Mental Health Department, Faculty of Nursing and Midwifery affiliated to Iran Medical Sciences University, Yasemi, St. Valiasr Aven. Tehran, Iran
Biostatistics Department, Faculty of Management and Information Science Center affiliated to Iran Medical Sciences University, Valiasr Ave. Rajaie Heart Center, Tehran, Iran
Abstract
Background
College students are prone to stress due to the transitional nature of college life. High levels of stress are believed to affect students' health and academic functions. If the stress is not dealt with effectively, feelings of loneliness, nervousness, sleeplessness and worrying may result. Effective coping strategies facilitate the return to a balanced state, reducing the negative effects of stress.
Methods
This descriptive cross-sectional study was performed to determine sources of stress and coping strategies in nursing students studying at the Iran Faculty of Nursing & Midwifery. All undergraduate nursing students enrolled in years 1-4 during academic year 2004-2005 were included in this study, with a total of 366 questionnaires fully completed by the students. The Student Stress Survey and the Adolescent Coping Orientation for Problem Experiences Inventory (ACOPE) were used for data collection.
Results
Most students reported "finding new friends" (76.2%), "working with people they did not know" (63.4%) as interpersonal sources of stress, "new responsibilities" (72.1%), "started college" (65.8%) as intrapersonal sources of stress more than others. The most frequent academic source of stress was "increased class workload" (66.9%) and the most frequent environmental sources of stress were being "placed in unfamiliar situations" (64.2%) and "waiting in long lines" (60.4%). Interpersonal and environmental sources of stress were reported more frequently than intrapersonal and academic sources. Mean interpersonal (P=0.04) and environmental (P=0.04) sources of stress were significantly greater in first year than in fourth year students. Among coping strategies in 12 areas, the family problem solving strategies, "trying to reason with parents and compromise" (73%) and "going along with family rules" (68%) were used "often or always" by most students. To cope with engaging in demanding activity, students often or always used "trying to figure out how to deal with problems" (66.4%) and "trying to improve themselves" (64.5%). The self-reliance strategy, "trying to make their own decisions" (62%); the social support strategies, "apologizing to people" (59.6%), "trying to help other people solve their problems" (56.3%), and "trying to keep up friendships or make new friends" (54.4%); the spiritual strategy, "praying" (65.8%); the seeking diversions strategy, "listening to music" (57.7%), the relaxing strategy "day dreaming" (52.5%), and the effort to "be close with someone cares about you" (50.5%) were each used "often or always" by a majority of students. Most students reported that the avoiding strategies "smoking" (93.7%) and "drinking beer or wine" (92.9%), the ventilating strategies "saying mean things to people" and "swearing" (85.8%), the professional support strategies "getting professional counseling" (74.6%) and "talking to a teacher or counselor" (67.2%) and the humorous strategy "joking and keeping a sense of humor" (51.9%) were used "seldom or never".
Conclusion
First year nursing students are exposed to a variety of stressors. Establishing a student support system during the first year and improving it throughout nursing school is necessary to equip nursing students with effective coping skills. Efforts should include counseling helpers and their teachers, strategies that can be called upon in these students' future nursing careers.
Background
Stress has been identified as a 20th century disease and has been viewed as a complex and dynamic transaction between individuals and their environments
Academic stress among college students has been a topic of interest for many years. College students, especially freshmen, are particularly prone to stress due to the transitional nature of college life. For example, many college students move away from home for the first time, which can necessitate leaving all previously learned support systems such as parents, siblings and high school friends. Students may need to develop entirely new social contacts and are expected to take responsibility for their own needs. They may have difficulty adjusting to more rigorous academic expectations and the need to learn to deal with individuals of differing cultures and beliefs. Thus, stress may result from being separated from home for the first time, the transition from a personal to an impersonal academic environment, and the very structure of the academic experience at the college level
Stress-inducing academic demands include grade competition; lack of time and issues relating to time or task management, the need to adapt to new learning environments in terms of the increased complexity of the material to be learned and the greater time and effort required to do so; and the need to constantly self-regulate and to develop better thinking skills, including learning to use specific learning techniques. Another category that evokes stress is social adjustment, particularly adjusting to university life and separating from family and friends. Finally, there are financial pressures and other technical difficulties
Stress and the identification of potential stressors among nursing students have received much attention in the literature
In college and university students, some stress is motivating, whereas too high a level interferes with teaching
Student perception of high stress levels can lead to poor academic performance, depression, attrition and serious health problems. Methods to reduce student stress often include effective time management, social support, positive reappraisal, and engagement in leisure pursuits
Coping has been viewed as a stabilizing factor that may assist individuals in maintaining psychosocial adaptation during stressful events. The process of coping is a very complex response that occurs when an individual attempts to remove stress or a perceived threat from the environment. Thus, the actual reaction to an environmental event may be as important as the event itself
Coping responses can be described as positive or negative and as reactive (i.e. reacting to an individual's own thoughts and feelings) or active (dealing with actual stressful situations or events). Active or reactive coping responses can be positive or negative, depending on the situation and the content of the response
The individual may deal with stress through several methods, including removing the stressor through manipulating the environment, developing specific responses to help deal with the stressor or seeking diversion from the stressor
Failure to resolve student stress in the long term could have serious professional and personal consequences
Methods
The purpose of this descriptive cross-sectional study was to identify sources of stress in nursing students and to determine how they cope with stressful events. Research questions are:
What are the greatest stressors in different years?
What is the different between students of different years with regard to stressors?
What are the greatest coping mechanisms used by students?
The study population consisted of all 440 undergraduate nursing students enrolled in years 1–4 of an educational program at the Faculty of Nursing and Midwifery affiliated with Iran Medical Sciences University during the 2004–2005 academic year.
Written approval was obtained from the Ethical Review board of Iran Medical Sciences University, and permission was obtained from the Dean of Faculty, the Deputy of Educational Affairs and the Educational Affairs Administration to conduct the survey in the setting. After obtaining this approval for data collection, the researcher and her colleague introduced themselves to the students in each grade and informed all undergraduate students about the aim of this study and about guarantees of anonymity and confidentiality and the need for written informed consent. All students who agreed to participate and provided written informed consent were given questionnaires; all incomplete questionnaires were not included. A total of 366 students provided completed questionnaires.
Two survey instruments were used, The Student Stress Survey and the Adolescent Coping Orientation for Problem Experiences Inventory (ACOPE). The Student Stress Survey, based on the Student Stress Scale (Insel, & Roth, 1985), was used to measure stressors. This survey consists of 40 items divided into 4 categories of potential sources of stress: 6 items representing interpersonal sources of stress, 16 representing intrapersonal sources of stress, 8 representing academic sources of stress, and 10 representing environmental sources of stress. Interpersonal sources result from interactions with other people, such as a fight with a boyfriend or girlfriend or trouble with parents; intrapersonal sources result from internal sources, such as changes in eating or sleeping habits. Academic sources arise from school-related activities and issues, such as increased class workload or transferring between schools. Environmental sources result from problems in the environment outside of academics, such as car or computer problems and crowded traffic. Respondents provided a "Yes" or "No" answer to each item they had experienced during the current school year.
ACOPE has been used to assess coping strategies among adolescents, and was initially developed and tested with a sample of Midwestern junior and senior high school students by Patterson and McCubbin (1987). This scale has 54 items in 12 areas, each with Likert-scale responses (i.e. Never", "seldom", "Sometimes", "Often" and "Most of the time"): 6 items representing ventilating of feelings, 4 of relaxing, 8 of seeking diversions, 6 of developing self-reliance, 6 of optimism, 6 of developing social support, 6 of solving family problems, 5 of avoiding problems, 3 of seeking spiritual support, 2 of investing in close friends, 2 of seeking professional support, 4 of engaging in demanding activities, and 2 of being humorous.
After translating these 2 data gathering instruments in Farsi, their content validity was established by a panel of experts and their reliability was determined by Cronbach's Alpha, which was 0.78 for the Student Stress Survey and 0.85 for ACOPE.
All data were analyzed using SPSS for Windows Version 11. Sources of stress and coping strategies were assessed by descriptive analysis and groups were compared using inferential statistics. The binomial test was used to determine whether each source of stress was a significant stressor in all grades. Analysis of variance (ANOVA) was used to compare mean sources of stress in different years; for any that was significant, the Scheffe test was used to determine which group differed from the others.
Results
Most of the students were females (87.2%) single (89.6%) and were between 18 and 24 years old. About 57% of the students lived in the university dormitories and came from cities other than Tehran, the capital city. In respect to answer the research questions: "What are the greatest stressors in different years?" and "What is the different between students of different years with regard to stressors"?" findings revealed that the most common interpersonal sources of stress were "finding new friends" (76.2%) and "working with people they did not know" (63.4%). The binomial test showed that "finding new friends" was a significant stressor in students of all years (P = 0.00). First year students found that "finding new friends", "working with people they did not know" and "change in social activities" were more frequently stressors than did other students; these differences were statistically significant (Tables
Distribution of nursing students by experiencing interpersonal sources of stress
finding new friend
279
76.2
87
23.8
Work with people they don't know
232
63.4
134
36.6
Roommate conflict
191
52.2
175
47.8
Change in social activities
176
48.1
190
51.9
Fight with boyfriend/girlfriend
114
31.1
252
68.9
Trouble with parents
74
20.2
292
79.8
comparison of nursing students in different grade experiencing interpersonal sources of stress
Change in social activities
65.4
P = 009
44.2
42.2
44
Roommate conflict
47.4
56.8
55.9
47.3
Work with people you don't know
80.7
P = 0.00
52.6
62.8
60.4
Finding New friend
94.9
P = 0.00
73.6
P = 0.00
73.5
P = 0.00
66
P = 003
The most common intrapersonal sources of stress were "new responsibilities" (72.1%) and "starting college"(65.8%). The binomial test showed that "new responsibilities" was a stressor in students of all years (p = 0.00). The factors "started college" and "change in sleeping habits" were significantly greater stressors in first year students than in students of other years (Tables
Distribution of nursing students by experiencing intrapersonal sources of stress
New responsibilities
264
72.1
102
27.9
Started college
241
65.8
125
34.2
Change in sleeping habits
202
55.2
164
44.8
Change in eating habits
194
53
172
47
Outstanding personal achievement
142
38.8
224
61.2
Financial difficulties
128
35
238
65
Spoke in public
101
27.6
265
72.4
Change in religious beliefs
87
23.8
279
76.2
Minor law violation
81
22.1
284
77.9
Decline in personal health
53
14.5
313
85.5
Held a job
50
13.7
316
86.3
Change in use of alcohol or drugs
48
13.1
318
86.9
Engagement/Marriage
43
11.7
323
88.3
Death of a family member
21
5.7
345
94.3
Death of a friend
21
5.7
345
94.3
Severe injury
18
4.9
348
95.1
comparison of nursing students in different grades experiencing intrapersonal sources of stress
%
%
%
%
Started college
91
P = 000
75.8
P = 000
55
32.9
Change in sleeping habits
75.6
P = 000
54.7
52
41.8
Change in eating habits
61.5
56.8
50
45
New responsibilities
89.7
P = 0.00
68.4
P = 0.00
63.8
P = 008
70
P = 0.00
The most common academic stressor was "increased class workload" (66.9%); the binomial test showed that this item was a significant stressor in students of all years (P = 0.00) (Tables
Distribution of nursing students experiencing academic sources of stress
Increased class workload
245
66.9
121
33.1
Lower grade than anticipated
137
37.4
229
62.6
Anticipation of graduation
135
36.9
231
63.1
Search for graduate school/job
91
24.9
275
75.1
Missed too many classes
69
18.9
297
81.1
Serious argument with instructor
68
18.6
298
81.4
Change of Major
33
9
333
91
Transferred schools
18
4.9
348
95.1
comparison of nursing students in different grades experiencing academic sources of stress
%
%
%
%
Increased class workload
82
P = 000
73.7
P = 000
64.7
P = 000
49.5
Distribution of nursing students experiencing environmental sources of stress
Placed in unfamiliar situation
235
64.2
131
35.8
Waited in long line
221
60.4
145
39.6
Car trouble
207
56.6
159
34.4
Vacations/breaks
197
53.8
169
46.2
Change in living environment
165
45.1
201
54.9
Messy living conditions
122
33.3
144
66.7
Computer problems
115
31.4
251
68.6
Put on hold for extended period of time
108
29.5
258
70.5
Quit job
9
2.5
357
97.5
Divorce between parents
1
0.3
365
99.7
comparison of nursing students in different grades by experiencing environmental sources of stress
Environment sources
%
%
%
%
Vacations/breaks
38.5
48.4
63.7
61.5
Waited in long line
67.9
64.2
59.8
50.5
Placed in unfamiliar situation
76.9
P = 000
84.6
P = 000
60.8
P = 0.003
51.6
Change in living environment
62.8
52.6
39.2
28.6
Car trouble
62.8
52.6
39.2
28.6
Mean stress was significantly greater in first year than in fourth year nursing students (36.4 vs 29.3, F = 3.39, P = 0.009). Using ANOVA, the mean of sources experienced in all 4 category differed significantly by year (F = 3.1, P = 0.04). The Scheffe test showed that the first year students had significantly higher means of interpersonal (3.33 vs. 2.68, P = 0.02) and environmental (4.02 vs. 3.15, P = 0.04) sources of stress compared with fourth year students. Moreover, third year students experienced significantly greater environmental stressors than fourth year students (4.03 vs. 3.15, P = 0.02).
In the area of
Distribution of nursing students by using ventilating feelings
Say mean things to people, be sarcastic
314
85.8
34
9.3
18
4.9
Swear
314
85.8
33
9
19
5.2
Let off steam by complaining to your friends
211
57.7
118
32.2
69
18.9
Get angry and yell at people
209
57.1
90
24.6
67
18.3
Let off steam by complaining to family members
181
49.5
95
26
69
18.9
Cry
128
35
116
31.7
122
33.3
In the area of
Distribution of nursing students by seeking diversions
No
%
No
%
No
%
Go to a movie
263
71.9
70
19.1
33
9
Play video games
262
71.7
61
16.7
43
11.7
Use drugs
233
64.5
55
15
75
20.5
Listen to music-stereo
63
17.2
92
25.1
211
57.7
Read
110
30.1
134
36.6
122
33.3
Go shopping, buy things you like
156
42.6
111
30.3
99
27
Watch T. V
114
31.1
105
28.7
147
40.2
Sleep
113
30.9
118
33.2
135
36.9
In the area of
Distribution of nursing students by Relaxing
No
%
No
%
No
%
Work on a hobby
214
85.5
73
19.9
79
216
Eat food
188
51.4
105
28.7
73
19.9
Daydream
80
21.9
94
25.8
192
52.5
Ride around in the car
238
65
75
20.5
53
14.5
In the area of
Distribution of nursing students by self-Reliance
Get a job or work harder
294
80.3
53
14.5
19
5.2
Try to think of the good things
68
18.6
112
30.6
186
50.8
Try to make your own decisions
52
14.2
87
23.8
227
62
Organize your life and what you have to do
95
26
91
24.9
180
49.2
Get more involved in activities in school
87
23.8
137
37.4
142
38.8
Tell yourself the problem(s) is not important
124
33.9
105
28.7
137
37.4
In the area of
Distribution of nursing students by Developing Social Support
Blame others for what's going on
229
62.6
90
24.6
47
12.8
Apologize to people
39
13.4
99
27
218
59.6
Try to help other people solve their problems
63
17.2
97
26.5
206
56.3
Try to keep up friendships or make new friends
72
19.7
95
26
199
54.4
Say nice things to others
126
34.4
122
33.3
118
32.2
Talk to a friend about how you feel
125
34.2
105
28.7
136
37.2
In the area of
Distribution of nursing students by Solving Family Problems
Talk to your father about what bothers you
221
60.4
68
18.6
77
21
Try to reason with parents and talk things out, compromise
34
9.2
65
17.8
267
73
Go along with parent's requests and rules
35
9.6
82
22.4
249
68
Do things with your family
105
28.7
108
29.5
153
41.8
Talk to a brother or sister about how you feel
152
41.5
102
27.9
112
30.6
Talk to your mother about what bothers you
97
26.5
100
27.3
169
46.2
In the area of
Distribution of nursing students by Avoiding
Smoke
343
93.7
4
1.1
19
5.2
Use drugs prescribed by doctor
289
79
15
13.9
26
7.1
Try to stay away from home as much as possible
242
66.1
78
21.3
46
12.6
Try to see the good things in a difficult situation
103
28.1
105
28.7
158
43.2
Drink beer, wine, liquor
340
92.9
11
3
15
4.1
In the area of
Distribution of nursing students by Seeking Spiritual Support
Talk to a minister/priest/rabbi
249
68
80
21.9
37
10.1
Go to mosque
202
55.2
95
26
69
18.9
Pray
53
14.5
72
19.7
241
65.8
In the area of
Distribution of nursing students by Investing in Close Friends
Be close with someone you care about
86
23.5
95
26
185
50.5
Be with a boy friend or girlfriend
123
33.6
113
30.9
130
35.5
In the area of
Distribution of nursing students by Seeking Professional Support
Get professional counselling
273
74.6
54
14.8
39
10.7
Talk to a teacher or counsellor at school about what bothers you
246
67.2
72
19.7
48
13.1
In the area of
Distribution of nursing students by Engaging in Demanding Activity