Changes in stress levels and coping strategies among Finnish nursing students

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Rinnakkaistallenteet Terveystieteiden tiedekunta

2021

Changes in stress levels and coping

strategies among Finnish nursing students

Bhurtun, Hanish Dev

Elsevier BV

Tieteelliset aikakauslehtiartikkelit

CC BY-NC-ND https://creativecommons.org/licenses/by-nc-nd/4.0/

http://dx.doi.org/10.1016/j.nepr.2020.102958

https://erepo.uef.fi/handle/123456789/25692

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Changes in stress levels and coping strategies among Finnish nursing students.

Hanish Dev BHURTUN, Hannele TURUNEN, Matti ESTOLA, Terhi SAARANEN

PII: S1471-5953(20)31044-1

DOI: https://doi.org/10.1016/j.nepr.2020.102958 Reference: YNEPR 102958

To appear in: Nurse Education in Practice

Received Date: 9 June 2020 Accepted Date: 16 December 2020

Please cite this article as: Dev BHURTUN, H., TURUNEN, H., ESTOLA, M., SAARANEN, T., Changes in stress levels and coping strategies among Finnish nursing students., Nurse Education in Practice, https://doi.org/10.1016/j.nepr.2020.102958.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Title of manuscript

List of all authors

Author 1 (corresponding author)

Hanish Dev BHURTUN, RN, M.Sc., PhD student

Department of Nursing Science, Faculty of Health Sciences,

University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland.

Tel. +358417536009

E-mail: hanishdevbhurtun@gmail.com / hanishb@uef.fi

Author 2

Hannele TURUNEN

Professor (Full) and Chair, PhD, RN, Nurse Manager (part time) Head of the Department of Nursing Science

Department of Nursing Science Faculty of Health Sciences, Kuopio Kuopio University Hospital

University of Eastern Finland +358403552629

E-mail hannele.turunen@uef.fi

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Author 3 Matti ESTOLA Ph.D.

Senior Lecturer

University of Eastern Finland,

Faculty of Social Sciences and Business Studies, Joensuu Campus P.O. Box 111, FIN-80101, Joensuu, Finland.

E-mail: matti.estola@uef.fi

Author 4

Terhi SAARANEN, Professor (acting), Docent PhD, RN, PHN

E-mail: terhi.saaranen@uef.fi

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for- profit sectors.

Disclaimer or disclosure information

The authors declare no conflict of interest.

Acknowledgments

We would like to thank all students that participated in this study.

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Title

Abstract

Nursing students may face significant stress in their clinical learning environment and may use coping strategies to alleviate such stresses. However, little empirical evidence exists about the evolution of such stresses and coping strategies across study years. The aim of this study was to explore changes in stress levels and coping strategies among nursing students in clinical learning environment. Nursing students (N = 131) were followed during their first and second study year.

Descriptive statistics and paired sample t-tests were used to measure changes in the variables within the same cohort. Nurse students perceived more stress in their second clinical practice compared to first one, with mean scores of 1.03 and 1.66, respectively. Stress from lack of professional knowledge and skills remained the main stress factor while transference was the main coping strategy across the two study years. Nursing educators should support nursing students to develop effective coping strategies from clinical stressors, especially from stressors such as lack of professional knowledge and skills and prepare their students mentally for clinical placement.

Keywords: Nurses; Nursing student; Clinical learning environment; Stress; Coping methods

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Introduction

Prolonged stress has been documented to have negative effects on nursing students’ learning, academic performance, and well-being (Gurková & Zeleníková, 2018; Labrague et al., 2016;

Labrague et al., 2018). Stressors perceived by nursing students in their clinical learning environment include caring for patients, assignments and workload, and lack of knowledge and skills (Gurková & Zeleníková, 2018). These forms of stressors cannot be completely avoided, and thus developing effective strategies to cope with and learn from them is important (Bektas, Terkes, & Ozer, 2018; Khater, Akhu-Zaheya, & Shaban, 2014). Recent literature has shown that nursing students tend to use both effective (i.e. problem solving and staying optimistic) and ineffective coping strategies (i.e. avoidance and transference) (Alzayyat & Al‐Gamal, 2014;

Labrague et al., 2016). The purpose of this study was to examine changes in stress levels and coping strategies among bachelor’s level nursing students in Finnish universities of applied sciences.

Background

Although several studies have reported that for nursing students, the first period of practice is the most stressful (Ching, Cheung, Hegney, & Rees, 2020; Rasha & Haya, 2016) others have shown that stress among first year nursing students is either low or moderate (Chan, So, & Fong, 2009;

Khater et al., 2014). Several other studies have found that compared with first year students, second and third year students tend to perceive lower levels of stress (Labrague et al., 2016;

Zupiria Gorostidi et al., 2007). In a literature search, we identified only one longitudinal study where stress was measured over three years among nursing students in clinical learning

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environments, and their stress levels were observed to decrease over the time of studying (Zupiria Gorostidi et al., 2007).

Some studies have shown that nursing students mainly utilize a problem-based approach, such as being “optimistic”, rather than emotional-based approaches, including “avoidance” and

“transference”, when experiencing stress (Bektas et al., 2018; Gibbons, 2010; Labrague, 2013).

Stress levels and coping strategies are likely to change and develop over study years, and therefore a longitudinal design is preferable as it can detect the evolution of stress and coping strategies by tracking the same participants over time, so far, we have identified only two studies, both from Spain, that explored stress longitudinally (Fornes - Vives, 2016; Zupiria Gorostidi et al., 2007). However, both of these studies recommended more international studies to further produce evidence on the evolving nature of stress and whether it increases or decreases over study years.

Theoretical framework

Several studies investigating stress in the field of nursing education have used Lazarus’

theoretical framework (Alzayyat & Al‐Gamal, 2014a; Gurková, Elena & Zeleníková, 2018;

Labrague et al., 2018), that explained stress in the context of the relationship between the person and the environment (Lazarus & Folkman, 1984). Coping strategies (the constant effort to sustain a balanced state) are important when experiencing and managing stress. The two types of coping strategies are problem-based and emotion-based. Problem-based coping aims at changing the stress producing event, while emotion-based coping objective is to dampen and manage emotions related with the stress producing event (Lazarus & Folkman, 1984). Lazarus and Folkman (1984) stress theory was chosen as the guiding concept for the present study for the

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following reasons. First, it describes the nature of stress and the relationship between stress, coping and the environment. Second, it explains the relationships among the stress levels, their extent, and problem-based and emotion-based coping processes.

Clinical nursing education in Finland

Nursing students in Finland complete a general nursing degree programme in 3.5 years at universities of applied sciences (UAS) as higher education institutions, previously known as polytechnics. In Finland, based on the EU directives, a total of 210 European Credit Transfer and Accumulation System (ECTS) credit points are needed to complete the Bachelor of Health Care degree requirement, with one ECTS point equivalent to 27 hours of student work. Altogether, the clinical practice is worth 75 ECTS points and is conducted in a clinical learning environment outside the institution. Nursing students must undergo one clinical practice each semester, and the whole study programme consists of seven semesters. Consequently, they complete seven clinical practices (each between six to seven weeks), equating to about 2025 hours spent in clinical settings. Students are required to undergo clinical practice in the following fields:

nursing homes and healthcare centres (first year); medical, surgical, internal medicine, emergency care, intensive care, and mental health (second year); home nursing, geriatrics, gynaecology, and other specialist wards (third and fourth year).

Aims

The objective of this study was to examine changes in stress levels and coping strategies among bachelor’s level nursing students in Finnish universities of applied sciences.

The following research questions guided this study:

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1. What changes occur in nursing students’ stress levels when comparing their first and second clinical practice?

2. What changes occur in nursing students’ coping strategies when comparing their first and second clinical practice?

Design

A longitudinal descriptive comparative study.

Sample

A convenience sample (N = 253) was recruited from five UASs located mainly in the Eastern part of Finland. The initial sample (M1) consisted of 189 undergraduate nursing students. The inclusion criteria were as follows: 1) first year nursing students following an undergraduate nursing bachelor’s of health care degree programme in any of the five UAS; 2) students who had completed their first year clinical practice in a clinical learning environment (normally 6-7 weeks), such as a general hospital or nursing home; 3) students who agreed to participate in the study; and 4) answered the questionnaires completely. For the follow-up (M2), the same sample (n=189) was recruited in their second study year. Only students that had completed the questionnaires and consent forms completely on both occasions (M1 and M2), had progressed to their second year and were completing or had completed their second year clinical practice (normally 6-7 weeks) were included in the definitive sample (inclusion criteria). Of these, 131 matched the criteria at M2 (69.3%). Attrition bias was evaluated by comparing the socio- demographic characteristics, stress levels and coping strategies of the final sample (n = 131) with those of students that dropped out and had to be excluded (n = 58). No significant differences in socio-demographic characteristics, stress levels and coping strategies were found (Table 1) (p-

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values > 0.05), except for higher education institute whose distribution differed between the included and excluded group.

Instruments

Nursing students provided data on their background information, clinical learning environment related variables, levels and sources of stress, and coping strategies by self-completing the Perceived Stress Scale (PSS) and Coping Behaviour Inventory (CBI) questionnaires. Permission was received to use modified versions of the PSS and CBI. Both questionnaires were translated into the native language to achieve linguistic appropriateness (Guillemin, Bombardier, & Beaton, 1993). The translation process included forward translation into Finnish by a native Finn who is an experienced lecturer in nursing and back-translation into English conducted by a qualified translator (English lecturer). A group discussion comprising of the principal author and three senior researchers was organised to evaluate the back-translated version. All three senior researchers have doctoral qualification (two of them in nursing sciences and one in statistics). All feedbacks for e.g. use of appropriate synonyms were discussed and consensus was achieved.

The group ensured and agreed that the translated version matched the original one in the context of diction and meaning, and that they were conceptually equivalent.

Background information and clinical practice related variables

Socio-demographic data, e.g. gender and age, and clinical learning environment practice-related variables, e.g. higher education institute, type of practice, study year, interest in nursing and type of clinical practice place, were collected.

Levels and sources of stress

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The modified PSS comprised a 29-item 5-point Likert scale from 0 to 4 classified into six sub- dimensions as follows: 1) stress from taking care of patients (8 items), 2) stress from teachers and nursing personnel (6 items), 3) stress from assignment and workload (5 items), 4) stress from peers and daily life (4 items), 5) stress from lack of professional knowledge and skills (3 items), and 6) stress from the clinical environment (3 items). The PSS evaluated the degree of stress that occurred during clinical practice. A score of 0 corresponding to “never” indicated an absence of stress for each particular item, whereas a score of 4 signified “always”, indicating constant stress (Sheu, Lin, & Hwang, 2002). Cronbach’s alpha coefficient of the Finnish version was found to be 0.92, indicating excellent internal consistency reliability (Field, 2018).

Coping strategies

The CBI comprised a 19 item, four sub-dimension scale. The sub-dimensions were as follows: 1) avoidance behaviour (6 items), 2) problem-solving behaviour (6 items), 3) optimistic coping behaviour (4 items), and 4) transference behaviour (3 items). It was rated on a 5-point Likert scale from 0 to 4 to evaluate the degree to which students utilized the corresponding coping strategies (Sheu et al., 2002). Cronbach’s alpha coefficient of the Finnish version was found to be 0.74, indicating reasonable internal consistency reliability (Field, 2018).

Data collection

Baseline (M1)

Five UAS located mainly in the Eastern part of Finland granted permission to collect data. 253 students were contacted by email and asked to participate in the study between May - October 2018. Participants could either fill in the questionnaires online or as a paper version during the last week of their clinical practice. The paper versions were returned to the researcher in a sealed

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envelope within 1 week. In total, 189 participants completed the consent form and questionnaires completely, giving a response rate of 74.7%.

Follow-up (M2)

The same 189 participants were contacted again to participate during February - May 2019. Of those, 131 participants completed the consent form and questionnaires completely, giving a response rate of 69.3%. The same data collection techniques and instruments were used during both data collection events.

Ethical considerations

The ethical committee of the university where the study was conducted and all participating UAS (decision number 26.3.2018.62) approved the study (3/2018). The purpose of the study, data collection process and analysis methods were explained to all participants through an information sheet. Participants were asked to write their names on the questionnaires to allow for corresponding data linking for the follow-up (M1 to M2). However, during the analysis phase, all participant-identifying information was removed to maintain anonymity.

Data analysis

We used the Statistical Package for the Social Sciences (SPSS; version 25) for data screening.

We conducted descriptive statistics by measuring mean (M) and standard deviation (SD) values.

We applied paired sample t-tests to measure changes between groups and Cohen’s d to measure the effect size; d = 0.10 was considered as small, d = 0.30 medium and d = 0.50 as large effect sizes (Field, 2018).

Validity and reliability

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A systematic literature review was conducted to identify previous literature on stress and use of coping strategies (Authors, 2019) and the present study was designed based on its findings and recommendations. Previous literature reviews revealed that quantitative studies predominantly employed PSS and CBI questionnaires to measure stress and use of coping strategies, respectively (Alzayyat & Al‐Gamal, 2014; Labrague et al., 2016; Pulido-Martos, Augusto- Landa, & Lopez-Zafra, 2012). Several studies have tested these two instruments and reported that both have sound psychometric properties, including Cronbach’s alpha and content validity (Al‐Gamal, Alhosain, & Alsunaye, 2018; Alzayyat & Al‐Gamal, 2016; Gurková & Zeleníková, 2018).

Power analysis

R statistical software was used to determine the appropriate sample size. The minimum sample size to control for type I and type II errors was determined to be 64 (Field, 2018) and considering previous similar studies that used a medium effect size of 0.5, power of 0.8 and significance level of 0.05 (Shaban, Khater, & Akhu-Zaheya, 2012). As a precaution a larger sample was recruited to allow for incomplete questionnaires, attrition and provide greater insight.

Results

The response rate at baseline (M1) was 74.7% and 69.3% at follow-up (M2). Students were between 19 and 53 years old. The mean age was 26.4 (SD = 8.96) and 84% of all participants were female. 36.6% reported having previous experience in the health and social services sector by working as healthcare assistants before joining the bachelor’s degree programme. 53.4%

reported having a family member, such as siblings, parents or children, with a nursing background, including nursing and midwifery.

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Nursing students reported more stress in the second year

Nursing students felt more stressed in general and in all sub-dimensions of the PSS at M2 (Fig.

1). The mean stress scores at two occasions (M1 & M2) of measurement can be seen in Table 2.

We observed a statistically significant difference in the overall stress scores at M1 (M = 1.03, SD

= 0.52) and M2 (M = 1.66, SD = 0.49); t (129) = −12.01, p < .05, d = 1.23. Further, we noticed a statistically significant difference in the PSS factor “stress from lack of professional knowledge and skills” at M1 (M = 1.51, SD = 0.85) and M2 (M = 3.03, SD = 0.70); t (129) = −15.21, p <

0.05, d = 1.95. The latter factor was perceived as the most stressful at both occasions. Although some factors retained their ranking at both occasions, others changed. For example, “stress from taking care of patients” was perceived as the second most stressful factor at M1 but the fourth most stressful at M2. Furthermore, although “stress from peers and daily life” was perceived as the least stressful sub-dimension of the PSS at both M1 (M = 0.61, SD = 0.62) and M2 (M = 1.04, SD = 0.68), we observed a statistically significant difference in the score levels for these two separate moments; t (129) = −6.27, p < .05, d = 0.67. Considering the specific items of the PSS, items “unable to provide appropriate responses to doctors', teachers', and patients' questions” (M = 1.59, SD = 0.87) and “unable to reach one's expectations” (M = 1.57, SD = 0.99) had the highest means at M1. In contrast, at M2, being “unfamiliar with medical history and terms” (M = 2.08, SD = 1.03) and “lack of experience and ability in providing nursing care and in making judgments” (M = 1.96, SD = 0.80) were reported as the most stressful items. The item “cannot get along with other peers in the group” remained one of the least stressful events reported at both M1 (M = 0.26, SD = 0.52) and M2 (M = 0.67, SD = 0.76), but the score difference from baseline to follow-up of this latter item was statistically significant; t (127) =

−5.38, p < 0.05, d = 0.63.

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Nursing students reported that they used coping strategies more frequently in the second year

Students used all coping strategies more frequently in their second year than in their first year (Fig. 2). All four coping factors of the CBI retained the same ranking at both measurements (Table 3). Students used “transference” as their main strategy to cope with stress during their clinical practice. Specifically, a statistically significant difference was detected in the CBI sub- dimension “transference” at M1 (M = 2.75, SD = 0.73) and M2 (M = 2.92, SD = 0.76); t (129) =

−2.08, p < 0.05, d = 0.23. Considering the specific items on the CBI, items “to employ past experience to solve problems” and “to feast and take a long sleep” were reported as the most used coping strategies at M1 and M2, respectively, whereas “to avoid teachers” and “to expect miracles so one does not have to face difficulties” were reported as the least used coping strategies at M1 and M2, respectively. Interestingly, we noted a significant change in ranking of item “to feast and take a long sleep” from rank 10 at M1 to rank 1 at M2.

Discussion

The aim of this two-wave longitudinal study was to examine changes in stress levels and coping strategies among nursing students in their clinical learning environment during their first and second years of studying. In line with previous studies, we showed that the degree and sources of stress that students perceived over their study years changed (Evans, 2004; Gurková &

Zeleníková, 2018; Jimenez, 2010; Timmins, 2002). The overall stresses, “stress from taking care of patients”, “stress from assignments and workload”, “stress from lack of professional knowledge and skills”, “stress from the environment”, “stress from peers and daily life”, and

“stress from teachers and nursing staff” were greater for students in their second year of nursing studies compared to their first year. Students perceived “stress from lack of professional

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knowledge and skills” as the most stressful situation at both M1 and M2. Further, although there was a statistically significant change in all six sub-dimensions of the PSS, we observed that the sub-dimension “stress from lack of professional knowledge and skills” had the biggest change (Table 2).

Some previous studies have indicated that second year nursing students feel more stress than their first-year counterparts, and several possible explanations have been proposed to validate these differences. Firstly, second year nursing students engage more in their studies, thus exposing themselves to stressful situations more often (Admi, 2018; Ching et al., 2020; Tully, 2004). Secondly, students may be given more responsibility in their second-year clinical learning environment than during their first year (Chan et al., 2009; Khater et al., 2014). Thirdly, as they progress through their studies, students may expect more from themselves (Tully, 2004).

Moreover, the evaluation criteria and academic requirements to pass the clinical practice in the second year are stricter than in the first year in Finnish UAS, which may also account for higher levels of stress among second year students. Finally, first year nursing students’ clinical learning environments are usually relatively straightforward and quiet, such as residential care homes. On the other hand, more experienced second and third year nursing students often conduct their practice in complex, technologically advanced clinical settings. These clinical settings often include noisy beeping monitors that constantly monitor the vitals of patients. Such environments have been documented to cause alarm fatigue and eventually stress (Landro, 2016).

At M2, the item “unfamiliar with medical history and terms” was reported as the highest stress causing situation. This finding is interesting and supports the fact that during the second year of study, students are given more responsibility, including understanding a patient’s history and medical jargon in patient records. These medical terms are often introduced at the start of the

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third year of studies in their study institutions, which may explain why they are unfamiliar with these terms. Consequently, we encourage nursing lecturers to familiarise their students with complex nursing terms as much as possible from as early as their second year. The rankings of the PSS six sub-dimensions changed from M1 to M2, the sub-dimension “stress from peers and daily life” was the least stressful on both occasions. One possible justification for this may be that in Finland, students do not generally see their peers as competitors and teachers place less emphasis on competition and comparison. While the sub-dimension “stress from taking care of patients” was the second most stress causing factor in the first year, it ranked fourth in the second study year. One justification for this is maybe that first-year students felt more pressure to take care of patients because it was their first time to do so as suggested by two previous studies (Bahadır-Yılmaz, 2016; Bodys-Cupak, Majda, Skowron, Zalewska-Puchala, & Trzcinska, 2018).

The sub-dimension “stress from lack of professional knowledge and skills” was reported as the most stressful in both the first and second years. Specific items that formed this PSS sub- dimension were “unfamiliar with medical history and terms”, “unfamiliar with professional nursing skills” and “unfamiliar with patients’ diagnoses and treatments”. We found a statistically significant change in two of these items, i.e. “unfamiliar with medical history and terms”, and

“unfamiliar with patients’ diagnoses and treatments”. Furthermore, all these items focus on the students themselves and are unsurprisingly related to unfamiliarity. They actually form the core concept of Lazarus & Folkman stress theory (Lazarus & Folkman, 1984), which views stress as the relationship between the individual and the unfamiliar environment. Consequently, our findings justify the use of a transactional process approach to understand stress (Lazarus &

Folkman, 1984).

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The participants in this study used all coping strategies found in the CBI more frequently in their second year (M2) clinical practice compared with the first year (M1). This may be because during their second year, they experienced higher levels of stress, and therefore reported using coping strategies more regularly, a result partly observed in another study (Fornés-Vives, Garcia- Banda, Frias-Navarro, & Rosales-Viladrich, 2016). Furthermore, our participants reported using

“transference” predominantly to cope with stress during both their first and second study years of clinical practice (M1 and M2). Items in this sub-dimension included “to feast and take a long sleep”, “to save time for sleep and maintain good health to face stress”, and “to relax via TV, movies, a shower, or physical exercises”. These are emotion-based coping strategies that are often seen as ineffective ways to cope (Gibbons, 2010), but our participants nevertheless used them to cope with rising stress levels. This finding is difficult to interpret given that our nursing students also reported using problem-based coping strategies. For example, nursing students employed “problem-solving” and “staying optimistic” strategies more extensively in their second year than in the first year. This may be because as they progressed through their studies, they became more experienced and confident at using effective coping strategies, such as better time management skills (Chan et al., 2009; Lo, 2002).

Although emotion-based coping seems to be less preferred by nursing students and sometimes ineffective in comparison to problem-based strategies (Alzayyat & Al‐Gamal, 2016; Gibbons, 2010; Labrague et al., 2016), our findings suggest that students still use them to alleviate stress.

The effectiveness of a coping strategy depends on which stressor it is being used against. For example, a coping item such as “to set up objective to solve problems” to deal with stress from

“unfamiliarity with medical history and terms” may be a better way of coping than “to feast and take a long sleep”. However, in the case of stress from a specific stressor such as “feel that the

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requirements of clinical practice exceed one's physical and emotional endurance”, eating and sleeping adequately may be more effective than making a step-by-step plan on improving one’s physical and emotional endurance for the next day of clinical practice. Consequently, to understand the complexities of stress, we endorse more research to link specific clinical stressors (stressors specific to the clinical learning environment) to explicit coping strategies. This will equip nurse educators and clinical learning environment mentors to better support their nursing students by providing them empirically tested coping strategies against specific stressors. The item “to feast and take a long sleep” moved from rank 10 in the first year to rank 1 in the second year. Again, this result is challenging to interpret. However, we believe that it may be related to the interrelation between problem-focused and emotion-focused coping strategies (Lazarus &

Folkman, 1984). Maybe, the students used “to feast and take a long sleep”, which is an emotion- focused coping strategy, to immediately dampen distress emotions caused by stress in their clinical practice, after which they were able to identify and use effective problem-focused coping strategies calmly that were not obvious previously. Based on the results, we recommend nursing lecturers and mentors to recognise the evolving nature of stress and support their students by empowering them to use effective coping strategies such as problem-solving. Previous studies recommended that, nursing students should be encouraged to developed positive coping skills and the role of self-efficacy and coping should be emphasised (Yamashita, Saito, & Takao, 2012;

Zhao, Lei, He, Gu, & Li, 2015). One important new evidence that this study revealed is that the factors that seemed to be stressful in the first year continue to be even more stressful in the second year, with a general increase in scores of all sub-dimensions of stress. Therefore, nursing students should prepare themselves better by knowing how you use coping skills already at the

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start of their studies. In terms of coping, this study produced initial evidence on the interrelating relationship between problem-focused and emotion-focused coping strategies.

Limitations

The findings of this study were from five UAS in Finland, and therefore we recommend caution when extrapolating these results to different countries and cultural contexts. Additionally, we followed participants in their first and second study years only. It would be interesting to see whether stress levels decreased in the third year of study, as observed in nursing students by one previous study (Zupiria Gorostidi et al., 2007). Our lower response rate at M2 as compared to M1 could be a limitation in our study. However, we observed no significant differences in stress levels and coping strategies between the definitive sample (n = 131) and excluded group (n = 58). Further, correlations between stress factors and coping strategies and relationships of variables across time to predict changes have not been studied – which may be possible in future studies. One major strength of our study was the ability to reveal changes in variables within the same cohort because of the longitudinal study design.

Conclusion

Our findings indicate that overall stress levels among nursing students increase over time from their first to second study year. The main source of stress and significant rise in stress scores originates from a “lack of professional knowledge and skills”. This can be remedied by encouraging nursing students to acquaint themselves with a broader range of medical terms and diagnoses as early as possible. Additionally, the study revealed that nursing students use both problem-based and emotion-based coping strategies more frequently in their second study year.

They used “transference”, specifically “to feast and take a long sleep” as a coping strategy

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predominantly during the second year, which may be because of the more complex clinical learning environments, such as acute-care settings. Based on our results, we suggest that nurse educators and clinical nursing mentors should emphasise the importance of understanding and assimilating stressful events and specific stressors unique to the clinical learning environment to nursing students. By supporting the development of both effective problem-based and emotion- based coping strategies at the beginning of study, nurse educators can promote the well-being of their students.

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Table 1. Socio-demographic, mean scores of stress (Perceived Stress Scale) and coping (Coping Behavior Inventory) in the excluded group and final sample

Excluded group (n =

58)

Final sample (n =

131)

p

mean sd mean sd

Female 86.20% 84.00% 0.828

Had previous experience in nursing 34.50% 36.60% 0.870

Has a family in nursing sector 55.20% 53.40% 0.875

Age (years) 25.12 6.01 26.44 8.96 0.309

Amount of experience before starting nursing (years) 1.38 3.14 1.39 3.17 0.985

Interest in nursing 1.16 0.37 1.15 0.38 0.894

Overall stress score 1.08 0.49 1.03 0.52 0.152

Stress from taking care of patients 1.35 0.56 1.21 0.55 0.104 Stress from assignments and workload 1.32 0.78 1.16 0.77 0.194 Stress from lack of professional knowledge and skills 1.45 0.75 1.51 0.85 0.695 Stress from the environment 1.09 0.68 0.92 0.69 0.105 Stress from peers and daily life 0.72 0.62 0.61 0.62 0.267 Stress from teachers and nursing staff 0.96 0.59 0.80 0.59 0.089

Avoidance 0.67 0.42 0.60 0.46 0.311

Problem Solving 2.37 0.75 2.45 0.68 0.505

Stay Optimistic 2.35 0.50 2.37 0.50 0.859

Transference 2.96 0.71 2.75 0.73 0.065

No significant differences detected between excluded group and final sample, all p values > .05

Interest in nursing scale is from 1-4; 1 = very interested, 2 = Somwhat intersted, 3 = little intersted, 4 = Not interested Stress scale is from 0 - 4; 0 = never, 1 = infrequently, 2 = sometimes, 3 = frequently, 4 = always.

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Table 2

Average stress scores measured by the Perceived Stress Scale (PSS) of students who belonged to the final sample on the two moments M1 and M2 of this study (n= 131)

M1 M2

p dc

Stress factor

factor ranking

item

ranking mean sd factor ranking

item

ranking mean sd

1. Stress from taking care of patients 2 1.21 0.55 4 1.43 0.54 < 0.001 0.42

Lack of experience and ability in providing nursing care and in making judgments 5 1.53 0.87 2 1.96 0.80 < 0.001 0.51

Do not know how to help patients with physio-psycho-social problems 11 1.22 0.86 3 1.92 0.82 < 0.001 0.83

Unable to reach one's expectations 2 1.57 0.99 14 1.53 0.92 0.732

Unable to provide appropriate responses to doctors', teachers', and patients' questions 1 1.59 0.87 7 1.75 0.94 0.183

Worry about not being trusted or accepted by patients or patients' family 15 1.09 0.82 22 1.37 0.74 0.003 0.36

Unable to provide patients with good nursing care 7 1.45 0.98 19 1.41 0.85 0.720

Do not know how to communicate with patients 24 0.62 0.70 27 0.71 0.74 0.377

Experience difficulties in changing from the role of a student to that of a nurse 25 0.58 0.76 26 0.81 0.81 0.018 0.29

2. Stress from assignments and workload 3 1.16 0.77 2 1.62 0.82 < 0.001 0.57

Worry about bad grades 9 1.30 1.10 12 1.60 1.09 0.012 0.28

Experience pressure from the nature and quality of clinical practice 13 1.18 0.94 4 1.91 0.99 < 0.001 0.76

Feel that one's performance does not meet teachers' expectations 12 1.19 1.04 10 1.61 0.96 < 0.001 0.42

Feel that the requirements of clinical practice exceed one's physical and emotional endurance 18 0.86 0.90 21 1.38 0.96 < 0.001 0.56 Feel that dull and inflexible clinical practice affects one’s family and social life 10 1.29 1.13 11 1.61 1.23 0.004 0.27

3. Stress from lack of professional knowledge and skills 1 1.51 0.85 1 3.03 0.70 < 0.001 1.96

Unfamiliar with medical history and terms 6 1.53 0.96 1 2.08 1.03 < 0.001 0.55

Unfamiliar with professional nursing skills 3 1.57 0.98 8 1.69 0.88 0.237

Unfamiliar with patients' diagnoses and treatments 8 1.42 0.90 6 1.89 0.89 < 0.001 0.53

4. Stress from the environment 4 0.92 0.69 3 1.45 0.79 < 0.001 0.72

Feel stressed in the hospital environment where clinical practice takes place 22 0.76 0.87 16 1.53 0.99 < 0.001 0.82

Unfamiliar with the ward facilities 17 0.91 0.89 23 1.20 0.93 0.008 0.31

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Feel stressed from the rapid change in patient's condition 16 1.04 0.96 9 1.63 0.98 < 0.001 0.61

5. Stress from peers and daily life 6 0.61 0.62 6 1.04 0.68 < 0.001 0.67

Experience competition from peers in school and clinical practice 23 0.74 0.98 20 1.40 1.12 < 0.001 0.63

Feel pressure from teachers who evaluate students' performance by comparison 14 1.12 1.22 17 1.51 1.27 0.002 0.31

Feel that clinical practice affects one's involvement in extracurricular activities 28 0.30 0.66 29 0.57 0.93 0.002 0.35

Cannot get along with other peers in the group 29 0.26 0.52 28 0.67 0.76 < 0.001 0.63

6. Stress from teachers and nursing staff 5 0.80 0.59 5 1.40 0.72 < 0.001 0.92

Experience discrepancy between theory and practice 4 1.55 0.95 5 1.89 0.88 0.001 0.38

Do not know how to discuss patients' illness with teachers or medical and nursing personnel 27 0.45 0.68 25 0.82 0.85 < 0.001 0.48 Feel stressed that teacher's instruction is different from one's expectations 21 0.78 0.91 18 1.45 0.99 < 0.001 0.71

Doctors lack empathy and are not willing to help 20 0.78 0.85 13 1.58 1.04 < 0.001 0.85

Feel that teachers do not give fair evaluation on students 26 0.47 0.79 24 1.15 1.08 < 0.001 0.72

Lack of care and guidance from teachers 19 0.79 0.99 15 1.53 1.06 < 0.001 0.72

p value with statistically significant differences (p < 0.001) (in bold) using t-test for related samples between M1 and M2

dc = Cohen effect size

Stress scale is from 0 - 4; 0 = never, 1 = infrequently, 2 = sometimes, 3 = frequently, 4 = always.

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Table 3

Average coping behaviour scores measured by the Coping behaviour Inventory (CBI) of students who belonged to the final sample on the two moments M1 and M2 of this study (n= 131)

M1 M2

p dc

Coping item

factor ranking

item

ranking mean sd factor ranking

item

ranking mean sd

1. Avoidance 4 0.60 0.46 4 0.92 0.67 < 0.001 0.56

To avoid difficulties during clinical practice 13 1.67 1.45 13 1.97 1.40 0.062

To avoid teachers 19 0.12 0.39 17 0.49 0.83 < 0.001 0.61

To quarrel with others and lose temper 18 0.15 0.38 18 0.48 0.82 < 0.001 0.55

To expect miracles so one does not have to face difficulties 17 0.27 0.65 19 0.47 0.81 0.020 0.27

To expect others to solve the problem 16 0.47 0.73 16 0.65 0.74 0.024 0.25

To attribute to fate 15 0.96 1.03 14 1.40 1.21 < 0.001 0.39

2. Problem Solving 2 2.45 0.68 2 2.83 0.80 < 0.001 0.52

To adopt different strategies to solve problems 9 2.37 0.87 8 2.79 1.15 0.001 0.42

To set up objectives to solve problems 8 2.44 0.96 9 2.75 1.06 0.005 0.31

To make plans, list priorities, and solve stressful events 6 2.61 0.99 5 2.96 0.90 0.001 0.37

To find the meaning of stressful incidents 11 2.22 1.09 11 2.66 1.04 < 0.001 0.41

To employ past experience to solve problems 1 2.99 0.80 2 3.28 0.95 0.006 0.33

To have confidence in performing as well as senior schoolmates 12 2.02 1.11 12 2.49 1.18 < 0.001 0.41

3. Stay Optimistic 3 2.37 0.50 3 2.59 0.52 < 0.001 0.44

To keep an optimistic and positive attitude in dealing with everything in life 2 2.97 0.81 4 3.17 0.82 0.020 0.25

To see things objectively 7 2.55 0.82 10 2.73 0.95 0.066

To have confidence in overcoming difficulties 3 2.89 0.74 3 3.19 0.85 < 0.001 0.38

To cry, to feel moody, sad, and helpless 14 1.06 0.96 15 1.27 0.90 0.008 0.23

4. Transference 1 2.75 0.73 1 2.92 0.76 0.039 0.22

To feast and take a long sleep 10 2.31 0.80 1 3.42 4.56 0.006 0.41

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To save time for sleep and maintain good health to face stress 4 2.79 0.93 7 2.85 0.92 0.524

To relax via TV, movies, a shower, or physical exercises 5 2.71 1.00 6 2.92 0.92 0.032 0.22

p value with statistically significant differences (p < 0.001) (in bold) using t-test for related samples between M1 and M2 d_c = Cohen effect size

Coping scale is from 0 - 4; 0 = never, 1 = infrequently, 2 = sometimes, 3 = frequently, 4 = always.

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Figure 1. Changes in stress scores measured by the Perceived Stress Scale (PSS) of students who belonged to the final sample on the two moments M1 and M2 (n= 131)

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Figure 2. Changes in coping scores measured by the Coping Behavior Inventory (CBI) of students who belonged to the final sample on the two moments M1 and M2 (n= 131)

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Highlights

• Nursing students’ stress levels evolve during their study years

• Lack of professional knowledge and skills remains a significant stressor

• Students cope by utilizing both problem-based and emotion-based strategies

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Disclaimer or disclosure information

The authors declare no conflict of interest.

List of all authors

Author 1 (corresponding author)

Hanish Dev BHURTUN, RN, M.Sc., PhD student

Tel. +358417536009

E-mail: hanishdevbhurtun@gmail.com / hanishb@uef.fi

Author 2

Hannele TURUNEN

Professor (Full) and Chair, PhD, RN, Nurse Manager (part time) Head of the Department of Nursing Science

Department of Nursing Science Faculty of Health Sciences, Kuopio Kuopio University Hospital

University of Eastern Finland +358403552629

E-mail hannele.turunen@uef.fi

Author 3 Matti ESTOLA

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Ph.D.

Senior Lecturer

University of Eastern Finland,

Faculty of Social Sciences and Business Studies, Joensuu Campus P.O. Box 111, FIN-80101, Joensuu, Finland.

E-mail: matti.estola@uef.fi

Author 4

Terhi SAARANEN, Professor (acting), Docent PhD, RN, PHN

E-mail: terhi.saaranen@uef.fi