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International Journal of Nursing Practice 2015; 21: 297–302
RESEARCH PAPER
Nursing students in Iran identify the clinical environment stressors Shahla Najafi Doulatabad MSc in Nursing Instructor, Department of Medical Surgical Nursing, Yasuj University of Medical Sciences, Yasuj, Iran
Sima Mohamadhosaini MSc in Nursing Instructor, Department of Medical Surgical Nursing, Yasuj University of Medical Sciences, Yasuj, Iran
Hamid Reza Ghafarian Shirazi PhD in Biostatic Assistant Professor, Department of Social Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
Zinat Mohebbi MSc and PhD Candidate in Nursing Instructor, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
Accepted for publication June 2013 Najafi Doulatabad S, Mohamadhosaini S, Ghafarian Shirazi HR, Mohebbi Z. International Journal of Nursing Practice 2015; 21: 297–302 Nursing students in Iran identify the clinical environment stressors Stress at clinical environment is one of the cases that could affect the education quality among nursing students. The study aims to investigate Iranian nursing students’ perceptions on the stressors in clinical environment in the South Western part of Iran. A cross-sectional descriptive study was conducted in 2010 to include 300 nursing students after their completion of second clinical nursing course in a hospital environment. Data were collected using a researchermade questionnaire, with focus on the clinical environment stressors from personal, educational and training viewpoints. Data analysis was performed using SPSS software (IBM Corporation, Armonk, NY, USA) and descriptive statistics tests. Among the various stressors, the highest scores were given to the faculty (71 ± 19.77), followed by the students’ personal characteristics (43.15 ± 21.79). Given that faculty-related factors provoked more stress in nursing students, nursing administration should diligently evaluate and improve communication skills among faculty to reduce student stress and enhance learning. Key words: clinical nursing, nursing students, stressors.
INTRODUCTION Clinical education is an important part of the nursing and midwifery curriculum and faculty function. Clinical
Correspondence: Zinat Mohebbi, Nursing and Midwifery College, Nemazi Square, Zand Street, Shiraz 71936-13119, Iran. Email: [email protected] doi:10.1111/ijn.12276
training requires an interactive process between the trainer, trainee and the clinical environment. Through practical training, the students learn how to apply each concept correctly.1 In fact, clinical education is a dynamic process and over 50% of nursing and midwifery programmes require clinical training. To provide high quality clinical education, nursing and midwifery programmes need efficiently trained and skilled faculty in various © 2014 Wiley Publishing Asia Pty Ltd
298
S Najafi Doulatabad et al.
areas.2 Student success in clinical education is directly influenced by the training environment. Inadequately skilled faculty and unprepared training environment are contributing factors to severe stress in nursing students, followed by psychological effects such as anxiety and depression.3 Literature identifies other factors associated with the student stress such as the nature of nursing profession itself4 as well as the academic programme.5 In a study, researchers highlighted the areas that provoked stress in students such as: content inconsistencies in theory and clinical part of the course, lack of specific clinical objectives, stressful environment, unwilling trainer to be present on site to teach skills, absence of an evaluation process and inadequate facility for training.6 Each or a combination of the aforementioned list served as an obstacle to achieve the desired clinical education goals. Students reported lack of opportunities to carry out standard clinical procedures due to inadequate supplies and poor clinical conditions which were against many of the theoretical principles taught in classroom.7 Results of a study in Hong Kong showed students’ lack of knowledge and professional skills as the main problems in clinical training.8 Similarly, Evans and Kelly reported that students’ assessment of patient and inconsistencies between theoretical and clinical courses created a major problem for clinical training and skills development.9 Clinical trial possesses a specific importance in the formation of professional skills and abilities of nursing students, and is the first step in improvement of the quality of nursing programme and recognizing the clinical problems of students.10 Due to the importance of the matter, the work-related stress in this field has been taken into consideration extensively11 because a series of factors in nursing field play the role of physical or psychological stressors. These stressors could affect the performance of individuals.12 Psychological stressors, which include the confounding factors of psychical health status of students at clinical environment, will be considered in this research.
PURPOSE This research has been carried out with the aim to answer the question that, to what extent the faculty, educational system, the rate of student’s skill, patient, nursing nature, environmental factors and personal characteristics of students at clinical environment play role in the incidence of students stress. © 2014 Wiley Publishing Asia Pty Ltd
METHODS This cross-sectional descriptive study was carried out in 2010 and included 300 undergraduate nursing students in second semester of the academic year. Purposeful selection of enrolled students who have completed clinical courses or in training in semesters 2, 3, 4, 5, 6, 7 and 8 was made. It is important to add that Iranian nursing students start their supervised clinical training with a hospital rotation on the second term of their 4 year education. The clinical component of the course earns one semester credit for 51 contact hours. Students are commonly rotated in a medical–surgical unit for skills development and nursing care of adult patients. This training continues through third, fourth, fifth and sixth terms. On the seventh and eighth terms, nursing students are assigned to specialty units with faculty supervision and given slight autonomy. Demographic data included information such as age, gender, residence, marital status, academic semester, father’s occupation and mother’s occupation. Students responded to questions on stressors associated with the clinical course such as the hospital environment and personal views of stressors in relation to the faculty style, type of patients, nursing profession, clinical skills and the academic program. In the domain of personal characteristic of student, stressors like uninterested in nursing field, low selfconfidence, inability to relate to faculty, inability to relate to patient, inability to relate to classmates, inability to take responsibilities, physical and mental status of students were studied. In environmental stressor factors, the items like encounter with supervisor, encounter with the unit supervisor, encounter with the ward personnel, number of students in the ward, noisy ward, unfamiliar with instruments available at workplace, unfamiliar with patient’s accent, discrimination between nursing students and other students, lack of conference room, and lack of dressing room were evaluated. Also, in the domain of factors related to master, the stressor cases like divesting of student’s independence from faculty, the communicative style between the faculty and student, non-support of faculty when a problem arises, fear of poor evaluation by faculty, unjust student evaluation by faculty, faculty criticism of student in front of patient and personnel, question and answer of student by faculty in front of others, reproaching student by faculty in the presence of others, faculty style provoking stress, and ineffective faculty–student relation were being
Clinical environment stressors
studied. In the domain of the stressor factors related to patient, the stressors of contact with patient’s relatives, contact with patient, physical status of patient, psychological condition of patient, caring for infectious patients, and facing mortality of patients were also evaluated from the viewpoint of students. Stressor factors related to the nature of nursing were another evaluated domain. In this domain, the items like being anxious to be affected by infectious and communicable diseases, looking at wound and doing dressing, cleaning patient’s furniture and washing them, cleaning of patient after defecation, and too much work were also studied. The stressor factors related to the student’s skill were also evaluated. In this domain, the cases including insufficiency of clinical knowledge, inability to use the equipment available at ward, giving oral and non-oral medicines, lack of necessary readiness while providing bedside care, fear of injuring patient, being anxious of making a mistake and its results, and fear from unfamiliar cases were studied. The stressor factors related to the educational system, like inconsistencies between theoretical and clinical concepts, lack of clear clinical objectives for training, concerns for scientific work in a poorly equipped clinical environment and routine of the work at various wards were also studied. The 52-item questionnaire was formatted in Likert scale and scored from too high (4) to ineffective (0), and given the score ranges of 0–100. A higher score in each category meant a greater stress-provoking effect on the student. The instrument was piloted among 10 faculty members for validity and reliability, and took 15 min to be completed. Of 300 questionnaires distributed among the students, 261 were completed and returned. Researchers obtained permission from the research deputy and Education and Development Medicine Center of Yasuj University of Medical Sciences and research deputy of Shiraz University of Medical Sciences. It is noteworthy to mention that data collection was scheduled for the last day of student clinical training for each group immediately after their mandatory course evaluations were to be completed. Upon institutional approval, researcher met with the students at their clinical training location to explain the study aims and obtain written consent and offer each student the questionnaire with a returned envelope addressed to the researcher. In most cases, researcher remained on site to collect the completed questionnaires and be available to answer any question as needed.
299
Scientific content validity of the instrument was determined by 10 faculty members in Shiraz and Yasuj Schools of Nursing and Midwifery. Instrument reliability was determined by using test–retest method for this study (α = 0.80). In addition, students’ perceptions were used when instrument was piloted and the questionnaire was prepared. Data were analysed using SPSS software (IBM Corporation, Armonk, NY, USA) and descriptive tests.
RESULTS Demographic data revealed that the student age range was between 20 and 27 years, with an average age of 21.6 ± 1.39. There were 59% women, of whom 71.3% lived in dormitories, 25.7% lived at home with their families and 3% lived alone in rental properties. Of the sample, 91% were single and 9% were married. Students reported self-employed father at 47%, and 92% of mothers were housewives. Students identified that the most common cause of stress in their clinical course was related to the faculty (71 ± 19.77) and the lowest score related to the students’ personal characteristics (43.15 ± 21.79) see Table 1. Also among faculty related factors, blaming student in the presence of others by faculty (3.17 ± 1.0) and nonobservance by faculty while taking care (2.50 ± 1.23) allocated the maximum and minimum stressor rates, respectively. The mean stressor of other understudied factors in this domain are the way of facing of faculty (3.17 ± 1.0), notification by faculty in front of patient and personnel (3.0 ± 1.17), existence of ineffective relation between faculty and students (2.94 ± 1.15), divesting independency of student by faculty (2.94 ± 1.0), Table 1 The mean and standard deviation of stressors of clinical environment from the viewpoint of nursing students Stressor factors
Mean
Standard deviation
Factors related to faculty Factors related to educational system Factors related to the student’s skill Factors related to patient Factors related to the nature of nursing Environmental factors Factors related to personal characteristics of student
71.0 66.13 65.0 62.0 60.92 57.39 43.15
19.77 21.62 18.5 20.87 24.44 19.13 21.79
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non-support of faculty during problem occurrence (2.77 ± 1.23), unjust evaluation by faculty (2.74 ± 1.22), stressfulness of faculty (2.66 ± 1.2), questioning and answering by faculty in the presence of others (2.62 ± 1.21), and finally, fear from being evaluated by faculty (2.5 ± 1.23). Among factors related to the educational system, inconsistency between clinical and theoretical learning (2.84 ± 1.0) and routine working at different and specific wards (2.46 ± 1.19) allocated maximum and minimum mean stressors, respectively. Non-scientific working at clinic due to the lack of facilities (2.74 ± 1.1), fear from unknown cases (2.69 ± 1.13) and lack of clear objects of training (2.54 ± 1.17) were also among the other stressor factors in this domain. Among factors related to the skill of students, the maximum mean stressor was related to insufficiency of clinical knowledge (3.0 ± 1.0) and the minimum was related to giving oral medicines (1.78 ± 1.29). Anxiety from mistaking and its outcome (2.93 ± 1.0), inability to use available equipment at the ward (2.86 ± 1.0), fearing of causing injury to patient (2.64 ± 1.0), lack of the necessary readiness while providing bedside care (2.52 ± 1.16) and giving non-oral medicines (1.86 ± 1.23) were among other stressor factors in this domain. Among the stressor factors related to patient, encounter with mortality of patients (2.73 ± 1.2) possessed the maximum stressor rate and patients’ contact (2.28 ± 1.0) possessed the minimum stressor rate. Caring for infectious patients (2.69 ± 1.1), psychical status of patient (2.58 ± 1.0), physical status of patients (2.37 ± 1.2) and contact of patient’s relative (2.29 ± 1.18) were among the other stressor factors in this domain. Among stressor factors related to the nature of nursing, cleaning patient after defecation (3.0 ± 1.26) and looking at the wound and doing dressing (1.65 ± 1.32) were among the maximum and minimum stressor factors from the viewpoint of students. Anxiety from from being affected by infectious and communicable diseases (2.93 ± 1.23), high working load (2.34 ± 1.36), and cleaning and washing patient’s equipment (2.23 ± 1.41) were among other stressor factors in this domain. Among environmental factors, discrimination between nursing students and the students of other fields (2.84 ± 1.23), and unfamiliarity with patient’s accent (1.52 ± 1.32) possessed the maximum and minimum stressor rates, respectively. Lack of dressing room (2.62 ± 1.31), unfamiliarity with available equipment at © 2014 Wiley Publishing Asia Pty Ltd
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the working environment (2.57 ± 1.12), noisy ward (2.44 ± 1.28), lack of conference room (2.42 ± 1.42), the number of students at the ward (2.23 ± 1.35), encounter with the manager and personnel of the ward (2.0 ± 1.21), and encounter with supervisor (1.86 ± 1.26) were among the other factors from the viewpoint of stressors. Among personal characteristics of students, disinterest in nursing field (2.19 ± 1.31) and psychical status of the student (2.19 ± 1.29) were the maximum stressor factors, and inability to make relation with classmates (1.12 ± 1.14) was the minimum stressor factor from the viewpoint of students. Lack of confidence (1.96 ± 1.3), inability to make relation with faculty (1.88 ± 1.22), inability to make relation with patient (1.57 ± 1.16), physical status of student (1.51 ± 1.34) and inability to take responsibility (1.5 ± 1.21) were among the other studied factors in this domain.
DISCUSSION AND CONCLUSION Students identified faculty as the greatest source of stress. Reasons were listed as the communicate style between the faculty and student as stress provoking. In fact, Saki and Rohandeh found that public show of disrespect for the student and inappropriate communication between the faculty and student in training were important stress factors for students.13 Timmins and Kaliszer reported inappropriate communication between the trainer and trainee as a source of stress in students.14 Another study by Omidvar et al. showed that 14.5% of students expressed dissatisfaction with the trainer’s level of respect for them.15 Interpersonal characteristics such as behaviour, planning ability, determining student readiness and the ability to hold a proper training session are all important factors in clinical education. It is essential for the clinical trainer to have sufficient knowledge of the subject, theory and clinical contents, learner’s readiness, general laws of education, the importance of providing feedback to students and evaluation. Appropriately assigned clinical trainer with sufficient knowledge and skills to train can reduce unnecessary student stress and improve the learning environment as suggested by Kilminster and Jolly.16 Ignoring student needs and inattention to faculty preparedness influence student’s behaviour and mood, and might result in irreversible emotional trauma. Such psychological effects might result in the negative views of nursing profession,
Clinical environment stressors
difficulty in learning, and appearing stressed and anxious. Because clinical nursing requires direct interaction between faculty and student to teach and learn skills and procedures, any degree of emotional setback could influence student progress. Another perspective expressed by students in this study related to the academic programme. Students perceived that inconsistencies in theory and practice content were very stressful. Research results from Jones and Johnston showed that programme-related stress regarding curriculum and course contents added to the nursing student dissatisfaction and stress.17 The difference between theoretical and practical lessens was reported by students to be the most important challenges and stressors in the research of Abazari et al.18 Among the factors assessed with the highest average scores were the student skills and inadequate clinical knowledge. In a study from Hong Kong, nursing students recognized their stressors related to personal lack knowledge and professional skills.8 Moreover, researchers believe that there is a relationship between nursing knowledge and clinical performance,19 and in students’ view, patient-related factors were ranked fourth among stressors especially if they faced a patient’s demise. Indeed, patients’ death is an uncomfortable event which can affect all health-care providers. However, students with limited experience find it far more difficult and stressful. The nursing profession and all it entails was a stressor for some students when it involved certain skills and tasks regarding bathing and other intimate physical care for patients with urinary or faecal incontinence. Some students would refuse to care for such patients and are often forced to perform the task. Also, teaching and learning environments were stress provoking when nursing students felt discriminated against compared with the students in other disciplines such as medicine. This is a new finding when compared with other studies on the same subject. Hospital staff and health-care providers discriminating between nursing and medical students created much stress and discontent among the nursing students and their faculty. Researcher had similar experiences and was able to emphasize with nursing student’s perceptions. Of the variables considered in this study, the lowest score was found in relation to the student’s characteristics with sensitive emotions and low self-confidence. Researchers asserted that lack of self-confidence led to an
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array of problems. In fact, researchers have associated low self-esteem with increased risk of psychological problems.20 Low self-esteem leads to depression and anxiety which affects students’ thinking, learning, clinical functions and clinical work performance.21 In conclusion, considering various factors, one might claim that stress is a problem for Iranian nursing students during their clinical training. We identified numerous physical and psychological factors with negative effects on the quality of clinical nursing education. Using the results of this and other studies, it seems prudent for the Iranian governing bodies in nursing and medical sciences to focus on the student’s concerns and assign skilled faculty with appropriate communication styles to teach in the clinical courses according to the didactic content outlines to reduce unnecessary stress for students.
ACKNOWLEDGEMENTS Hereby, the researchers highly appreciate Development Medicine Center of Yasuj and Shiraz University of Medical Sciences, as well as the research deputy of Yasuj and Shiraz University of Medical Sciences, and Hazrat-e-Fatemeh School of Nursing and Midwifery in Shiraz for funding this research.
REFERENCES 1 Joyce M, Hendricks-Thomas JM, Crosby DM, Mooney DC. Education in critical care nursing: A new beginning. Intensive and Critical Care Nursing 1995; 11: 93–99. 2 Shahbazi L, Salimi T. The nursing and midwifery students view of status of cilinical education. Journal of Shahid Sadoughi University of Medical Sciences 2000; 8: 97–103 (in Persian). 3 Pryjmachuk S, Richards DA. Mental health nursing students differ from other nursing students: Some observations from a study on stress and coping. International Journal of Mental Health Nursing 2007; 16: 390–402. 4 Urden LD, Stacy KM, Lough ME. Text Book of Critical Care Nursing: Diagnosis and Management. Philadelphia: Mosby Co, 2000. 5 Hadizade Talasaz F, Firouzi M, Shamaieyan Razavi N. Evaluation of clinical education in viewpoint of nursing and midwifery students of Gonadad Nursing and Midwifery of medical sciences. Iranian Journal of Medical Education 2006; 5: 71–78 (in Persian). 6 Aabedini S, Aabedini S, Aghamolaii T, Jomeazade A, Kamjo A. Problem of clinical education in viewpoint of nursing and midwifery students of Hormozgan Nursing and Midwifery of Medical Sciences. Journal of Hormozgan Medical University 2008; 4: 249–253 (in Persian). © 2014 Wiley Publishing Asia Pty Ltd
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7 Dehghani K, Dehghani H, Fallahzadeh H. The educational problems of clinical field training based on nursing teachers and last year nursing students view points of Shahid Sagoughi Nursing & Midwifery University. Iranian Journal of Medical Education 2005; 5: 25–33 (in Persian). 8 Chan CKL, So WKW, Fong DYT. Hong Kong baccalaureate nursing students’ stress and their coping strategies in clinical practice. Journal of Professional Nursing 2009; 25: 307–313. 9 Evans W, Kelly B. Pre-registration diploma student nurse stress and coping measures. Nurse Education Today 2004; 24: 473–482. 10 Hasan Pour SH, Bani S. The viewpoint of midwifery students about clinical education problems in Tabriz University. 7th national congress on education-Iran, 2005; 12–15 (in Persian). 11 Mimura C, Griffiths P. The effectiveness of current approaches to workplace stress management in the nursing profession: An evidence based literature review. Occupational and Environmental Medicine 2003; 60: 10–15. 12 Ahmady S, Changiz T, Masiello I, Brommels M. Organizational role stress among Medical School Faculty members in Iran: Dealing with role conflict. Journal of Biomedical Education 2007; 7: 72–82. 13 Saki M, Rohandeh M. Sudying the stressor factors of clinical practical of nursing from the view point of nursing students and practical solutions regarding the improvement of quality of clinical education. Iranian Journal of Medical Education, Supplement 2005; 14: 169 (in Persian).
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14 Timmins F, Kaliszer M. Aspects of nurse education programmes that frequently cause stress to nursing students— fact-finding sample survey. Nurse Education Today 2002; 22: 203–211. 15 Omidvar SH, Bakouii F, Salimian H. Problem of clinical education in viewpoint of midwifery students of Babol Nursing and Midwifery of Medical Sciences. Iranian Journal of Medical Education 2005; 5: 18–23 (in Persian). 16 Kilminster SM, Jolly BC. Effective supervision in clinical practice setting: A literature review. Medical Education 2000; 34: 827–840. 17 Jones MC, Johnston DW. Distress, stress and coping in first-year student nurses. Journal of Advanced Nursing 1997; 26: 475–482. 18 Abazari F, Abbaszadeh A, Arab M. Studying the rate and sources of stress among nursing students. The journal of Strides in Development of Medical Education 2004; 1: 23–31 (in Persian). 19 Coderre S, Jenkins D, McLaughlin K. Qualitative differences in knowledge structure are associated with diagnostic performance in medical students. Advances in Health Sciences Education: Theory and Practice 2009; 14: 677–684. 20 Ni C, Liu X, Hua Q, Lv A, Wang B, Yan Y. Relationship between coping, self-steem, individual factors and mental health among Chinese nursing students: Amatched case– control study. Nurse Education Today 2010; 30: 338–343. 21 Melo K, Williams B, Ross C. The impact of nursing curricula on clinical practice anxiety. Nurse Education Today 2010; 30: 773–778.
International Journal of Nursing Practice 2015; 21: 297–302
RESEARCH PAPER
Nursing students in Iran identify the clinical environment stressors Shahla Najafi Doulatabad MSc in Nursing Instructor, Department of Medical Surgical Nursing, Yasuj University of Medical Sciences, Yasuj, Iran
Sima Mohamadhosaini MSc in Nursing Instructor, Department of Medical Surgical Nursing, Yasuj University of Medical Sciences, Yasuj, Iran
Hamid Reza Ghafarian Shirazi PhD in Biostatic Assistant Professor, Department of Social Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
Zinat Mohebbi MSc and PhD Candidate in Nursing Instructor, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
Accepted for publication June 2013 Najafi Doulatabad S, Mohamadhosaini S, Ghafarian Shirazi HR, Mohebbi Z. International Journal of Nursing Practice 2015; 21: 297–302 Nursing students in Iran identify the clinical environment stressors Stress at clinical environment is one of the cases that could affect the education quality among nursing students. The study aims to investigate Iranian nursing students’ perceptions on the stressors in clinical environment in the South Western part of Iran. A cross-sectional descriptive study was conducted in 2010 to include 300 nursing students after their completion of second clinical nursing course in a hospital environment. Data were collected using a researchermade questionnaire, with focus on the clinical environment stressors from personal, educational and training viewpoints. Data analysis was performed using SPSS software (IBM Corporation, Armonk, NY, USA) and descriptive statistics tests. Among the various stressors, the highest scores were given to the faculty (71 ± 19.77), followed by the students’ personal characteristics (43.15 ± 21.79). Given that faculty-related factors provoked more stress in nursing students, nursing administration should diligently evaluate and improve communication skills among faculty to reduce student stress and enhance learning. Key words: clinical nursing, nursing students, stressors.
INTRODUCTION Clinical education is an important part of the nursing and midwifery curriculum and faculty function. Clinical
Correspondence: Zinat Mohebbi, Nursing and Midwifery College, Nemazi Square, Zand Street, Shiraz 71936-13119, Iran. Email: [email protected] doi:10.1111/ijn.12276
training requires an interactive process between the trainer, trainee and the clinical environment. Through practical training, the students learn how to apply each concept correctly.1 In fact, clinical education is a dynamic process and over 50% of nursing and midwifery programmes require clinical training. To provide high quality clinical education, nursing and midwifery programmes need efficiently trained and skilled faculty in various © 2014 Wiley Publishing Asia Pty Ltd
298
S Najafi Doulatabad et al.
areas.2 Student success in clinical education is directly influenced by the training environment. Inadequately skilled faculty and unprepared training environment are contributing factors to severe stress in nursing students, followed by psychological effects such as anxiety and depression.3 Literature identifies other factors associated with the student stress such as the nature of nursing profession itself4 as well as the academic programme.5 In a study, researchers highlighted the areas that provoked stress in students such as: content inconsistencies in theory and clinical part of the course, lack of specific clinical objectives, stressful environment, unwilling trainer to be present on site to teach skills, absence of an evaluation process and inadequate facility for training.6 Each or a combination of the aforementioned list served as an obstacle to achieve the desired clinical education goals. Students reported lack of opportunities to carry out standard clinical procedures due to inadequate supplies and poor clinical conditions which were against many of the theoretical principles taught in classroom.7 Results of a study in Hong Kong showed students’ lack of knowledge and professional skills as the main problems in clinical training.8 Similarly, Evans and Kelly reported that students’ assessment of patient and inconsistencies between theoretical and clinical courses created a major problem for clinical training and skills development.9 Clinical trial possesses a specific importance in the formation of professional skills and abilities of nursing students, and is the first step in improvement of the quality of nursing programme and recognizing the clinical problems of students.10 Due to the importance of the matter, the work-related stress in this field has been taken into consideration extensively11 because a series of factors in nursing field play the role of physical or psychological stressors. These stressors could affect the performance of individuals.12 Psychological stressors, which include the confounding factors of psychical health status of students at clinical environment, will be considered in this research.
PURPOSE This research has been carried out with the aim to answer the question that, to what extent the faculty, educational system, the rate of student’s skill, patient, nursing nature, environmental factors and personal characteristics of students at clinical environment play role in the incidence of students stress. © 2014 Wiley Publishing Asia Pty Ltd
METHODS This cross-sectional descriptive study was carried out in 2010 and included 300 undergraduate nursing students in second semester of the academic year. Purposeful selection of enrolled students who have completed clinical courses or in training in semesters 2, 3, 4, 5, 6, 7 and 8 was made. It is important to add that Iranian nursing students start their supervised clinical training with a hospital rotation on the second term of their 4 year education. The clinical component of the course earns one semester credit for 51 contact hours. Students are commonly rotated in a medical–surgical unit for skills development and nursing care of adult patients. This training continues through third, fourth, fifth and sixth terms. On the seventh and eighth terms, nursing students are assigned to specialty units with faculty supervision and given slight autonomy. Demographic data included information such as age, gender, residence, marital status, academic semester, father’s occupation and mother’s occupation. Students responded to questions on stressors associated with the clinical course such as the hospital environment and personal views of stressors in relation to the faculty style, type of patients, nursing profession, clinical skills and the academic program. In the domain of personal characteristic of student, stressors like uninterested in nursing field, low selfconfidence, inability to relate to faculty, inability to relate to patient, inability to relate to classmates, inability to take responsibilities, physical and mental status of students were studied. In environmental stressor factors, the items like encounter with supervisor, encounter with the unit supervisor, encounter with the ward personnel, number of students in the ward, noisy ward, unfamiliar with instruments available at workplace, unfamiliar with patient’s accent, discrimination between nursing students and other students, lack of conference room, and lack of dressing room were evaluated. Also, in the domain of factors related to master, the stressor cases like divesting of student’s independence from faculty, the communicative style between the faculty and student, non-support of faculty when a problem arises, fear of poor evaluation by faculty, unjust student evaluation by faculty, faculty criticism of student in front of patient and personnel, question and answer of student by faculty in front of others, reproaching student by faculty in the presence of others, faculty style provoking stress, and ineffective faculty–student relation were being
Clinical environment stressors
studied. In the domain of the stressor factors related to patient, the stressors of contact with patient’s relatives, contact with patient, physical status of patient, psychological condition of patient, caring for infectious patients, and facing mortality of patients were also evaluated from the viewpoint of students. Stressor factors related to the nature of nursing were another evaluated domain. In this domain, the items like being anxious to be affected by infectious and communicable diseases, looking at wound and doing dressing, cleaning patient’s furniture and washing them, cleaning of patient after defecation, and too much work were also studied. The stressor factors related to the student’s skill were also evaluated. In this domain, the cases including insufficiency of clinical knowledge, inability to use the equipment available at ward, giving oral and non-oral medicines, lack of necessary readiness while providing bedside care, fear of injuring patient, being anxious of making a mistake and its results, and fear from unfamiliar cases were studied. The stressor factors related to the educational system, like inconsistencies between theoretical and clinical concepts, lack of clear clinical objectives for training, concerns for scientific work in a poorly equipped clinical environment and routine of the work at various wards were also studied. The 52-item questionnaire was formatted in Likert scale and scored from too high (4) to ineffective (0), and given the score ranges of 0–100. A higher score in each category meant a greater stress-provoking effect on the student. The instrument was piloted among 10 faculty members for validity and reliability, and took 15 min to be completed. Of 300 questionnaires distributed among the students, 261 were completed and returned. Researchers obtained permission from the research deputy and Education and Development Medicine Center of Yasuj University of Medical Sciences and research deputy of Shiraz University of Medical Sciences. It is noteworthy to mention that data collection was scheduled for the last day of student clinical training for each group immediately after their mandatory course evaluations were to be completed. Upon institutional approval, researcher met with the students at their clinical training location to explain the study aims and obtain written consent and offer each student the questionnaire with a returned envelope addressed to the researcher. In most cases, researcher remained on site to collect the completed questionnaires and be available to answer any question as needed.
299
Scientific content validity of the instrument was determined by 10 faculty members in Shiraz and Yasuj Schools of Nursing and Midwifery. Instrument reliability was determined by using test–retest method for this study (α = 0.80). In addition, students’ perceptions were used when instrument was piloted and the questionnaire was prepared. Data were analysed using SPSS software (IBM Corporation, Armonk, NY, USA) and descriptive tests.
RESULTS Demographic data revealed that the student age range was between 20 and 27 years, with an average age of 21.6 ± 1.39. There were 59% women, of whom 71.3% lived in dormitories, 25.7% lived at home with their families and 3% lived alone in rental properties. Of the sample, 91% were single and 9% were married. Students reported self-employed father at 47%, and 92% of mothers were housewives. Students identified that the most common cause of stress in their clinical course was related to the faculty (71 ± 19.77) and the lowest score related to the students’ personal characteristics (43.15 ± 21.79) see Table 1. Also among faculty related factors, blaming student in the presence of others by faculty (3.17 ± 1.0) and nonobservance by faculty while taking care (2.50 ± 1.23) allocated the maximum and minimum stressor rates, respectively. The mean stressor of other understudied factors in this domain are the way of facing of faculty (3.17 ± 1.0), notification by faculty in front of patient and personnel (3.0 ± 1.17), existence of ineffective relation between faculty and students (2.94 ± 1.15), divesting independency of student by faculty (2.94 ± 1.0), Table 1 The mean and standard deviation of stressors of clinical environment from the viewpoint of nursing students Stressor factors
Mean
Standard deviation
Factors related to faculty Factors related to educational system Factors related to the student’s skill Factors related to patient Factors related to the nature of nursing Environmental factors Factors related to personal characteristics of student
71.0 66.13 65.0 62.0 60.92 57.39 43.15
19.77 21.62 18.5 20.87 24.44 19.13 21.79
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non-support of faculty during problem occurrence (2.77 ± 1.23), unjust evaluation by faculty (2.74 ± 1.22), stressfulness of faculty (2.66 ± 1.2), questioning and answering by faculty in the presence of others (2.62 ± 1.21), and finally, fear from being evaluated by faculty (2.5 ± 1.23). Among factors related to the educational system, inconsistency between clinical and theoretical learning (2.84 ± 1.0) and routine working at different and specific wards (2.46 ± 1.19) allocated maximum and minimum mean stressors, respectively. Non-scientific working at clinic due to the lack of facilities (2.74 ± 1.1), fear from unknown cases (2.69 ± 1.13) and lack of clear objects of training (2.54 ± 1.17) were also among the other stressor factors in this domain. Among factors related to the skill of students, the maximum mean stressor was related to insufficiency of clinical knowledge (3.0 ± 1.0) and the minimum was related to giving oral medicines (1.78 ± 1.29). Anxiety from mistaking and its outcome (2.93 ± 1.0), inability to use available equipment at the ward (2.86 ± 1.0), fearing of causing injury to patient (2.64 ± 1.0), lack of the necessary readiness while providing bedside care (2.52 ± 1.16) and giving non-oral medicines (1.86 ± 1.23) were among other stressor factors in this domain. Among the stressor factors related to patient, encounter with mortality of patients (2.73 ± 1.2) possessed the maximum stressor rate and patients’ contact (2.28 ± 1.0) possessed the minimum stressor rate. Caring for infectious patients (2.69 ± 1.1), psychical status of patient (2.58 ± 1.0), physical status of patients (2.37 ± 1.2) and contact of patient’s relative (2.29 ± 1.18) were among the other stressor factors in this domain. Among stressor factors related to the nature of nursing, cleaning patient after defecation (3.0 ± 1.26) and looking at the wound and doing dressing (1.65 ± 1.32) were among the maximum and minimum stressor factors from the viewpoint of students. Anxiety from from being affected by infectious and communicable diseases (2.93 ± 1.23), high working load (2.34 ± 1.36), and cleaning and washing patient’s equipment (2.23 ± 1.41) were among other stressor factors in this domain. Among environmental factors, discrimination between nursing students and the students of other fields (2.84 ± 1.23), and unfamiliarity with patient’s accent (1.52 ± 1.32) possessed the maximum and minimum stressor rates, respectively. Lack of dressing room (2.62 ± 1.31), unfamiliarity with available equipment at © 2014 Wiley Publishing Asia Pty Ltd
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the working environment (2.57 ± 1.12), noisy ward (2.44 ± 1.28), lack of conference room (2.42 ± 1.42), the number of students at the ward (2.23 ± 1.35), encounter with the manager and personnel of the ward (2.0 ± 1.21), and encounter with supervisor (1.86 ± 1.26) were among the other factors from the viewpoint of stressors. Among personal characteristics of students, disinterest in nursing field (2.19 ± 1.31) and psychical status of the student (2.19 ± 1.29) were the maximum stressor factors, and inability to make relation with classmates (1.12 ± 1.14) was the minimum stressor factor from the viewpoint of students. Lack of confidence (1.96 ± 1.3), inability to make relation with faculty (1.88 ± 1.22), inability to make relation with patient (1.57 ± 1.16), physical status of student (1.51 ± 1.34) and inability to take responsibility (1.5 ± 1.21) were among the other studied factors in this domain.
DISCUSSION AND CONCLUSION Students identified faculty as the greatest source of stress. Reasons were listed as the communicate style between the faculty and student as stress provoking. In fact, Saki and Rohandeh found that public show of disrespect for the student and inappropriate communication between the faculty and student in training were important stress factors for students.13 Timmins and Kaliszer reported inappropriate communication between the trainer and trainee as a source of stress in students.14 Another study by Omidvar et al. showed that 14.5% of students expressed dissatisfaction with the trainer’s level of respect for them.15 Interpersonal characteristics such as behaviour, planning ability, determining student readiness and the ability to hold a proper training session are all important factors in clinical education. It is essential for the clinical trainer to have sufficient knowledge of the subject, theory and clinical contents, learner’s readiness, general laws of education, the importance of providing feedback to students and evaluation. Appropriately assigned clinical trainer with sufficient knowledge and skills to train can reduce unnecessary student stress and improve the learning environment as suggested by Kilminster and Jolly.16 Ignoring student needs and inattention to faculty preparedness influence student’s behaviour and mood, and might result in irreversible emotional trauma. Such psychological effects might result in the negative views of nursing profession,
Clinical environment stressors
difficulty in learning, and appearing stressed and anxious. Because clinical nursing requires direct interaction between faculty and student to teach and learn skills and procedures, any degree of emotional setback could influence student progress. Another perspective expressed by students in this study related to the academic programme. Students perceived that inconsistencies in theory and practice content were very stressful. Research results from Jones and Johnston showed that programme-related stress regarding curriculum and course contents added to the nursing student dissatisfaction and stress.17 The difference between theoretical and practical lessens was reported by students to be the most important challenges and stressors in the research of Abazari et al.18 Among the factors assessed with the highest average scores were the student skills and inadequate clinical knowledge. In a study from Hong Kong, nursing students recognized their stressors related to personal lack knowledge and professional skills.8 Moreover, researchers believe that there is a relationship between nursing knowledge and clinical performance,19 and in students’ view, patient-related factors were ranked fourth among stressors especially if they faced a patient’s demise. Indeed, patients’ death is an uncomfortable event which can affect all health-care providers. However, students with limited experience find it far more difficult and stressful. The nursing profession and all it entails was a stressor for some students when it involved certain skills and tasks regarding bathing and other intimate physical care for patients with urinary or faecal incontinence. Some students would refuse to care for such patients and are often forced to perform the task. Also, teaching and learning environments were stress provoking when nursing students felt discriminated against compared with the students in other disciplines such as medicine. This is a new finding when compared with other studies on the same subject. Hospital staff and health-care providers discriminating between nursing and medical students created much stress and discontent among the nursing students and their faculty. Researcher had similar experiences and was able to emphasize with nursing student’s perceptions. Of the variables considered in this study, the lowest score was found in relation to the student’s characteristics with sensitive emotions and low self-confidence. Researchers asserted that lack of self-confidence led to an
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array of problems. In fact, researchers have associated low self-esteem with increased risk of psychological problems.20 Low self-esteem leads to depression and anxiety which affects students’ thinking, learning, clinical functions and clinical work performance.21 In conclusion, considering various factors, one might claim that stress is a problem for Iranian nursing students during their clinical training. We identified numerous physical and psychological factors with negative effects on the quality of clinical nursing education. Using the results of this and other studies, it seems prudent for the Iranian governing bodies in nursing and medical sciences to focus on the student’s concerns and assign skilled faculty with appropriate communication styles to teach in the clinical courses according to the didactic content outlines to reduce unnecessary stress for students.
ACKNOWLEDGEMENTS Hereby, the researchers highly appreciate Development Medicine Center of Yasuj and Shiraz University of Medical Sciences, as well as the research deputy of Yasuj and Shiraz University of Medical Sciences, and Hazrat-e-Fatemeh School of Nursing and Midwifery in Shiraz for funding this research.
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