Journal of Nursing Education

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The Process of Seeking Stress-Care: Coping as Experienced by Senior Baccalaureate Nursing Students in Response to Appraised Clinical Stress

Sharon P Shipton, PhD, RN, CNS

Abstract

ABSTRACT

High levels of clinical stress experienced by nursing students continue to be identified in the literature. However, much is still unexplored about the coping processes of nursing students in response to appraised clinical stress. A grounded theory methodological approach was used to acquire a substantive theory of the processes through which senior baccalaureate nursing students manage the demands of the clinical person-environment relationships that are appraised as stressful and the emotions they generate. A theoretical sample of 16 volunteer senior generic nursing students from two baccalaureate nursing programs was determined by saturation of the data. Each participant was interviewed twice. The basic social problem experienced by these senior baccalaureate nursing students was the chaos created in their lives while trying to manage the demands of the appraised clinical stress (i.e., the clinical person-environment relationship). The three-stage process of seeking stress- care, including encountering changing self, loss of self, and regaining managed self, helped the students manage this chaos. Each of the stages related to the processes that transpired within the students as they dealt with the chaos created in their life while trying to manage the demands of appraised clinical stress. Implications include the development of the stress-care construct and innovative instructor interventions in the clinical setting.

Abstract

ABSTRACT

High levels of clinical stress experienced by nursing students continue to be identified in the literature. However, much is still unexplored about the coping processes of nursing students in response to appraised clinical stress. A grounded theory methodological approach was used to acquire a substantive theory of the processes through which senior baccalaureate nursing students manage the demands of the clinical person-environment relationships that are appraised as stressful and the emotions they generate. A theoretical sample of 16 volunteer senior generic nursing students from two baccalaureate nursing programs was determined by saturation of the data. Each participant was interviewed twice. The basic social problem experienced by these senior baccalaureate nursing students was the chaos created in their lives while trying to manage the demands of the appraised clinical stress (i.e., the clinical person-environment relationship). The three-stage process of seeking stress- care, including encountering changing self, loss of self, and regaining managed self, helped the students manage this chaos. Each of the stages related to the processes that transpired within the students as they dealt with the chaos created in their life while trying to manage the demands of appraised clinical stress. Implications include the development of the stress-care construct and innovative instructor interventions in the clinical setting.

Stress has been experienced universally by all persons since the beginning of humankind. An old saying tells us, "To be alive is to be under stress." Stress is paradoxical because a certain amount of it is vital to motivate or enable learning, whereas stress in excess can lead to failure, economic loss, and unhappiness (Rothrock, 1974). According to the U.S. Department of Health and Human Services (1991), exogenous stresses can interfere with an "individual's ability to negotiate the daily challenges and social interactions of life" (p. 60). Stress and coping health promotion priority objectives have been identified in the U.S. Department of Health and Human Services' (1991) Healthy People 2000 Summary Report: National Health Promotion and Disease Prevention Objectives.

LITERATURE REVIEW

The purpose of nursing education is to provide academic and clinical experiences in an environment that facilitates student learning and creates an emotional climate, which will facilitate the development of students as people and nurses (Birch, 1979; Gunter, 1969; Williams, 1993). The high levels of academic, clinical, and socialpersonal stress experienced by nursing students throughout their nursing education (Beck & Srivastava, 1991; Booker & Rouhiainen, 1981; Davitz, 1972; Eifert, 1976; Fox, Diamond, Walsh, & Knopf, 1965; Fox, Diamond, Walsh, Knopf, & Hodgin, 1963a, 1963b; Garrett, Manuel, & Vincent, 1976; Gunter, 1969; Lindop, 1991; Pagana, 1989; Shipton, 1982; Williams, 1993) indicate the difficulty in providing an optimal emotional environment for learning. These studies indicate that clinical experiences produce the dominant source of stress for nursing students. Nursing education should create an optimal emotional environment to facilitate learning. However, high levels of clinical stress experienced by nursing students throughout their nursing education interfere with students' capability for problem solving and use of the intellectual processes (Byrne & Thompson, 1978). The learning experiences of students focused on managing high levels of stress will be jeopardized (Williams, 1988).

The professional development of nursing students inevitably involves periods of stress and discontent (Beck & Srivastava, 1991; MacMaster, 1979) that require them to cope. The literature is consistent in its identification of academic, clinical, and social-personal situations that have been appraised as stressful by nursing students (Beck & Srivastava, 1991; Booker & Rouhiainen, 1981; Davitz, 1972; Eifert, 1976; Fox et al., 1963a, 1963b; Fox et al., 1965; Garrett et al., 1976; Gunter, 1969; Lindop, 1991; Pagana, 1989; Shipton, 1982; Williams, 1993) and require effective coping. However, nursing education research regarding the coping process through which nursing students manage the demands of the academic, clinical, and social-personal environment relationships that are appraised as stressful and the emotions they generate has greatly lagged behind research on the concept of stress, although both concepts are closely related. Nursing education research needs to shift from the nature of student stress to how students cope with stress.

Effective coping with stress involves an intricate interplay of transactions among the nature of the event, cognitive appraisal of the event, available personal and social coping resources, and the actual coping strategies that are used (Lazarus & Folkman, 1984). According to Lazarus and Folkman (1984), the effectiveness or ineffectiveness of a specific coping strategy or method is dependent on the context in which it is used. The determination that a specific person-environment relationship is stressful relies on cognitive appraisal (Lazarus & Folkman, 1984).

Cognitive appraisal generates emotions that influence coping processes and change the person-environment relationship, which is reappraised and leads to a change in emotion quality and intensity (Folkman & Lazarus, 1988). Folkman and Lazarus (1988) viewed coping as a mediator of the emotional response in this process. The literature indicates a variety of coping methods and strategies used by nursing students in response to academic, clinical, and social-personal situations that have been appraised as stressful (Affeldt, 1990; Alexander & Shaw, 1991; Charlesworth, Murphy, & Beutler, 1981; Foley & Stone, 1988; Johansson, 1991; Lee, 1988; Mahaffey, 1992; Manderino & Yonkman, 1985; Mattson, 1990; Parkes, 1985, 1986; Price, 1985; Russler, 1991; Vincino, 1987; Warner, 1991; Zweig, 1988).

According to Beck and Srivastava (1991), responsible educators are confronted with the challenge of responding to students' cries of being overstressed. To maximize clinical educational experiences for nursing students, faculty must understand stressors, how they are appraised, and the processes nursing students use to cope with stressful person-environment transactions. This knowledge can be used to anticipate and alter situations in which learning and performance may be impaired (Strauss & Hutton, 1983). To help students meet their individual needs, nurse educators must focus on developing interventions that will enable nursing students to effectively cope when responding to appraised clinical stress. However, before effective interventions can be developed, it is imperative that a comprehensive description be composed of the processes through which nursing students manage the demands of the clinical person-environment relationships that are appraised as stressful and the emotions they generate. The intent of this study was to explore these processes, and it was guided by the following research questions:

* What are the clinical person-environment relationships that senior baccalaureate nursing students appraise as stressful?

* What are the processes through which senior baccalaureate nursing students manage the demands of the clinical person-environment relationships that are appraised as stressful?

* What are the emotions generated by the processes through which senior baccalaureate nursing students manage the demands of the clinical person-environment relationships that are appraised as stressful?

METHOD

Sample and Setting

Thirteen female and three male senior baccalaureate nursing students (N = 16) enrolled in a National League for Nursing accredited baccalaureate nursing program at either a private college or a state university in western Pennsylvania served as participant informants. The ages of the participants ranged from 21 to 36 years with a mean age of 24.63 years (SD = 4.89). At the time of the study, 4 students (25%) reported they were married, and 12 students (75%) indicated they were single. Fifty percent of the student participants resided on campus and 50% commuted to school. Eleven students (69%) reported they had no previous nursing or hospital experience before enrolling in their nursing program. Five students (31%) reported a combined total of 15.5 years of previous nursing or hospital-related experience.

Primary selection was used to acquire the theoretical sample of students. According to Morse (1991), the efficiency of primary selection enables the sample size to be as small as possible. The small sample size of this study was served by the homogeneity of the sample to the study population and the participants' ability to elicit initial descriptions of the phenomenon of interest (Brink, 1987; Cobb & Hagemaster, 1987; Kane, 1990). The final sample size was determined by saturation of the data. Three additional volunteer senior generic baccalaureate nursing students participated in the pilot study of the interview schedule. Senior RN baccalaureate nursing students were excluded from this study because of their clinical work experience. Participants neither received payment nor were assessed a fee for participation in this study.

Instrumentation

The instruments used in this study were an open-ended, semi-structured interview (Berg, 1989) schedule and a demographic data sheet. This approach allowed participants the greatest input in providing data for the study. The interview schedule initially addressed the broadest questions to obtain as much of the participants' own descriptions as possible. Succeeding questions were more specific to obtain information about the sources of appraised clinical stress, responses to the appraised clinical stress, and generated emotions. Information obtained from the demographic data sheet was used to compile a profile description of the study participants. Both the interview schedule and demographic data sheet were pilot tested for clarity, accuracy, and validity with one male and two female volunteer senior baccalaureate nursing students.

Procedures

Predata Collection. Permission was obtained from the nursing department chairpersons at the two research sites to contact senior baccalaureate nursing students prior to a scheduled nursing class. The investigator presented a brief overview of the study to the students and addressed their questions concerning the research study and participation. Students were asked to complete a form indicating their interest or noninterest in volunteering to participate in this study. A list of potential participants was compiled from the returned forms.

Data Collection. After receiving approval from the appropriate institutional review boards, the interviewer contacted students from the potential participant list via telephone until saturation of the data occurred. Students were informed that they were free to participate or refuse participation in this study, and that they could terminate their participation in the study at any time, without consequences. This type of study, which asks participants to explore a psychosocial process, is essentially risk free.

Initial interviews were conducted face to face. Prior to the start of the initial interview, students were provided with an explanation of the study and a copy of the information sheet. Initial interviews were audiotaped and lasted approximately 40 minutes, although the time varied from 28 to 54 minutes. Prior to the start of each interview, participants completed a brief demographic data sheet.

A second briefer telephone interview for clarification and validation of the emerging categories and constructs was conducted by the initial interviewer 12 to 16 weeks following the first interview. These interviews lasted approximately 16 minutes, although the time varied from 10 to 21 minutes. Data collection transpired during a period of 3Y¿ months. Strict confidentiality of all data obtained in this study was maintained.

Reliability and Validity. Reliability and validity of the research results were built into the grounded theory method (Glaser & Strauss, 1967; Hutchinson, 1986; Strauss & Corbin, 1990) of this study. This type of approach allowed for gathering of data with a minimum of imposed bias. Reliability was enhanced by having the same investigator conduct all of the student interviews, and by using an open-ended, semi-structured interviewing schedule. Face validity of the interview schedule was established with three doctoral nurse educators who had extensive clinical teaching experience with baccalaureate nursing students and qualitative nursing research expertise in the use of an open-ended interview schedule. Feasibility of the data recording methods was established during the pilot testing of the interview schedule. Validity was enhanced by using an inductive approach (Lincoln & Guba, 1985).

Student participants and clinical nursing faculty with qualitative research experience, who were not affiliated with the student participants, corroborated and validated the accuracy of the essence of the emerging substantive theory. One doctoral-prepared clinical nursing faculty member with qualitative research experience followed the data analysis audit trail, beginning with level I coding and ending with the emergence of the substantive theory. The use of open-ended, non value-laden questions enhanced the completeness of the descriptions from the participants.

Participants were viewed as investigators in the study and were informed of the importance of their role in the study. Pilot testing of the interview schedule and demographic data sheet was conducted by the investigator with three senior baccalaureate nursing students who were not actual participants in the study. The pilot tests were conducted for clarity, accuracy, and validity. Data analysis began during data collection. This provided an opportunity to seek participants' clarification and validation of the emerging theory during the second interview. The emerging theory also was validated by clinical nursing faculty with qualitative research experience, who were not affiliated with the student participants.

Data Analysis. Grounded theory methodology (Glaser, 1978; Glaser & Strauss, 1967; Hutchinson, 1986; Strauss & Corbin, 1990, 1994) procedures and techniques were used in this study. This methodological approach, based on symbolic interactionism, sought to generate substantive theory by discovering how people view a situation and interact, and how these processes change (Wilson & Hutchinson, 1991). Analysis of data was conducted as a continuous, ongoing process that was integrated with data collection. Transcribed interviews were reviewed, coded, and analyzed using the method of constant comparative analysis. All codes then were compared and contrasted with each other to discover evolving patterns and trends. Categories and theoretical constructs began to emerge from the continual comparison, clustering, merging, and receding of the codes.

Data were coded using the three levels of coding described by Hutchinson (1986; 1993; SA. Hutchinson, personal communication, June 11, 1994). Open coding was used on every sentence to discover as many in vivo codes as possible to enhance full theoretical coverage (Hutchinson, 1986). Level I coding (in vivo codes) was more concrete and involved the process of breaking the data into smaller pieces. As level I codes were condensed and consolidated, level II coding resulted in the emergence of categories. Level III coding resulted in theoretical constructs that explored the relationships among the categories. Exploration of conditions, strategies, and consequences through logic diagrams (Strauss & Corbin, 1990) facilitated the discovery of theoretical relationships. The theoretical constructs (level ?? codes) were grounded in the in vivo (level I codes) and categorical codes (level II codes), thus substantiating the abstract theorizing that has evolved. Theoretical constructs provided scope to the emerging theory (Glaser, 1978) and were the core concepts of the theory.

RESULTS

The research question, "What are the clinical personenvironment relationships that senior baccalaureate nursing students appraise as stressful?," guided the exploration of the context in which the process of seeking stress-care occurred. The context is "the specific set of properties that pertain to a phenomenon" (Strauss and Corbin, 1990, p. 96). According to Strauss and Corbin (1990), "Context represents the particular set of conditions within which the action/interactional strategies are taken" (p. 96). Senior baccalaureate nursing students identified the context of seeking stress-care as appraised stressful clinical person-environment relationships they experienced during the current semester or throughout their nursing education. The categories of appraised stressful clinical person-environment relationships identified by the students included:

* Actions of the clinical faculty.

* Actions of the nursing staff.

* Actions of peers.

* Implementing nursing procedures.

* Preparing for clinical assignments.

* Encountering new clinical rotations.

Actions of the Clinical Faculty

Students appraised the following as stressful:

* Clinical evaluations.

* Waiting on the clinical instructor.

* Incompetent behavior.

* Moody behavior.

* Being observed by the clinical instructor.

Students reported the following related accounts:

* Clinical evaluations used to be stressful, especially last semester. There were some instructors who were out to point out the negatives no matter what.

* Another instructor my junior year was all over you if you didn't know your mede. She'd yell if you didn't know them. If you were waiting to give your meds that would really make you stressed.

* I think the big one is that I have to deal with, and I don't like it but I run into it all the time, is waiting for my instructor. We had a clinical instructor this fall who didn't know anything. I was more competent than her. That was stressful. She would make me second guess myself and that made me stressed.

* Some faculty are more stressful than others. Every day you're not sure what kind of mood they will be in. You're on your toes all the time. You don't know if one day your head will be bitten off for not doing something or the next day they won't care if you did it or not. Tve had several clinical nursing faculty like that.

* Instructors observing a new procedure is the biggest one for me, or if they question me and I didn't know the answer and then say well it didn't matter, but they were just checking to see if I did. That puts a lot of stress on me because then I feel like I have to know everything.

Actions of the Nursing Staff

Students described negative attitudes, actions, and comments of the nursing staff as stressful. Nursing staff were described as "demeaning," "nasty," and "not wanting to be bothered." Three students stated:

* Sometimes nurses on the floors aren't very nice and that makes you feel a little demeaned sometimes when they treat you that way.

* Then there's the staff you might get one who will help you if you need anything or you get one who disappears and you never Bee them again; they don't want to be bothered.

* The nursing staff has produced stress for us this semester. I can't believe how nasty nurses are. I don't know what it is.

Students felt that some of the staff took advantage of them just because they were students. One student stated:

There was this one nurse who took advantage of us so bad. We'd help her out when we had a break, then she'd scream at 11:00 o'clock because not everything had been done for our patient. Another day she didn't have any students and she screamed at us all day long.

Actions of Peers

Competition among classmates and dependent or clinging peers was person-environment relationships appraised by the students as "very stressful." The students stated:

* Sometimes my nursing student peers make me stressed, especially when they start to compare who's got this and that done. Students comparing makes me very stressed.

* There is so much competition among our nursing class. That's a big source of stress. We're all in the same boat. Grades are important, but lef s all lend a hand and help each other. Sometimes the competition gets to me.

* Classmates! We're a small class, and we're getting sick of each other. Before we used to help each other, now everybody wants to jump down every body else's throat. If you don't go to lunch with the group, everybody will sit around and talk about you. I find this very stressful.

Implementing Nursing Procedures

Implementing new procedures was described by the students as "stressful," "scary," and causing "butterflies and flutters." Students expressed concern about lack of experience, implementing technical skills, and the need for more time in the hospital. One student stated, "I felt very insecure about my technical skills and still do." According to students, the reality of graduating after one more semester of clinical experience stressed them out. Students stated:

* I feel like I'm not getting enough techniques. Tve only ever given one injection. That stresses me out when I think about graduation next semester. We are really lacking with hands-on experiences.

* I already feel weak as most of us do in technical skills, and we need more time in the hospital to learn these skills.

Preparing for Clinical Assignments

Students frequently identified transactions involved in clinical preparations as stressful. Two areas of particular concern were the writing of care plans and medication cards. The significant amount of time students spent on writing these assignments was described as stressful. One student stated:

Care plans in general have been very stressful for me. It takes me forever to write a care plan. It is good but it takes so much time.

Students also verbalized their frustrations with one clinical instructor who would not allow them to use their preprinted medication cards, which had been permitted by other clinical faculty. Students were required to write their own medication cards, which took more time and increased their appraised clinical stress. According to the students:

* Care plans are stressful- we have to do them the night before. We get our assignments on Tuesday and we have to do our care plans Tuesday night. We haven't even had this patient and we're doing care plans. Then they have to be finished and turned in on Thursday. That wouldn't be bad if we didn't have to write out all those mede instead of using preprinted med cards. As long as you know the information, I don't know what makes the difference. It would save a lot of time. So care plans are stressful.

* We had to write our drugs out on paper instead of using our drug cards. She made us write. That was ridiculous. It would take me at least 3 hours to do that. I would sit there and curse.

* We have to write out all our meds and this is the first time we haven't been allowed to use our pre-printed med cards. It is so task oriented and a waste of time. It's very frustrating.

Going to a clinical experience fully prepared to provide knowledgeable patient care only to discover assigned patients had been discharged was identified as stressful. One student stated:

A lot of times my patients will have been discharged after I've done all the research and then you have to get three new patients that morning and know nothing about them; that's stressful to me because I'm giving meds I don't know anything about.

Encountering New Clinical Rotations

Students appraised encountering new clinical rotations as stressful. Descriptions told of the "fear of the unknown," "not knowing what to expect," and the "getting used to" encountered in the beginning of new clinical rotations. According to the students:

* I think one of the first things is this fear of the unknown. You start a new clinical course and you don't know what to expect. You don't know what the course requirements are- sure you have a syllabus and this nice fancy outline, which doesn't mean a whole lot in the beginning. If s just a piece of paper and you're thinking, 'my lord, how am I ever going to accomplish all of this.' That stuff is really frustrating, and because it is a new clinical rotation, something you've never done before, that's frustrating.

* Sometimes a new clinical setting can be scary getting used to them, and stuff like that can be stressful.

Specialty rotations, such as community, psychiatric, and maternity, were described as stressful by the students, who stated:

* My community rotation was stressful for me just getting in with the thentele, of going to the home. That's something new that I have to get used to and develop.

* I was very stressed during our psych rotation. I didn't care for the psych rotation. I was scared the whole time I was there.

* Maternity in my junior year was stressful, especially my first postpartum patient.

THE PROCESS: SEEKING STRESS-CARE

The research questions that guided the discovery of the basic social problem and the development of the basic social-psychological process used to resolve this problem included:

* What are the processes through which senior baccalaureate nursing students manage the demands of the clinical person-environment relationships that are appraised as stressful?

* What are the emotions generated by the processes through which senior baccalaureate nursing students manage the demands of the clinical person-environment relationships that are appraised as stressful?

The basic social problem for students experiencing appraised clinical stress, which they ultimately managed, was the chaos created in their lives while trying to manage the demands of appraised clinical stress. One student gave the following poignant account of appraised clinical stress:

I start feeling real jumpy and I start asking stupid questions. I see that in myself and other nursing students. If I'm getting stressed, I ask where is the thermometer or something really dumb. My hands get cold, my ears get cold, my nose gets cold, my hands get very cold. Actually, the entire clinical is stressful. Yeah, maybe some instances are more stressful than others, but clinical is so stressful. The moment I get off the elevator my heart starts beating faster, my blood pressure goes up, and my hands get freezing cold when Fm on the unit. I get butterflies and flutters in my stomach whenever I have to do a new procedure or something I haven't done before. It's what I would call a general feeling of uptightness from 6:45 a.m. until 3:30 p.m.

Lack of time to complete everything that needed to be accomplished and lack of control over the students' situations and lives contributed greatly to the chaos in their lives. Some of the students' descriptions include the following:

* Preparing for cluneals is stressful for me. I probably add stress to my life because I have a daughter and it stresses me because I don't have enough time to spend with her. I feel guilty so I try to give her as much time as possible, which means I have to let my clinical preparation go until later at night, and Fm already tired before I start, and I find that very stressful.

* Just having too much to do and not enough time to get it done. A lot of times I don't have time to do anything for myself No me time. Fd like to try and workout a little bit, but for me I have to put that on the back burner. I probably shouldn't, but that's what I do. I know that if I did workout that it would probably help me as far as dealing with things, but there is just no time.

The basic social-psychological process that helped the students manage this chaos is described as the threestage process of seeking stress-care. Senior baccalaureate nursing students encountering an appraised stressful clinical person-environment relationship sought stresscare to help manage the demands of that transaction. Stress-care can be described as any internal or external means that students use to facilitate their ability to manage the demands of appraised clinical stress.

Three stages of seeking stress-care that evolved from the data include:

* Encountering changing self.

* Loss of self.

* Regaining managed self.

Each of these stages relates to the processes that transpire within the students' selves as they cope with the chaos created in their lives while trying to manage the demands of appraised clinical stress. Figure 1 illustrates the three-stage process of seeking stress-care.

The process of seeking stress-care revealed a spectrum of emotions expressed by the students as they tried to manage the demands of appraised clinical stress. Some of the emotions included nervousness, depression, anxiety, fear, frustration, anger, hopelessness, loneliness, and inferiority. These and other emotions expressed by the students were interwoven throughout each stage of the stress-care process.

Encountering Changing Self

The initial stage of the process of seeking stress-care is encountering changing self (Figure 2), which can be described as conditions, the events that lead to the occurrence (Strauss & Corbin, 1990) of the stress-care process. Following the appraisal of a clinical person-environment relationship as stressful, students frequently experienced changes in their normal physical and psychosocial functioning. The two changes that evolved from the students' descriptions of their encounters were changing of physical self and changing of psychosocial self. Some of these changes occurred immediately after the appraisal, while others were delayed and occurred over a period of time. During the interpretive analysis, changing of physical self and changing of psychosocial self emerged into the theoretical construct of encountering changing self

Changing of Physical Self. The appraisal of a clinical person-environment relationship as stressful evoked physical changes such as perspiring, tachycardia, diarrhea, stomach upset, loss of appetite, sleep disturbances, headaches, and skin disturbances. As previously mentioned, some of these physical changes were immediate, whereas others occurred over time. The following are student descriptions of their changing physical self:

* My palms get sweaty, and my heart beats fast. My stomach gets queasy, and I feel like Fm going to throw up. I lose my appetite. I get diarrhea, and later after Fve been stressed I get a headache.

* My heart palpates, and my chest tightens. I get sweaty all over. I can't sleep at night because Fm constantly thinking about what's going on, especially the night before clinical.

* My palms sweat, my stomach turns, and my heart races, especially if I feel unprepared.

* I get these big red blotches all over me. I get flushed cheeks, my ears get red, and if it gets really bad, it goes down my arms. Remember that one clinical instructor I was telling you about, I had a lot of blotches this semester.

Changing Psychosocial Self. The psychosocial changes that resulted from appraised clinical stress included inability to prioritize, mood changes, anxiety, depression, withdrawal, loss of self-control, panic attacks, and nervousness. Again, some of these changes were immediate, whereas other were delayed.

Students described the following:

* I get panic attacks. When I get an attack, I just feel like I can't function. Ill just want to eat everything I can get my hands on. You know you're in trouble when dry cereal starts tasting good.

* I just kind of get down and just want to withdraw from people.

* I get moody and cranky. FIl snap at people who don't deserve it, especially when a lot of things are going on at once.

* I think the big one is depression. I get depressed because I don't know what I should do first.

Loss of Self

The second stage in the process of seeking stress-care is loss of self (Figure 3), which can be described as consequences, the outcomes or results of the previous action and interaction (Strauss & Corbin, 1990) of the stresscare process. Following encountering a changing self, students began to experience more turmoil in their lives, which they eventually internalized. Ultimately, the turmoil depleted the students until they relinquished and succumbed to it and didn't know who they were anymore. Thus, the construct loss of self and its categories, turmoil within self and surrendering of self, emerged.

Figure 1 . The three-stage process of seeking stress-care.

Figure 1 . The three-stage process of seeking stress-care.

Turmoil Within Self. This category describes the internal conflict students felt after encountering a changing self. Students were engaged in an internal struggle to regain some control over their lives. They described these conflicted emotions as defensiveness, frustration, lack of control, uncertainty, sadness, unhappiness, anger, and mood swings. The following accounts of this turmoil were provided by the students:

* I get very defensive because I feel like Fm being attacked and have to defend myself I felt like she was attacking me as an individual. If Fm attacked as an individual, I get really defensive.

* I never knew what she was going to ask. The pressure was unreal. I was so stressed out that even when I tried to learn I couldn't because I was so afraid.

* I feel like Fm on a roller coaster. I have no control over my Ufe.

* I get tense and wound up. I feel like a powder keg about to explode. Just kind of like, if one more thing happensthat's going to be it!

* I try to manage my time, but there is just so much that I have to get done. I get so frustrated.

* She gets me so fired up that I actually get mad. FIl get so steamed. It's like, 'you've got to be kidding.'

Surrendering of Self. Surrendering of self describes the students' submission of an exhausted self to the turmoil within themselves. Students had been overwhelmed to the point where they no longer knew who they were. They felt inadequate, inferior, and hopeless, and began to doubt themselves. The students described surrendering of self as the following:

* I often feel inferior and inadequate. I especially feel inferior around the instructors. It is often like a snowball effect. They make you feel inferior, so you act inferior.

* I just felt so overpowered and buried under that I just wanted to withdraw. I just can't explain it.

* I feel so overwhelmed and hopeless sometimes. It makes me so sad and depressed sometimes that I just want to sleep but I can't because I have all this work to do.

* I don't fee] like I know myself anymore. I put all my energy into nursing. I don't have time to be tuned in to my emotions anymore. It's all nursing, nursing, nursing. I don't know who I am anymore. I never have time for myself I feel overwhelmed and hopeless sometimes.

* Sometimes I feel alone and overpowered by problems. I will start questioning my feelings.

Regaining Managed Self

The third stage in the process of seeking stress-care is regaining managed self (Figure 4), which can be described as strategies and tactics designed to manage or respond to a phenomenon (Strauss & Corbin, 1990). In the stresscare process, students respond to the phenomenon of loss of self. During the stage of regaining managed self, students design strategies to cope with loss of self. Strategies used by students to regain a managed self include seeking relaxation, venting, escaping, seeking support, and taking action.

Figure 2. Sampie audit trail for the construct encountering changing sett.

Figure 2. Sampie audit trail for the construct encountering changing sett.

Figure 3. Sample audit trail for the construct loss of self.

Figure 3. Sample audit trail for the construct loss of self.

Figure 4. Sample audit trail for the construct regaining managed self.

Figure 4. Sample audit trail for the construct regaining managed self.

Seeking Relaxation. The students sought relaxation through deep breathing exercises, focusing techniques, regrouping, and music therapy. Of particular interest is music therapy. All of the students interviewed listened to music either immediately following the clinical day or later that evening. Students generally had a specific routine and listened to music for the purpose of relaxing, thus it was interpreted as music therapy. The type of music they listened to spanned the spectrum from hard rock to classical. The following students describe how they sought relaxation:

* I'll close my eyes and take several deep breaths.

* I'll drive 100 miles to my home just so I can use the hot tub. It helps me relax and is worth the drive.

* As soon as I get in my car after clinical I turn the radio on and listen to all kinds of music. I don't think there is anything that can make me happier than country music because I can sing along with the music.

* A lot of times if I have a stressful clinical day, ?? come back and put on some music- that's what I do the most. It depends on my mood as to what I listen to. If Fm in an angry mood, 111 listen to heavy metal. Mainly I like to listen to classical rock.

* There isn't much you can do on the clinical but refocus and calm yourself.

Venting. The students described "releasing" their stress in various ways, including through humor, crying, screaming, complaining, exercising, and overeating. Exercising was important to the students. They discussed walking, running, lifting weights, dancing, aerobics, biking, and many other activities that made them "feel better.'' However, when students needed to exercise the most- when they felt very stressed- they didn't have the time, which only compounded their stress. This may be referred to as the exercise paradox.

Regarding food, students said they ate chocolate because it made them "feel better." Chocolate frequently was eaten by the students when they felt stressed. Several students described using alcohol, especially on the weekends, as a means of venting. The following are some of the students' descriptions of venting:

* I'll exercise on the bike because that seems to help or I'll take a walk.

* I scream. I'll close my door and just scream as loud as I can. It helps.

* I'll clean up a storm. It helps vent my frustrations.

* I've noticed when I exercise my stress level is so much less.

* I lock myself in a room and cry for a while and then I read.

* Usually on Fridays, we'll go out and party. I don't party during the week because I dont feel it would be right to drink the night before clinical. Besides, there is never any time to do anything the night before clinical.

Escaping. The students escaped by isolating themselves or sleeping. They did not describe escaping as something negative, but rather as a way of rejuvenating oneself. The following are the students' accounts of isolating and sleeping:

* Sometimes I like it to be just me. I just close out the world and get the time I need for me.

* On the weekends, 111 sleep for 14 or 16 hours at a time. I have to if I want to be able to make it through another week.

Seeking Support. The studente sought support from peers, loved ones, faculty, and through religious beliefs. Prayer and Bible reading frequently were used. It is interesting that students often sought support from individuals who created stress in their lives. It was not always the same person who was creating the turmoil, but another individual of the same relationship. For example, if students were experiencing difficulties with a clinical instructor, they often would go to another clipfr-pl faculty member for support. The same thing was true of peer, family, and clinical relationships. The following are the students' accounts of how they sought support:

* I'll call my boyfriend. He doesn't understand what it's like in nursing but he always listens.

* I'll go out with my friends.

* I share things with a fellow student. It really helps me reflect back on what happened, and she'll always help me look at the situation and give me good advice.

* There is this one nursing instructor I can talk to about anything. She is very supportive.

* I pray a lot. Fm really into praying. Prayer helps me through a lot.

* I pray because it's the only way. If Tm at the end of my rope, FIl say to myself, why didn't you pray to begin with?

Taking Action. Students took action by confronting, prioritizing, and resolving the situation. The following describe actions of the students:

* I think about the problem and just take care of what needs to be done.

* I set priorities so I can best juggle everything.

* I deal with the situation. You could say Fm an action person.

DISCUSSION

The three-stage social process of seeking stress-care discovered in this theory-generating research revealed the processes senior baccalaureate nursing students use to manage the demands of appraised clinical stress are an enigmatic interactional cognitive and emotional experience that affects the self. Each of the stages of seeking stress-care- encountering changing self, loss of self, and regaining managed self- relates to processes that transpire within the students' selves as they cope with the chaos created in their lives while trying to manage the demands of appraised clinical stress. The findings of this study indicate that students ultimately managed the demands of appraised clinical stress. However, the chaos created in the students' lives while they tried to manage these demands also caused turmoil.

Analysis of this study's data indicates the clinical learning experience in nursing education continues to be a highly stressful and sometimes painful experience for senior baccalaureate nursing students. Stress at this high level alters a person's ability to learn and focus on a situation (Blainey, 1980). The nursing education clinical experience occurs in a stressful, complex learning environment. The context of seeking stress-care derived from the students' descriptions of appraised stressful clinical person-environment relationships is composed of both nonmodifiable and modifiable factors. Patients, nursing staff, clinical faculty, new procedures, clinical preparation, and fellow nursing students are nonmodifiable factors that are the reality of the clinical learning experience. However, there are various factors related to these student-appraised clinical person-environment relationships that are modifiable. The discovery of the stress-care process alludes implications for both nursing education and nursing practice that has ramifications for the future of the nursing profession.

Role of Nursing Faculty

Nursing faculty are in a position to ameliorate stressful clinical experiences encountered by students. Nevertheless, they generally have ignored the stressful nature of the students' clinical experience. The literature has revealed that nursing faculty are often a major source of stress for the nursing student (Admi, 1997; Beck & Srivastava, 1991; Birch, 1979; Booker & Rouhiainen, 1981; Davitz, 1972; Eifert, 1976; Fox et al., 1963a, 1963b; Fox et al., 1965; Garrett et al., 1976; Gunter, 1969; Lindop, 1991; Mahat, 1996; MacMaster, 1979; Oermann, 1998; Pagana, 1988, 1989; Shipton, 1982; Shipton & Labant, 1992). However, little has been done to resolve this problem. Initially, nurse educators must recognize the nursing clinical educational experience as being a sometimes painful and frequently stressful experience that creates chaos in the lives of the students. Nurse educators need to use their crucial position to help nursing students manage the demands of appraised stress and reduce chaos by making the complex clinical learning environment more student friendly.

Clinical nursing faculty need to be realistic with patient and written assignments that are related to clinical preparation. Why is it necessary for students to write medication cards when they already have been permitted in previous clinical courses to use preprinted cards? What difference does it make if medication cards are preprinted or self-written, provided students understand the necessary information to administer medications accurately and safely?

While clinical skills confirm the nursing profession, implementation of these skills is a stressful experience for nursing students. Prior to implementing a new procedure, it is vital for clinical nursing faculty to assess students' understanding of the procedure as well as the anxiety level of the students. Excessive anxiety and an unclear understanding of what needs to be completed can interfere with students' ability to focus and think clearly. Faculty need to concentrate on supporting and helping students through the new experience, rather than being authoritarian and judgmental. Students need more positive feedback and support from faculty (Mozingo, Thomas, & Brooks, 1995). This not only will promote the welfare of patients, but also will create a positive learning environment for students.

If clinical nursing skills confirm the profession for nursing students, then it is important for clinical nursing faculty to keep correct with the nuance of change to improve those skills. The confidence of students can only be enhanced by clinical faculty who demonstrate confidence in their own abilities. The development of students' clinical nursing skills can be enhanced by inviting professional nurses to share their clinical expertise with students.

Clinical nursing faculty must be sensitive to students who experience fear of the unknown related to various aspects of the clinical learning experience. Nursing students must have a thorough orientation to each new clinical setting prior to receiving clinical patient assignments. It also is essential for clinical instructors to assess the previous clinical skills of each nursing student to determine who needs to experience and develop certain clinical skills. Knowing procedural implementation gaps in students' clinical experiences can help faculty build on each student's previous clinical experience. In this manner, students will have a greater opportunity to learn needed clinical skills prior to graduation, thus reducing their fear of graduating without experiencing necessary clinical skills.

Marshall (1989) indicated that social support facilitates student functioning and retention. Clinical nursing faculty can use clinical post-conference time as an opportunity to develop social support for students through quality student-faculty and student-student interactions. Sharing concerns and clinical experiences will facilitate the development of a clinical learning environment that is nurturing, supportive, and caring.

Nurse educators need to facilitate communication between nursing staff and students. Nursing staff need to be kept apprised of the specific learning objectives for students' clinical experiences. Clinical faculty must bridge the gap between students and nursing staff. It is up to the clinical faculty to incorporate the entire nursing staff into students' clinical experiences. Nurses need to understand the significance and importance of being professional role models for nursing students. Both nursing students and nursing staff need to be reminded they are a part of the same team, whose primary concern is the health and welfare of patients.

RECOMMENDATIONS FOR PRACTICE

* Develop stress-care interventions that focus on ameliorating the chaos created in students' lives while they try to manage appraised clinical stress.

* Formulate a realistic perspective that clinical stress cannot be eliminated and focus on interventions to facilitate students' appraisal process.

* Incorporate and implement stress management measures within nursing programs.

* Develop guideUnes to ensure consistency in the requirements for nursing care plans, medication cards, and other student assignments throughout the nursing curriculum.

* Implement a hands-on clinical procedures review for students at the beginning of all clinical courses.

* Orient students to all new clinical agencies and facilities.

CONCLUSION

The nursing students of today are the future of the nursing profession. If the nursing community does not show them how to care, support, and nurture one another, they will never change the mindset that nursing devours its young. Leininger (1984) stated, "Care is the essence and the central, unifying, and dominant domain to characterize nursing" (p. 3). Care is supportive, facultative, or helpful actions taken for others to improve conditions or needs (Leininger, 1984). Ultimately, if nurse educators, administrators, and practitioners do not take the necessary helpful actions with nursing students and new graduates who are seeking stress-care, nursing as a profession will fail to thrive.

The discovery of the process of seeking stress-care has provided new insight into how senior baccalaureate nursing students manage the demands of appraised clinical stress. This discovery has provided a new awareness of the stressful and sometimes painful nature of clinical experiences for nursing students and the direction nurse educators need to take to change this complex learning environment. Initially, it will be the responsibility of nurse educators to bridge the gap with nursing administrators and practitioners to initiate the changes needed to ameliorate the effect of the clinical learning experience on students' lives. Ultimately, it will be the responsibility of all nurses to initiate helpful actions for nursing students to nurture the development of the nursing profession.

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