Nurse Education in Practice xxx (2014) 1e4
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
Assessment of nursing students' stress levels and coping strategies in operating room practice Ummu Yildiz Findik a, 1, Ayfer Ozbas b, 2, Ikbal Cavdar b, 2, Sacide Yildizeli Topcu a, *, Ebru Onler c, 3 a b c
Trakya University Faculty of Health Sciences, Nursing Department, Edirne, Turkey _ Istanbul University Florence Nightingale Nursing Faculty, Istanbul, Turkey , Turkey Namık Kemal University, School of Health, Tekirdag
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 10 November 2014
The aim of this study was to evaluate the stress levels and stress coping strategies of nursing students in their first operating room experience. This descriptive study was done with 126 nursing students who were having an experience in an operating room for the first time. Data were collected by using Personal Information Form, Clinical Stress Questionnaire, and Styles of Coping Inventory. The nursing students mostly had low clinical stress levels (M ¼ 27.56, SD ¼ 10.76) and adopted a self-confident approach in coping with stress (M ¼ 14.3, SD ¼ 3.58). The nursing students generally employed a helpless/selfaccusatory approach among passive patterns as their clinical stress levels increased, used a selfconfident and optimistic approach among active patterns as their average age increased, and those who had never been to an operating room previously used a submissive approach among passive patterns. The results showed that low levels of stress caused the nursing students to use active patterns in coping with stress, whereas increasing levels of stress resulted in employing passive patterns in stress coping. The nursing students should be ensured to maintain low levels of stress and use active patterns in stress coping. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Clinical stress Coping with stress Nursing student Operating room practice
Introduction The clinical practice in the nursing education is essential to the acquisition of nursing competence (Blomberg et al.). However, several studies suggest that clinical practices, which constitute an important part of nursing training, are very stressful for nursing students (Gorostidi et al., 2007; Pryjmachuk and Richards, 2007; Sharif and Masoumi, 2005; Sendir and Acaroglu, 2008; Sheu et al., 2002). In the literature, it is stated that the practical parts of nursing training programs were more stressful than the academic parts (Blomberg et al., 2014; Tas¸delen and Zaybak, 2013), and Blomberg et al. (2014) determined that 57% of nursing students
* Corresponding author. Tel.: þ90 284 213 30 42; fax: þ90 284 212 61 07. E-mail addresses: uyildizfi[email protected] (U. Yildiz Findik), ayferozbas@ hotmail.com (A. Ozbas), [email protected] (I. Cavdar), sacideyildizeli@yahoo. com (S. Yildizeli Topcu), [email protected] (E. Onler). 1 Tel.: þ90 284 213 30 42; fax: þ90 284 212 61 07. 2 Tel.: þ90 212 440 00 00; fax: þ90 212 224 49 90. 3 Tel.: þ90 282 293 23 82; fax: þ90 282 293 35 18.
experienced stress in the clinical field. Reasons for stress in clinical practices vary among nursing students. Chan et al. (2009) determined the most common reason for stress is lack of knowledge and skills. The first clinical experience, fear of making mistakes, emergency situations, expectations, irregularity of clinical training, patients, communication problems between the health professionals and clinical trainers, academic assessments on the clinical field, practicing on humans, and equipment and operation of the clinical areas are significant causes of stress (Gorostidi et al., 2007; Pryjmachuk and Richards, 2007; Sharif and Masoumi, 2005; Sendir and Acaroglu, 2008; Timmins and Kaliszer, 2002). Another cause for nursing students' increased clinical stress is practicing in special units. Children's services, intensive care units, emergency services, and operation rooms where the nursing students are required to practice in their second and third years are more stressful clinical practice areas due to the heavy workload and the assignment of too much responsibility to the students (Evans and Kelly, 2004; Kipping, 2000; Pryjmachuk and Richards, 2007). In their study, Sharif and Masoumi (2005) found that nursing students experienced much more stress during their second, third, and fourth years
http://dx.doi.org/10.1016/j.nepr.2014.11.008 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yildiz Findik, U., et al., Assessment of nursing students' stress levels and coping strategies in operating room practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.008
2
U. Yildiz Findik et al. / Nurse Education in Practice xxx (2014) 1e4
in nursing training. Stress is viewed as a complex and dynamic transaction between individuals and their environments (Evans and Kelly, 2004). The presence and level of stress has positive and negative effects on learning and thinking where high levels of stress impedes learning; low levels motivate students while learning (Burnard et al., 2007; Gammon and Morgan-Samuel, 2005; Sendir and Acaroglu, 2008; Tully, 2004). The effects of stress on individuals depend on the sufficiency of their coping behaviors. Lazarus and Folkman (1984) define it as “continuous effort by an individual to overcome the imbalance between the internal and external conditions” (Gammon and Morgan-Samuel, 2005; Sawatzky, 1998; Sheu et al., 2002). When coping efforts are successful, the stressful situation can be resolved and balance is retained by reducing the negative effects of stress (Sheu et al., 2002). In the scale developed for university students, Lazarus and Folkman (1984) defined the problem-oriented/active and emotion-oriented/passive patterns as coping patterns for different stressful situations. The problem-oriented/active coping patterns aim to change or manage the situation causing the stress, whereas the aim of emotion-oriented/passive coping patterns is organizing the emotional responses to stressors (Burnard et al., 2007; Evans and Kelly, 2004; Sawatzky, 1998; Temel et al., 2007). Gammon and Morgan-Samuel (2005) determined in their study that the nursing students with high stress levels had low coping levels. Presence and level of stress affect the academic performance and coping efforts of students in clinical practices (Gammon and Morgan-Samuel, 2005; Sendir and Acaroglu, 2008; Sheu et al., 2002). One of the practice areas for the surgical diseases nursing course provided Turkey's second-year nursing training is the operating room. In operating room practice, nursing students gain knowledge and skills in caring for patients undergoing surgery. The operating rooms are distressing for students because of their specific structure, operational rules, experience on patients, and the first-time experience of the students with regard to an operation on a patient. Despite of the fact that studies in the clinical area about stress among nursing students increased from day by day, there is no study evaluating the stress levels and stress coping behaviors of the nursing students in an operating room. Determination of the stress levels and stress coping behaviors of the nursing students will provide guidance to the nursing instructors in reducing the negative effects of stress and providing an effective clinical training in operating room practice (Kaya et al., 2007; Sheu et al., 2002). The aim of this study is to determine the stress levels and stress coping patterns of nursing students in their first operating room practice. Study questions What is the stress level of nursing students in their first operating room experience? What are the stress coping patterns of nursing students in their first operating room experience? What is the relationship between the stress level and stress coping patterns of nursing students in their first operating room experience? Materials and methods This study was conducted as a descriptive study at Trakya University and two Healthcare Schools in the region between February 1, 2008, and May 15, 2009. Data collection forms were given to 160 nursing students who experienced their first operating room practice; 126 of them (78.75%), who completed the forms fully, were included in the study. The survey forms were distributed to the students at the end of their first operating room practice and the students were asked to
return the forms to the researchers after 20 min. Before distributing the survey forms, the researchers explained that the students were not required to participate in the study or identify themselves, that the data were to be used for a scientific research, and that the students might ask any questions about the study. The students were left on their own while completing the survey forms. A Personal Information Form, Clinical Stress Questionnaire, and Stress Coping Patterns Scale were used as data collection materials. Personal Information Form Collects data about age, sex, school of the students, and information such as whether the students have seen an operating room and their preference of school. Clinical Stress Questionnaire (CSQ) A Likert-type self-assessment scale developed by Pagana in 1989 to determine the initiation value of the stress levels of the nursing students or requiring them to struggle in their first clinical practice experience. The Clinical Stress Questionnaire can be used in all internal and surgical clinics at the end of the day the student experiences his/her first clinical practice. The items of the questionnaire consists of four scales including threat (I was sad, I was nervous, I was bored, I was affected, I was cowered, I was scared), struggle (I was stimulated, I was cheerful, I was hopeful, I liked it, I was aspired, I was excited, I was happy), harm (I was furious, I was grieved, I felt guilty, I was disgusted, I was disappointed), and benefit (I was relieved, I was in confidence). Each item is assessed in 5 levels; the students are asked to choose one of the following: “0none”, “1- a little”, “2- medium”, “3- pretty much”, “4- very much.” On the basis of points for each item, the minimum score of the questionnaire is “0” and maximum is “80”. Low scores indicate low stress levels, whereas high scores indicate high stress levels. The reliability and validity of the Turkish form was demonstrated by Sendir and Acaroglu (2008). Stress-coping patterns scale (SCPS) A scale for university students in relation with coping mechanismsdin particular, depression, solidarity, and psychosomatic problemsdand valid for short, different distressing situations, prepared on the basis of the stress-coping Ways Inventory (developed by Lazarus and Folkman (1984)). The reliability and validity of the Turkish form consisting of 30 items was demonstrated by Sahin and Durak (1995). It is a four Likert-type scale to measure two major stress-coping patterns, including problem-oriented/active patterns and emotion-oriented/passive patterns. Active patterns include sub-scales of “seeking social support (SSS), optimistic approach (OA) and self-confident approach (SCA)”, and passive patterns include sub-scales of “helpless approach (HA)” and “submissive approach (SA)”. The Cronbach alpha consistency coefficients of the scales are determined to be 0.63 for SSS, 0.68 for OA, 0.61 for SCA, 0.70 for HA, and 0.51 for SA. Items 8, 10, 14, 16, 20, 23, and 26 of the scale are related to SCA; 2, 4, 6, 12, and 18 are related to OA; 3, 7, 13, 15, 21, and 24 are related to HA; 5, 7, 13, 15, 21, and 24 are related to SA; and 1, 9, 29, and 30 are related to SSS. The scale has been developed to determine what individuals do to cope with troubles in life and stress (Kaya et al., 2007; Temel et al., 2007). Statistical analysis The data were assessed on computer by using percentage, average, t-test, and Pearson correlation test. The value of P < 0.05 was accepted as the statistical significance limit.
Please cite this article in press as: Yildiz Findik, U., et al., Assessment of nursing students' stress levels and coping strategies in operating room practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.008
2.18 2.83 2.76 2.56 ± ± ± ± 4.66 5.66 5.53 5.10
2.71 10.76 2.71 1.14 2.75 2.29 ± ± ± ± ± ± 5.42 27.56 5.42 20.48 5.46 4.86
9.28 9.79 9.67 9.62
± ± ± ±
4.09 4.24 4.15 4.35
0.149** 0.047** 0.136 0.064 1.048 0.307 b t/p 0.620 0.537 0.056 0.956 4.24 10.76 4.24 1.14 4.26 3.53 ± ± ± ± ± ± 9.68 27.56 9.68 20.48 9.77 8.73
8.00 7.20 7.47 7.27
± ± ± ±
2.29 2.47 2.35 2.67
0.046 0.303 0.031 0.366 0.768 0.452 b t/p 1.736 0.087 0.404 0.688 2.44 10.76 2.44 1.14 2.48 2.17 ± ± ± ± ± ± 7.38 27.56 7.38 20.48 7.46 7.00
9.60 8.80 9.26 8.45
± ± ± ±
2.22 3.07 2.80 3.02
0.007 0.470 0.205** 0.011** e 1.198 0.242 b t/p 1.629 0.107 1.451 0.151 2.89 10.76 2.89 1.14 2.99 1.64 ± ± ± ± ± ± 8.95 27.56 8.95 20.48 8.93 9.60 10.76 1.14 10.92 9.27
11.28 10.55 11.32 9.17 ± ± ± ± Seen Not seen Willingly Unwillingly
27.56 20.48 27.45 27.26
± ± ± ±
0.103 0.126 0.073 0.942 b t/p 0.495 0.623 1.141 0.257
14.86 14.10 14.59 13.65
± ± ± ±
3.09 379 3.72 3.36
0.109 0.111 0.199** 0.013** 0.633 0.533 b t/p 1.156 0.251 1.431 0.156 3.58 10.76 3.58 1.14 3.74 2.63 ± ± ± ± ± ± e 27.56 ± 10.76
28.23 27.14 28.09 25.95
r/p a
X ± SS r/p a
X ± SS r/p a
X ± SS r/p a
X ± SS r/p a
X ± SS a
r/p
14.3 27.56 14.3 20.48 14.25 14.73
Having seen operating room previously School preference
21) 15) 12) 19) 16)
Female Male
¼ ¼ ¼ ¼ ¼
Sex
max max max max max
Age
6, 1, 1, 0, 0,
*p < 0.05. a Pearson correlation. b t test.
Health college.
¼ ¼ ¼ ¼ ¼
88.1 11.9 38.9 32.5 28.6 23.8 76.2 68.3 31.7
Stress
a
111 15 49 41 36 30 96 86 40
X ± SS
Female Male School attended (n/%) Edirne HCa Kırklareli HC HC Tekirdag Having seen operating room previously Seen Not seen School preference (n/%) Willingly Unwillingly Clinical stress level 27.56 ± 10.76 (min ¼ 7, max ¼ 66) Stress-coping patterns (X ± SD. min., max.) Self-confident approach 14.3 ± 3.58 (min Optimistic approach 8.95 ± 2.89 (min Seeking social support 7.38 ± 2.44 (min Helpless/self-accusatory approach 9.68 ± 4.24 (min Submissive approach 5.42 ± 2.71 (min
Problem-oriented/active patterns
Gender (n/%)
20.48 ± 1.14 (min ¼ 13, max ¼ 23)
Self-confident approach
Variables (n ¼ 126) Age (X ± SD. min., max.)
Variables
Table 1 Individual variables.
Stress
The nursing students were found to have low stress levels in operating room practice and to use the self-confident approach among active patterns. There is no study evaluating the stress levels and stress coping patterns of the nursing students in their first operating room experience. However, there are studies that have a similar assessment as our study in terms of low stress levels in first clinical practices. In the delivery room practice, which we thought to be similar to operating room practice, Sirin et al. (2003) found no difference in anxiety levels of the students before, during, and after the practice. Similarly, Sheu et al. (2002) found the stress levels of the students during their first clinical practice as mid-range, and Chan et al. (2009) determined the stress levels of the nursing students, again, as mid-range during clinical practices. In our study, we think that low stress levels of the nursing students were due to the fact that the first day in the operating room was used as adaptation day to the operating room environment and personnel, the students were not assigned important responsibilities, and the data were collected at the end of that day.
Table 2 Correlation between individual characteristics and stress and stress coping.
Discussion
Optimistic approach
Seeking social support
Emotion-oriented/passive patterns
The average age of the nursing students participating in their first operating room experience was 20.48 (min ¼ 18, max ¼ 23), 88% were female, 39% were attending Edirne Health College, 76% had never seen an operating room before, and 68% chose the profession willingly (Table 1). The average clinical stress score of the nursing students in their first operating room practice was determined to be M ¼ 27.56, SD ¼ 10.76 (min ¼ 7, max ¼ 66) (Table 1). When the nursing students' stress-coping patterns examined, it was found that self-confident approach subscale score was 14.3 ± 3.58, optimistic approach score was 8.95 ± 2.89 (min ¼ 1, max ¼ 15), seeking social support score was 7.38 ± 2.44 (min ¼ 1, max ¼ 12), helpless/self-accusatory approach score was 9.68 ± 4.24 (min ¼ 0, max ¼ 19) and submissive approach score was 5.42 ± 2.71 (min ¼ 0, max ¼ 16) (Table 1). The nursing students used helpless/self-accusatory approach of the passive patterns (r ¼ 0.149, P ¼ 0.047) as their clinical stress levels increased, and self-confident and optimistic approaches of the active patterns (r ¼ 0.199, P ¼ 0.013, r ¼ 0.205, P ¼ 0.011, respectively) as their average age increased, and those who had never seen an operating room before used submissive approach of the passive patterns (t ¼ 2.155, P ¼ 0.034) (Table 2).
Helpless/self-accusatory approach
Submissive approach
Findings
3
0.087 0.167 0.058 0.261 0.928 0.365 b t/p ¡2.155** 0.034** 0.858 0.393
U. Yildiz Findik et al. / Nurse Education in Practice xxx (2014) 1e4
Please cite this article in press as: Yildiz Findik, U., et al., Assessment of nursing students' stress levels and coping strategies in operating room practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.008
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U. Yildiz Findik et al. / Nurse Education in Practice xxx (2014) 1e4
The study demonstrated that the nursing students mostly employed self-confident approach among active patterns. Temel et al. (2007) demonstrated that the nursing students mostly adopted self-confident approach among the active patterns. Tully (2004) determined that employment of the self-confident approach among the active patterns in coping with stress was related to low stress levels and an indication of adaptation to the situation. Chan et al. (2009) found in their study that the students with low stress levels used problem-solving (active patterns) in coping with stress. Gammon and Morgan-Samuel (2005) determined that education guidance decreased stress in students and increased their coping skills. The low stress levels and high use of the self-confident approach support each other in the study. Moreover, employment of active coping patterns by the students demonstrated that they could effectively cope with stress. It was determined that the nursing students used helpless/selfaccusatory approach of the passive patterns much more as their clinical stress levels increased. Kaya et al. (2007) found that the health care school students mostly used passive patterns (helpless/ self-accusatory) in their study where the nursing students were also included. Evans and Kelly (2004) showed that the nursing students used passive patterns much more in coping with stress, when they experience stress, and Chan et al. (2009) found that nursing students with high stress levels adopted “avoidance” strategy to a greater extent. Tully (2004) found in the study conducted with psychiatry nursing students that the students with high stress levels preferred to think different things, relieve pressure by eating, smoking, or consuming alcohol, take drugs, and try to forget about the situation (passive patterns) in coping with stress rather than problem-solving (active patterns). According to the results of our and other studies, high levels of stress lead to employment of ineffective stress coping patterns. The nursing students used self-confident and optimistic approaches among active patterns to a greater extent as their average age increased. In line with the study findings, Evans and Kelly (2004) found that the younger students had a greater emotional reaction (passive patterns) to stress than the older students. Gorostidi et al. (2007) found that the nursing students tended to perceive the stressful situations as less stressful as the nursing education proceeded (as well as their average age increased). In parallel with age, the students have increased knowledge, experience, and self-confidence, which reduce their stress. The students who had not seen the operating room before for any reason (e.g., illness), used a submissive approach among the passive patterns in coping with stress. An unknown environment causes stress in students. High levels of stress cause the nursing students to use ineffective patterns in stress coping (Tully, 2004). Conclusion The stress levels of the nursing students were low in the first day of operating room practice. The students were found to use selfconfident approach among active patterns in coping with stress. The nursing students generally employed helpless/self-accusatory approach among passive patterns as their clinical stress levels increased, they used self-confident and optimistic approach among active patterns as their average age increased, and those who had never been to an operating room previously used submissive approach among passive patterns. The first operating room practice showed that low levels of stress caused the nursing students to use active patterns in coping with stress while increasing levels of
stress resulted in employment of passive patterns in stress coping. In line with these results the following are recommended. Clinical teachers should be aware that students are at risk of stress and may have increased need of support during the clinical practice. The nursing instructors should take into consideration the stress levels of the nursing students who are to experience operating room practice, the stress-coping patterns, and affecting factors (age, having seen operating room before) to attain effective clinical training in the operating room environment. By teaching the stress management strategies in the educational process, the nursing students should be ensured to maintain low levels of stress and use active patterns in stress coping in operating room practices. References € m, A.K., Ohlsson, U., Johansson, A.S., Gustafsson, M., Blomberg, K., Bisholt, B., Engstro 2014. Swedish nursing students' experience of stress during clinical practice in relation to clinical setting characteristics and the organisation of the clinical education. J. Clin. Nurs. 23, 2264e2271. Burnard, P., Haji Abd Rahim, H.T., Hayes, D., Edwards, D., 2007. A descriptive study of Bruneian student nurses' perception of stress. Nurse Educ. Today 27, 808e818. Chan, C.K.L., So, W.K.W., Fong, D.Y.T., 2009. Honk Kong baccalaureate nursing students' stress and their coping strategies in clinical practice. J. Prof. Nurs. 25, 307e313. Evans, W., Kelly, B., 2004. Pre-registration diploma student nurse stress and coping measures. Nurse Educ. Today 24, 473e482. Gammon, J., Morgan-Samuel, H.A., 2005. A study to ascertain the effect of structured student tutorial support on student stress, self-esteem and coping. Nurse Educ. Pract. 5, 161e171. Gorostidi, X.Z., Egilegor, X.H., Erice, M.J.A., Iturriotz, X.H., Garate, I.E., Lasa, M.B., et al., 2007. Stress sources in nursing practice. Evaluation during nursing training. Nurse Educ. Today 27, 777e787. lık Yüksekokulu Kaya, M., Genc, M., Kaya, B., Pehlivan, E., 2007. Tıp Fakültesi ve Sag €g rencilerinde depresif belirti yaygınlıg ı, stresle bas¸a çıkma tarzları ve etkileyen o €rler (Prevalence of depressive symptoms, ways of coping and related fakto factors among medical school and health services higher education students). Türk Psikiyatr. Derg. (Turk. J. Psychiatry) 18, 137e146. Kipping, C.J., 2000. Stress in mental health nursing. Int. J. Nurs. Stud. 37, 207e218. Lazarus, R.S., Folkman, S., 1984. Stress, Appraisal, and Coping. Springer Publishing Company, New York. Pryjmachuk, S., Richards, D.A., 2007. Predicting stress in pre-registration nursing students. Br. J. Health Psychol. 12, 125e144. Sawatzky, J.A.V., 1998. Understanding nursing students' stress: a proposed framework. Nurse Educ. Today 18, 108e115. Sendir, M., Acaroglu, R., 2008. Reliability and validity of Turkish version of clinical stress questionnaire. Nurse Educ. Today 28, 737e743. Sharif, F., Masoumi, S., 2005. A qualitative study of nursing student experiences of clinical practice. BMC Nurs. 4 (6), 1e7. Sheu, S., Lin, H.S., Hwang, S.L., 2002. Perceived stress and physio- psycho- social status of nursing students during their initial period of clinical practice: the effect of coping behaviors. Int. J. Nurs. Stud. 39, 165e175. € g i: Üniversite Sahin, N.H., Durak, A., 1995. Stresle Bas¸a çıkma Tarzları Olçe €g rencileri için uyarlaması (Stress-Coping patterns scale: adaptation for unio versity students). Türk Psikol. Derg. (Turk. J. Psychol. 10, 56e73. umhane stajına çıkan o €g rencilerin durSirin, A., Kavlak, O., Ertem, G., 2003. Dog umluk-sürekli kaygı düzeylerinin belirlenmesi (Determination of the state-trait anxiety levels of students who are on labour room in maternity hospital). C.Ü.Hems¸ire. Yüksek. Derg. J. C.U. Nurs. Sch. 7, 28e32. €g _ rencilerinin Ilk Tasdelen, S., Zaybak, A., 2013. Hems¸irelik O Klinik Deneyim _ Sırasındaki Stres Düzeylerinin Incelenmesi (The determination the level of stress of nursing students during their first clinical experience). Florence Nightingale Hems¸ire. Derg. (Florence Nightingale J. Nurs. 21 (2), 101e106. €g renci hems¸irelerin stresle bas¸ etme tarzları Temel, E., Bahar, A., Cuhadar, D., 2007. O ve depresyon düzeylerinin belirlenmesi (Determination of coping attitude with lık Hizmetleri Derg. J. stress and depression level of nursing students). Fırat Sag Firat Health Serv. 2, 108e118. Timmins, F., Kaliszer, M., 2002. Aspects of nurse education programmes that frequently cause stress to nursing student-fact-finding sample survey. Nurse Educ. Today 22, 203e211. Tully, A., 2004. Stress, sources of stress and ways of coping among psychiatric nursing students. J. Psychiatri. Ment. Health Nurs. 11, 43e47.
Please cite this article in press as: Yildiz Findik, U., et al., Assessment of nursing students' stress levels and coping strategies in operating room practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.008
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
Assessment of nursing students' stress levels and coping strategies in operating room practice Ummu Yildiz Findik a, 1, Ayfer Ozbas b, 2, Ikbal Cavdar b, 2, Sacide Yildizeli Topcu a, *, Ebru Onler c, 3 a b c
Trakya University Faculty of Health Sciences, Nursing Department, Edirne, Turkey _ Istanbul University Florence Nightingale Nursing Faculty, Istanbul, Turkey , Turkey Namık Kemal University, School of Health, Tekirdag
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 10 November 2014
The aim of this study was to evaluate the stress levels and stress coping strategies of nursing students in their first operating room experience. This descriptive study was done with 126 nursing students who were having an experience in an operating room for the first time. Data were collected by using Personal Information Form, Clinical Stress Questionnaire, and Styles of Coping Inventory. The nursing students mostly had low clinical stress levels (M ¼ 27.56, SD ¼ 10.76) and adopted a self-confident approach in coping with stress (M ¼ 14.3, SD ¼ 3.58). The nursing students generally employed a helpless/selfaccusatory approach among passive patterns as their clinical stress levels increased, used a selfconfident and optimistic approach among active patterns as their average age increased, and those who had never been to an operating room previously used a submissive approach among passive patterns. The results showed that low levels of stress caused the nursing students to use active patterns in coping with stress, whereas increasing levels of stress resulted in employing passive patterns in stress coping. The nursing students should be ensured to maintain low levels of stress and use active patterns in stress coping. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Clinical stress Coping with stress Nursing student Operating room practice
Introduction The clinical practice in the nursing education is essential to the acquisition of nursing competence (Blomberg et al.). However, several studies suggest that clinical practices, which constitute an important part of nursing training, are very stressful for nursing students (Gorostidi et al., 2007; Pryjmachuk and Richards, 2007; Sharif and Masoumi, 2005; Sendir and Acaroglu, 2008; Sheu et al., 2002). In the literature, it is stated that the practical parts of nursing training programs were more stressful than the academic parts (Blomberg et al., 2014; Tas¸delen and Zaybak, 2013), and Blomberg et al. (2014) determined that 57% of nursing students
* Corresponding author. Tel.: þ90 284 213 30 42; fax: þ90 284 212 61 07. E-mail addresses: uyildizfi[email protected] (U. Yildiz Findik), ayferozbas@ hotmail.com (A. Ozbas), [email protected] (I. Cavdar), sacideyildizeli@yahoo. com (S. Yildizeli Topcu), [email protected] (E. Onler). 1 Tel.: þ90 284 213 30 42; fax: þ90 284 212 61 07. 2 Tel.: þ90 212 440 00 00; fax: þ90 212 224 49 90. 3 Tel.: þ90 282 293 23 82; fax: þ90 282 293 35 18.
experienced stress in the clinical field. Reasons for stress in clinical practices vary among nursing students. Chan et al. (2009) determined the most common reason for stress is lack of knowledge and skills. The first clinical experience, fear of making mistakes, emergency situations, expectations, irregularity of clinical training, patients, communication problems between the health professionals and clinical trainers, academic assessments on the clinical field, practicing on humans, and equipment and operation of the clinical areas are significant causes of stress (Gorostidi et al., 2007; Pryjmachuk and Richards, 2007; Sharif and Masoumi, 2005; Sendir and Acaroglu, 2008; Timmins and Kaliszer, 2002). Another cause for nursing students' increased clinical stress is practicing in special units. Children's services, intensive care units, emergency services, and operation rooms where the nursing students are required to practice in their second and third years are more stressful clinical practice areas due to the heavy workload and the assignment of too much responsibility to the students (Evans and Kelly, 2004; Kipping, 2000; Pryjmachuk and Richards, 2007). In their study, Sharif and Masoumi (2005) found that nursing students experienced much more stress during their second, third, and fourth years
http://dx.doi.org/10.1016/j.nepr.2014.11.008 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yildiz Findik, U., et al., Assessment of nursing students' stress levels and coping strategies in operating room practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.008
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U. Yildiz Findik et al. / Nurse Education in Practice xxx (2014) 1e4
in nursing training. Stress is viewed as a complex and dynamic transaction between individuals and their environments (Evans and Kelly, 2004). The presence and level of stress has positive and negative effects on learning and thinking where high levels of stress impedes learning; low levels motivate students while learning (Burnard et al., 2007; Gammon and Morgan-Samuel, 2005; Sendir and Acaroglu, 2008; Tully, 2004). The effects of stress on individuals depend on the sufficiency of their coping behaviors. Lazarus and Folkman (1984) define it as “continuous effort by an individual to overcome the imbalance between the internal and external conditions” (Gammon and Morgan-Samuel, 2005; Sawatzky, 1998; Sheu et al., 2002). When coping efforts are successful, the stressful situation can be resolved and balance is retained by reducing the negative effects of stress (Sheu et al., 2002). In the scale developed for university students, Lazarus and Folkman (1984) defined the problem-oriented/active and emotion-oriented/passive patterns as coping patterns for different stressful situations. The problem-oriented/active coping patterns aim to change or manage the situation causing the stress, whereas the aim of emotion-oriented/passive coping patterns is organizing the emotional responses to stressors (Burnard et al., 2007; Evans and Kelly, 2004; Sawatzky, 1998; Temel et al., 2007). Gammon and Morgan-Samuel (2005) determined in their study that the nursing students with high stress levels had low coping levels. Presence and level of stress affect the academic performance and coping efforts of students in clinical practices (Gammon and Morgan-Samuel, 2005; Sendir and Acaroglu, 2008; Sheu et al., 2002). One of the practice areas for the surgical diseases nursing course provided Turkey's second-year nursing training is the operating room. In operating room practice, nursing students gain knowledge and skills in caring for patients undergoing surgery. The operating rooms are distressing for students because of their specific structure, operational rules, experience on patients, and the first-time experience of the students with regard to an operation on a patient. Despite of the fact that studies in the clinical area about stress among nursing students increased from day by day, there is no study evaluating the stress levels and stress coping behaviors of the nursing students in an operating room. Determination of the stress levels and stress coping behaviors of the nursing students will provide guidance to the nursing instructors in reducing the negative effects of stress and providing an effective clinical training in operating room practice (Kaya et al., 2007; Sheu et al., 2002). The aim of this study is to determine the stress levels and stress coping patterns of nursing students in their first operating room practice. Study questions What is the stress level of nursing students in their first operating room experience? What are the stress coping patterns of nursing students in their first operating room experience? What is the relationship between the stress level and stress coping patterns of nursing students in their first operating room experience? Materials and methods This study was conducted as a descriptive study at Trakya University and two Healthcare Schools in the region between February 1, 2008, and May 15, 2009. Data collection forms were given to 160 nursing students who experienced their first operating room practice; 126 of them (78.75%), who completed the forms fully, were included in the study. The survey forms were distributed to the students at the end of their first operating room practice and the students were asked to
return the forms to the researchers after 20 min. Before distributing the survey forms, the researchers explained that the students were not required to participate in the study or identify themselves, that the data were to be used for a scientific research, and that the students might ask any questions about the study. The students were left on their own while completing the survey forms. A Personal Information Form, Clinical Stress Questionnaire, and Stress Coping Patterns Scale were used as data collection materials. Personal Information Form Collects data about age, sex, school of the students, and information such as whether the students have seen an operating room and their preference of school. Clinical Stress Questionnaire (CSQ) A Likert-type self-assessment scale developed by Pagana in 1989 to determine the initiation value of the stress levels of the nursing students or requiring them to struggle in their first clinical practice experience. The Clinical Stress Questionnaire can be used in all internal and surgical clinics at the end of the day the student experiences his/her first clinical practice. The items of the questionnaire consists of four scales including threat (I was sad, I was nervous, I was bored, I was affected, I was cowered, I was scared), struggle (I was stimulated, I was cheerful, I was hopeful, I liked it, I was aspired, I was excited, I was happy), harm (I was furious, I was grieved, I felt guilty, I was disgusted, I was disappointed), and benefit (I was relieved, I was in confidence). Each item is assessed in 5 levels; the students are asked to choose one of the following: “0none”, “1- a little”, “2- medium”, “3- pretty much”, “4- very much.” On the basis of points for each item, the minimum score of the questionnaire is “0” and maximum is “80”. Low scores indicate low stress levels, whereas high scores indicate high stress levels. The reliability and validity of the Turkish form was demonstrated by Sendir and Acaroglu (2008). Stress-coping patterns scale (SCPS) A scale for university students in relation with coping mechanismsdin particular, depression, solidarity, and psychosomatic problemsdand valid for short, different distressing situations, prepared on the basis of the stress-coping Ways Inventory (developed by Lazarus and Folkman (1984)). The reliability and validity of the Turkish form consisting of 30 items was demonstrated by Sahin and Durak (1995). It is a four Likert-type scale to measure two major stress-coping patterns, including problem-oriented/active patterns and emotion-oriented/passive patterns. Active patterns include sub-scales of “seeking social support (SSS), optimistic approach (OA) and self-confident approach (SCA)”, and passive patterns include sub-scales of “helpless approach (HA)” and “submissive approach (SA)”. The Cronbach alpha consistency coefficients of the scales are determined to be 0.63 for SSS, 0.68 for OA, 0.61 for SCA, 0.70 for HA, and 0.51 for SA. Items 8, 10, 14, 16, 20, 23, and 26 of the scale are related to SCA; 2, 4, 6, 12, and 18 are related to OA; 3, 7, 13, 15, 21, and 24 are related to HA; 5, 7, 13, 15, 21, and 24 are related to SA; and 1, 9, 29, and 30 are related to SSS. The scale has been developed to determine what individuals do to cope with troubles in life and stress (Kaya et al., 2007; Temel et al., 2007). Statistical analysis The data were assessed on computer by using percentage, average, t-test, and Pearson correlation test. The value of P < 0.05 was accepted as the statistical significance limit.
Please cite this article in press as: Yildiz Findik, U., et al., Assessment of nursing students' stress levels and coping strategies in operating room practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.008
2.18 2.83 2.76 2.56 ± ± ± ± 4.66 5.66 5.53 5.10
2.71 10.76 2.71 1.14 2.75 2.29 ± ± ± ± ± ± 5.42 27.56 5.42 20.48 5.46 4.86
9.28 9.79 9.67 9.62
± ± ± ±
4.09 4.24 4.15 4.35
0.149** 0.047** 0.136 0.064 1.048 0.307 b t/p 0.620 0.537 0.056 0.956 4.24 10.76 4.24 1.14 4.26 3.53 ± ± ± ± ± ± 9.68 27.56 9.68 20.48 9.77 8.73
8.00 7.20 7.47 7.27
± ± ± ±
2.29 2.47 2.35 2.67
0.046 0.303 0.031 0.366 0.768 0.452 b t/p 1.736 0.087 0.404 0.688 2.44 10.76 2.44 1.14 2.48 2.17 ± ± ± ± ± ± 7.38 27.56 7.38 20.48 7.46 7.00
9.60 8.80 9.26 8.45
± ± ± ±
2.22 3.07 2.80 3.02
0.007 0.470 0.205** 0.011** e 1.198 0.242 b t/p 1.629 0.107 1.451 0.151 2.89 10.76 2.89 1.14 2.99 1.64 ± ± ± ± ± ± 8.95 27.56 8.95 20.48 8.93 9.60 10.76 1.14 10.92 9.27
11.28 10.55 11.32 9.17 ± ± ± ± Seen Not seen Willingly Unwillingly
27.56 20.48 27.45 27.26
± ± ± ±
0.103 0.126 0.073 0.942 b t/p 0.495 0.623 1.141 0.257
14.86 14.10 14.59 13.65
± ± ± ±
3.09 379 3.72 3.36
0.109 0.111 0.199** 0.013** 0.633 0.533 b t/p 1.156 0.251 1.431 0.156 3.58 10.76 3.58 1.14 3.74 2.63 ± ± ± ± ± ± e 27.56 ± 10.76
28.23 27.14 28.09 25.95
r/p a
X ± SS r/p a
X ± SS r/p a
X ± SS r/p a
X ± SS r/p a
X ± SS a
r/p
14.3 27.56 14.3 20.48 14.25 14.73
Having seen operating room previously School preference
21) 15) 12) 19) 16)
Female Male
¼ ¼ ¼ ¼ ¼
Sex
max max max max max
Age
6, 1, 1, 0, 0,
*p < 0.05. a Pearson correlation. b t test.
Health college.
¼ ¼ ¼ ¼ ¼
88.1 11.9 38.9 32.5 28.6 23.8 76.2 68.3 31.7
Stress
a
111 15 49 41 36 30 96 86 40
X ± SS
Female Male School attended (n/%) Edirne HCa Kırklareli HC HC Tekirdag Having seen operating room previously Seen Not seen School preference (n/%) Willingly Unwillingly Clinical stress level 27.56 ± 10.76 (min ¼ 7, max ¼ 66) Stress-coping patterns (X ± SD. min., max.) Self-confident approach 14.3 ± 3.58 (min Optimistic approach 8.95 ± 2.89 (min Seeking social support 7.38 ± 2.44 (min Helpless/self-accusatory approach 9.68 ± 4.24 (min Submissive approach 5.42 ± 2.71 (min
Problem-oriented/active patterns
Gender (n/%)
20.48 ± 1.14 (min ¼ 13, max ¼ 23)
Self-confident approach
Variables (n ¼ 126) Age (X ± SD. min., max.)
Variables
Table 1 Individual variables.
Stress
The nursing students were found to have low stress levels in operating room practice and to use the self-confident approach among active patterns. There is no study evaluating the stress levels and stress coping patterns of the nursing students in their first operating room experience. However, there are studies that have a similar assessment as our study in terms of low stress levels in first clinical practices. In the delivery room practice, which we thought to be similar to operating room practice, Sirin et al. (2003) found no difference in anxiety levels of the students before, during, and after the practice. Similarly, Sheu et al. (2002) found the stress levels of the students during their first clinical practice as mid-range, and Chan et al. (2009) determined the stress levels of the nursing students, again, as mid-range during clinical practices. In our study, we think that low stress levels of the nursing students were due to the fact that the first day in the operating room was used as adaptation day to the operating room environment and personnel, the students were not assigned important responsibilities, and the data were collected at the end of that day.
Table 2 Correlation between individual characteristics and stress and stress coping.
Discussion
Optimistic approach
Seeking social support
Emotion-oriented/passive patterns
The average age of the nursing students participating in their first operating room experience was 20.48 (min ¼ 18, max ¼ 23), 88% were female, 39% were attending Edirne Health College, 76% had never seen an operating room before, and 68% chose the profession willingly (Table 1). The average clinical stress score of the nursing students in their first operating room practice was determined to be M ¼ 27.56, SD ¼ 10.76 (min ¼ 7, max ¼ 66) (Table 1). When the nursing students' stress-coping patterns examined, it was found that self-confident approach subscale score was 14.3 ± 3.58, optimistic approach score was 8.95 ± 2.89 (min ¼ 1, max ¼ 15), seeking social support score was 7.38 ± 2.44 (min ¼ 1, max ¼ 12), helpless/self-accusatory approach score was 9.68 ± 4.24 (min ¼ 0, max ¼ 19) and submissive approach score was 5.42 ± 2.71 (min ¼ 0, max ¼ 16) (Table 1). The nursing students used helpless/self-accusatory approach of the passive patterns (r ¼ 0.149, P ¼ 0.047) as their clinical stress levels increased, and self-confident and optimistic approaches of the active patterns (r ¼ 0.199, P ¼ 0.013, r ¼ 0.205, P ¼ 0.011, respectively) as their average age increased, and those who had never seen an operating room before used submissive approach of the passive patterns (t ¼ 2.155, P ¼ 0.034) (Table 2).
Helpless/self-accusatory approach
Submissive approach
Findings
3
0.087 0.167 0.058 0.261 0.928 0.365 b t/p ¡2.155** 0.034** 0.858 0.393
U. Yildiz Findik et al. / Nurse Education in Practice xxx (2014) 1e4
Please cite this article in press as: Yildiz Findik, U., et al., Assessment of nursing students' stress levels and coping strategies in operating room practice, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.11.008
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U. Yildiz Findik et al. / Nurse Education in Practice xxx (2014) 1e4
The study demonstrated that the nursing students mostly employed self-confident approach among active patterns. Temel et al. (2007) demonstrated that the nursing students mostly adopted self-confident approach among the active patterns. Tully (2004) determined that employment of the self-confident approach among the active patterns in coping with stress was related to low stress levels and an indication of adaptation to the situation. Chan et al. (2009) found in their study that the students with low stress levels used problem-solving (active patterns) in coping with stress. Gammon and Morgan-Samuel (2005) determined that education guidance decreased stress in students and increased their coping skills. The low stress levels and high use of the self-confident approach support each other in the study. Moreover, employment of active coping patterns by the students demonstrated that they could effectively cope with stress. It was determined that the nursing students used helpless/selfaccusatory approach of the passive patterns much more as their clinical stress levels increased. Kaya et al. (2007) found that the health care school students mostly used passive patterns (helpless/ self-accusatory) in their study where the nursing students were also included. Evans and Kelly (2004) showed that the nursing students used passive patterns much more in coping with stress, when they experience stress, and Chan et al. (2009) found that nursing students with high stress levels adopted “avoidance” strategy to a greater extent. Tully (2004) found in the study conducted with psychiatry nursing students that the students with high stress levels preferred to think different things, relieve pressure by eating, smoking, or consuming alcohol, take drugs, and try to forget about the situation (passive patterns) in coping with stress rather than problem-solving (active patterns). According to the results of our and other studies, high levels of stress lead to employment of ineffective stress coping patterns. The nursing students used self-confident and optimistic approaches among active patterns to a greater extent as their average age increased. In line with the study findings, Evans and Kelly (2004) found that the younger students had a greater emotional reaction (passive patterns) to stress than the older students. Gorostidi et al. (2007) found that the nursing students tended to perceive the stressful situations as less stressful as the nursing education proceeded (as well as their average age increased). In parallel with age, the students have increased knowledge, experience, and self-confidence, which reduce their stress. The students who had not seen the operating room before for any reason (e.g., illness), used a submissive approach among the passive patterns in coping with stress. An unknown environment causes stress in students. High levels of stress cause the nursing students to use ineffective patterns in stress coping (Tully, 2004). Conclusion The stress levels of the nursing students were low in the first day of operating room practice. The students were found to use selfconfident approach among active patterns in coping with stress. The nursing students generally employed helpless/self-accusatory approach among passive patterns as their clinical stress levels increased, they used self-confident and optimistic approach among active patterns as their average age increased, and those who had never been to an operating room previously used submissive approach among passive patterns. The first operating room practice showed that low levels of stress caused the nursing students to use active patterns in coping with stress while increasing levels of
stress resulted in employment of passive patterns in stress coping. In line with these results the following are recommended. Clinical teachers should be aware that students are at risk of stress and may have increased need of support during the clinical practice. The nursing instructors should take into consideration the stress levels of the nursing students who are to experience operating room practice, the stress-coping patterns, and affecting factors (age, having seen operating room before) to attain effective clinical training in the operating room environment. By teaching the stress management strategies in the educational process, the nursing students should be ensured to maintain low levels of stress and use active patterns in stress coping in operating room practices. References € m, A.K., Ohlsson, U., Johansson, A.S., Gustafsson, M., Blomberg, K., Bisholt, B., Engstro 2014. Swedish nursing students' experience of stress during clinical practice in relation to clinical setting characteristics and the organisation of the clinical education. J. Clin. Nurs. 23, 2264e2271. Burnard, P., Haji Abd Rahim, H.T., Hayes, D., Edwards, D., 2007. A descriptive study of Bruneian student nurses' perception of stress. Nurse Educ. Today 27, 808e818. Chan, C.K.L., So, W.K.W., Fong, D.Y.T., 2009. Honk Kong baccalaureate nursing students' stress and their coping strategies in clinical practice. J. Prof. Nurs. 25, 307e313. Evans, W., Kelly, B., 2004. Pre-registration diploma student nurse stress and coping measures. Nurse Educ. Today 24, 473e482. Gammon, J., Morgan-Samuel, H.A., 2005. A study to ascertain the effect of structured student tutorial support on student stress, self-esteem and coping. Nurse Educ. Pract. 5, 161e171. Gorostidi, X.Z., Egilegor, X.H., Erice, M.J.A., Iturriotz, X.H., Garate, I.E., Lasa, M.B., et al., 2007. Stress sources in nursing practice. Evaluation during nursing training. Nurse Educ. Today 27, 777e787. lık Yüksekokulu Kaya, M., Genc, M., Kaya, B., Pehlivan, E., 2007. Tıp Fakültesi ve Sag €g rencilerinde depresif belirti yaygınlıg ı, stresle bas¸a çıkma tarzları ve etkileyen o €rler (Prevalence of depressive symptoms, ways of coping and related fakto factors among medical school and health services higher education students). Türk Psikiyatr. Derg. (Turk. J. Psychiatry) 18, 137e146. Kipping, C.J., 2000. Stress in mental health nursing. Int. J. Nurs. Stud. 37, 207e218. Lazarus, R.S., Folkman, S., 1984. Stress, Appraisal, and Coping. Springer Publishing Company, New York. Pryjmachuk, S., Richards, D.A., 2007. Predicting stress in pre-registration nursing students. Br. J. Health Psychol. 12, 125e144. Sawatzky, J.A.V., 1998. Understanding nursing students' stress: a proposed framework. Nurse Educ. Today 18, 108e115. Sendir, M., Acaroglu, R., 2008. Reliability and validity of Turkish version of clinical stress questionnaire. Nurse Educ. Today 28, 737e743. Sharif, F., Masoumi, S., 2005. A qualitative study of nursing student experiences of clinical practice. BMC Nurs. 4 (6), 1e7. Sheu, S., Lin, H.S., Hwang, S.L., 2002. Perceived stress and physio- psycho- social status of nursing students during their initial period of clinical practice: the effect of coping behaviors. Int. J. Nurs. Stud. 39, 165e175. € g i: Üniversite Sahin, N.H., Durak, A., 1995. Stresle Bas¸a çıkma Tarzları Olçe €g rencileri için uyarlaması (Stress-Coping patterns scale: adaptation for unio versity students). Türk Psikol. Derg. (Turk. J. Psychol. 10, 56e73. umhane stajına çıkan o €g rencilerin durSirin, A., Kavlak, O., Ertem, G., 2003. Dog umluk-sürekli kaygı düzeylerinin belirlenmesi (Determination of the state-trait anxiety levels of students who are on labour room in maternity hospital). C.Ü.Hems¸ire. Yüksek. Derg. J. C.U. Nurs. Sch. 7, 28e32. €g _ rencilerinin Ilk Tasdelen, S., Zaybak, A., 2013. Hems¸irelik O Klinik Deneyim _ Sırasındaki Stres Düzeylerinin Incelenmesi (The determination the level of stress of nursing students during their first clinical experience). Florence Nightingale Hems¸ire. Derg. (Florence Nightingale J. Nurs. 21 (2), 101e106. €g renci hems¸irelerin stresle bas¸ etme tarzları Temel, E., Bahar, A., Cuhadar, D., 2007. O ve depresyon düzeylerinin belirlenmesi (Determination of coping attitude with lık Hizmetleri Derg. J. stress and depression level of nursing students). Fırat Sag Firat Health Serv. 2, 108e118. Timmins, F., Kaliszer, M., 2002. Aspects of nurse education programmes that frequently cause stress to nursing student-fact-finding sample survey. Nurse Educ. Today 22, 203e211. Tully, A., 2004. Stress, sources of stress and ways of coping among psychiatric nursing students. J. Psychiatri. Ment. Health Nurs. 11, 43e47.
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