thing at a time (i.e., classroom attendance only during the university session and clinical placements only during university vacation), as well as continuous clinical placements for at !east 3 consecutive days during the third and fourth years should lead to a lees stressful educational experience compared to the occurrence of all of these aspects of an educational program at the same time.
Introducing studente ta care of sick people daring the third year of atar educational program means students are not subjected to numerous overwhelming situations concurrently. By the time Students have to address the anxiety related to the unpredictability of the hospital clinical setting, they have at least mastered the "art" of being university studente.
The failure of students in the new program to make significant gains compared to those in the old program in terms of their academic performance can be attributed to a variety of factors. First, it might be these students simply took more courses than -would possibly have been the case if they had clinical placements to contend with as well as the initial years of university education. Second, the excitement of being in a new nursing degree program end the demand this new program placed on students in terms of their nursing courses might mean more time was spent studying and researching in preparation for the nursing courses rather than studying the supporting courses. Therefore, the time gained by not being in clinical placements was in fact filled by other academic demande rather than the traditional one or two social science and biomédical science courses.
Mean scores on academic performance were low for both groups. This could be explained by the fact that a large number OÍ students (54%) were from the educationally disadvantaged background.
Limitations. However, the results of this study should be interpreted with caution. Stress is multifactoria] in nature. A number of important confounding variables were not controlled for in this study. This waa not an experimental study but rather the study of a major curriculum change. This meant events could not be manipulated but had to be allowed to run their course. For example, the new program changed from the traditional lecture-based, teacher-directed approach need in the old program to a self-directed teaming approach with the fecuJty acting primarily as facilitators of learning in small tutorial groups. Furthermore, the faculty in the two programa were not the same. Because of natural attrition, by either resignation or retirement, some of the faculty who taught in the old program had left the Nursing Department.
A number of implications for curriculum planning in nursing education emerge from the resulte of this study. First, educational programs which introduce students to hospital-based clinical experiences in the first year should examine the impact of such a curriculum structure oo studente' perceptions of stress and how stress affects decisions to continue in a nursing program or to withdraw. Second, as schools and departments of nursing continue to reorganize and transform their educational programs, careful thought and debate should move beyond issues surrounding the substantive curriculum- This should include the organizational structure of the curriculum, especially as it relates to the timing and placement of clinical learning experiences in a nursing education program.
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