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The Effects of a Web-Based Nursing Process Documentation Program on Stress and Anxiety of Nursing Students in South Korea Eunjoo Lee, RN, PhD, and Hyun Kyung Noh, MSN, RN Eunjoo Lee, RN, PhD, is a Professor at the Research Institute of Nursing Science, College of Nursing, Kyungpook National University, Deagu, Korea, and Hyun Kyung Noh, MSN, RN, is an Assistant Professor at the Department of Nursing, Hosan University, Gyeongsan, Gyeongsangbuk-do, Korea.
Search terms: Anxiety, Korean nursing student, stress, web-based nursing process documentation program Author contact: [email protected], with a copy to the Editor: [email protected]
AIM: To examine the effects of a web-based nursing process documentation system on the stress and anxiety of nursing students during their clinical practice. METHODS: A quasi-experimental design was employed. The experimental group (n = 110) used a web-based nursing process documentation program for their case reports as part of assignments for a clinical practicum, whereas the control group (n = 106) used traditional paper-based case reports. Stress and anxiety levels were measured with a numeric rating scale before, 2 weeks after, and 4 weeks after using the web-based nursing process documentation program during a clinical practicum. The data were analyzed using descriptive statistics, t tests, chi-square tests, and repeated-measures analyses of variance. RESULTS: Nursing students who used the web-based nursing process documentation program showed significant lower levels of stress and anxiety than the control group. CONCLUSION: A web-based nursing process documentation program could be used to reduce the stress and anxiety of nursing students during clinical practicum, which ultimately would benefit nursing students by increasing satisfaction with and effectiveness of clinical practicum.
Nursing education has undergone many changes in the last decade with the adoption of information technology (Ozturk & Dinc, 2014). The integration of well-designed educational programs into nursing education is necessary to provide a basis for the competent future nurses (Button, Harrington, & Belan, 2014; Choi, 2003). Clinical practicum is an essential part of nursing education, as it provides nursing students with the opportunity to improve their ability to integrate theory and practice (Becker & Neuwirth, 2002; Moscaritolo, 2009). Through clinical practice, nursing students learn how to provide high-quality care for patients and learn about unique perspectives in the nursing profession (Elcigil & Sari, 2007; Lave & Wenger, 1999; Papp, Markanken, & Von Bonsdorff, 2003).
© 2015 NANDA International, Inc. International Journal of Nursing Knowledge Volume 27, No. 1, January 2016
Although clinical practice is an integral component of nursing education, nursing students generally suffer from a high degree of stress and anxiety during this component of their education (Galbraith & Brown, 2011; Melincavage, 2011; Moscaritolo, 2009; Shipton, 2002). Beck and Srivastava (1991), in a descriptive correlational study, found that undergraduate nursing students considered clinical practice to be the most stressful and anxiety-provoking aspect of the undergraduate nursing program. Jones and Johnston (1997) also reported that nursing students experienced higher levels of stress than did students in other health-related fields. If nursing students experience emotional impairment, such as stress and anxiety, their experiences in clinical practicum will be negatively affected,
35
The Effects of a Web-Based Nursing Process Documentation Program thus resulting in decreased academic performance and learning and poor coping skills (Beddoe & Murphy, 2004; Melincavage, 2011; Shields, 2001). This will, in turn, impair their professional lives and affect the quality of care provided once they become nurses (Evans, 2001; Leveck & Jones, 1996). Therefore, nursing educators should identify causes of stress and anxiety experienced by nursing students in clinical practice, and identify effective strategies to relieve this stress and anxiety, in order to cultivate professionalism in nursing and better quality of nursing care in the future. Many previous studies have reported that lack of knowledge, unfamiliar situations, fear of making mistakes, a gap between theory and practice, faculty evaluation, and ambiguous roles as nursing students in clinical settings were the main reasons for stress and anxiety (Elcigil & Sari, 2007; Han & Lee, 2012; Moscaritolo, 2009; Park & Kim, 2000). Among these factors, excessive amounts of assignments, such as preparing case studies and presenting case study results to clinical instructors and faculty members, were always ranked highly as the causes of stress and anxiety (Han & Lee, 2012; Kim, 1997; Park, Kim, Kim, Kim, & Park, 2005). These assignments caused anxiety because nursing students had difficulty selecting correct diagnoses, interventions, and expected outcomes due to a lack of knowledge and clinical experience (Lee & Lee, 2004; Yang, 1999). In addition, nursing students encountered patients with diverse health problems, but lacked critical thinking skills to collect, analyze, connect, and synthesize patient data, making them more anxious and stressed (Suliman & Halabi, 2007). The nursing process, which involves selecting correct diagnoses, interventions, and outcomes, is a basic and central component of patient care and all nursing care, and involves scientific and systematic solutions to nursing problems based on critical thinking (Lunney, 2008). Using this process, nurses can diagnose and treat patients for present or potential health problems, provide individualized care, offer continuity of care, and develop professionally (Johnson et al., 2006). The process also provides a tool to evaluate the effectiveness of nursing interventions, define the independent function of nurses, and enhance professional autonomy (Johnson et al., 2006). Therefore, application of the nursing process model to patient care has been accepted for clinical practice by the Korean Nurses Association as well as the American Nurses Association (ANA, 2014; The Korean Nurses Association News, 2001). A web-based nursing process documentation system that adopts standardized nursing languages (SNLs), such as the NANDA-I, Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC), could be an effective tool to reduce stress and anxiety levels in nursing students by providing a logical way to proceed through each step of the nursing process. Farren (2010) reported that SNLs not only aided in the ease of use of the nursing process model, but also promoted decision making in nursing students during clinical practicum by guiding criti-
36
E. Lee and H. K. Noh
Table 1. Research Design Posttest
Experimental Control
Pretest
Treatment
2 weeks
4 weeks
Q1 Q2
X
Q2 Q2
Q3 Q3
Q1, Q2, Q3, questionnaire survey; X, web-based nursing process documentation program.
cal thinking. Another study reported that using SNLs reduced nursing recording time and improved nursing documentation quality (Bulechek, Butcher, & Dochterman, 2008; Lunney, 2008; Moorhead, Johnson, Maas, & Swanson, 2008). However, most studies related to electronic nursing process programs were performed with nurses (Kelley, Brandon, & Docherty, 2011; Korst, Eusebio-Angeja, Chamorro, Aydin, & Gregory, 2003; Mahler et al., 2003; Robles, 2009), not nursing students. No studies have yet examined whether web-based nursing process documentation programs using NANDA-I, NIC, and NOC (NNN) linkages influence the stress and anxiety levels of nursing students during clinical practice. Therefore, the purpose of this study was to identify the effects of a web-based nursing process documentation program on the stress and anxiety levels of nursing students during their clinical practice. Through this research, we can develop better strategies to promote positive clinical training and effective nursing education by decreasing stress and anxiety among nursing students in clinical practice. Methods Study Design and Sample A quasi-experimental design was used in this study (Table 1). Study participants were nursing students enrolled in 3 years of nursing college (diploma program) in order to become registered nurses in Korea. The study employed a convenience sample of 216 second-year nursing students in K province of South Korea. Previous studies have reported that the second year is when nursing students start clinical practice, and that these students have higher stress than do students in subsequent years (Admi, 1997; Jones & Johnston, 1997; Suliman & Halabi, 2007). A sample size of 212 was calculated using G*Power version 3.1 (Franz Faul, Universitat Kiel, Germany), according to an effect size of 0.15, alpha of 0.05, and power of 0.80. These data demonstrate that our study sample size was appropriate. Instruments Web-based nursing process program. This study was conducted using a web-based nursing process documentation system, which integrated the SNLs of NANDA-I, NOC,
E. Lee and H. K. Noh
The Effects of a Web-Based Nursing Process Documentation Program
and NIC. In the web-based nursing process documentation system, a total of 202 NANDA-I nursing diagnoses and their related signs and symptoms (NANDA International, 2009), 542 nursing interventions with more than 9,000 nursing activities (Bulechek et al., 2008), and more than 2,000 nursing indicators belonging to 385 nursing outcomes (Moorhead et al., 2008) were integrated in English terminology with Korean translations. To complete the nursing process using the web-based nursing documentation system, nursing students input patient demographics, such as age, sex, admission date, insurance type, medical diagnosis, and type of operation. Then, students choose nursing diagnoses either from those categorized into the domains and classes of the NANDA-I taxonomy structure, or by using a search engine that required typing in the NANDA-I label. After nursing diagnoses are selected, their defining characteristics and related factors are displayed. Students can choose these by clicking the button corresponding to each defining characteristic and related factor. After choosing nursing diagnoses, students choose nursing outcomes, which are categorized by the domains and classes of the NOC taxonomy structure. After choosing appropriate nursing outcomes, students choose indicators and assess patient status using a 5-point Likert scale. After choosing the nursing outcomes and their indicators, students choose nursing interventions, which are categorized by the domains and classes of the NIC taxonomy structure. Thus, nursing diagnoses, outcomes, and interventions are selected in order (Bulechek et al., 2008; Moorhead et al., 2008). This program is available at http://medinfo.knu.ac.kr/ nursingprocess, and a paper on the development process was published in Korea previously (Hong & Kim, 2011). Questionnaire. Questionnaires developed in this study measured participants’ demographic characteristics and levels of stress and anxiety. Stress and anxiety levels were measured using a numeric rating scale (NRS). The score range of the NRS is from 0 to 100, and higher scores indicate that nursing students felt more stress and anxiety during their clinical practice. Data Collection This study was conducted after approval from the institutional review board of Kyungpook National University Medical Center. For data collection, the researcher directly visited three diploma nursing schools located in K province and asked for their participation in the study. After receiving approval, the researcher visited the nursing students and explained the research purpose and procedure, as well as their right to withdraw from the study at any time. The total number of nursing students registered in clinical practice was 227, and the number of nursing students who were willing to participate in the research was 223. Nursing students were assigned to either the experimental
(n = 115) or the control (n = 108) groups by the hospital in which they were doing clinical practice. However, seven students (five experimental and two control) did not complete all three questionnaire administrations; thus, a total of 216 students were included in the final sample. Finally, 110 nursing students completed case reports using the webbased nursing process documentation program (experimental condition), and 106 students completed their case reports using traditional paper-based methods (control condition). Completing the case report based on nursing process model is one of the mandatory assignments of any nursing students in South Korea. Therefore, it would not put any extra burden on nursing students participating in the study. The rate of participation in the study was 96.9%. Students were assigned by clinical practicum hospital to prevent diffusion effects among participants. The hospitals where clinical practicum was completed included two university-affiliated hospitals, two general hospitals, one women’s clinic, and one psychiatric special hospital. Questionnaires were administered three times during the study: at pretest (baseline), 2 weeks after the intervention, and 4 weeks after the intervention. Baseline stress and anxiety were measured 2 weeks after the first clinical practicum to allow nursing students to become oriented to clinical practice. The first questionnaire was distributed by the researcher directly to both the control and experimental groups. Immediately after the baseline data collection was complete, students in the experimental condition received 60 min of instruction from the researcher on how to use the SNLs of NANDA-I, NOC, and NIC, as well as how to complete care planning for patients using the web-based nursing process documentation program. They also practiced how to use the web-based nursing process documentation program in the computer lab for 20 min. The second and third questionnaires were distributed to the representatives of students, and then the representative students distributed the questionnaire to the participants to remove any pressure from the researcher or course instructors. After completing the questionnaires, participants returned the questionnaires to the representative students, and the representative students handed them out to the researcher. To remove any other effects to the participants, the researcher did not contact the participants during the study except for the instruction for the SNL and how to use web-based nursing process documentation system. In addition, extra instructions or special instructions were not provided to both the control and experimental groups during the study, which may influence the anxiety and stress level of the participants. Data Analysis Data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows version 19 (SPSS Inc., Chicago, IL, USA). Descriptive statistics, appropriate to the level of measurement, were used to describe the study
37
The Effects of a Web-Based Nursing Process Documentation Program
E. Lee and H. K. Noh
Table 2. Homogeneity Test Between the Experimental and Control Groups (N = 216) Experimental (n = 110)
Control (n = 106)
Variables
M ± SD or n (%)
M ± SD or n (%)
t or χ2
p
Age Gender Male Female Stress Anxiety
20.03 ± 1.779
20.40 ± 1.787
0.40 1.59
.692 .113
9 (8.18%) 101 (91.82%) 65.82 ± 16.66 59.55 ± 19.55
15 (14.15%) 91 (85.85%) 64.34 ± 20.38 59.53 ± 20.16
0.59 0.07
.561 .995
variables. Independent t tests, chi-square tests, and repeated-measures analyses of variance were used to assess the mean differences between the experimental and control groups. A p value of .05 was set for statistical significance. Results Characteristics of the Sample and Homogeneity Test of Variables In total, 216 students were enrolled in the study. The experimental group included 110 students and the control group included 106 students. The mean age of the experimental group was 20.03 years and that of the control group was 20.40 years. Most participants were female, both in the experimental group (91.82%) and the control group (85.85%). A homogeneity test was performed to examine the variables that may have resulted in differences in stress and anxiety levels between groups. There were no significant differences between groups in age (t = 0.40, p = .692) or gender (χ2 = 1.59, p = .113). In addition, there was no significant difference between groups in stress (t = 0.59, p = .561) or anxiety levels (t = 0.07, p = .995) (Table 2). Effect of Using the Web-Based Process Documentation Program on Stress Level The mean scores for stress of the experimental and control groups are presented in Table 3 and Figure 1. There were significant differences between the two groups (F = 8.03, p = .005), within groups over time (F = 67.66, p < .001), and an interaction between time and group (F = 11.75, p < .001) for stress level. In the control group, the mean score for stress decreased from 64.34 to 60.94 after 2 weeks. After 4 weeks, the mean score for stress was 53.58. This score was compared with the score at pretest and after 2 weeks, which showed that the changes in score were 10.76 and 7.36, respectively. In the experimental group, after 2 weeks, the mean score for stress changed from 65.82 to 55.91. After 4 weeks, the mean score for stress was 39.82. This score was compared
38
with the score at pretest and after 2 weeks, which showed that the changes in score were 26.00 and 16.09, respectively. In the control group, stress level was significantly lower after 4 weeks compared with at pretest (t = 4.48, p < .001), but there was no significant change after 2 weeks (t = 1.84, p = .069). In contrast, in the experimental group, stress level was significantly lower after 2 weeks compared with the pretest (t = 6.93, p < .001). Additionally, there were significant differences in stress level between the groups at 4 weeks (t = 5.19, p < .001). Effect of Using the Web-Based Process Documentation Program on Anxiety Level Mean scores for anxiety of the experimental and control groups are presented in Table 4 and Figure 2. There was a significant difference between the two groups (F = 8.53, p = .004), within groups over time (F = 46.80, p < .001), and for the interaction between time and group (F = 9.03, p < .001) for anxiety level. In the control group, the mean score for anxiety decreased from 59.53 to 57.50 after 2 weeks. After 4 weeks, the mean score for anxiety was 51.32. In the experimental group, after 2 weeks, the mean score for anxiety decreased from 59.55 to 51.09. After 4 weeks, the mean score for anxiety was 39.09. In the control group, anxiety was significantly lower after 4 weeks than at pretest (t = 3.43, p = .001), but there were no significant changes after 2 weeks (t = 1.05, p = .295). In contrast, anxiety was significantly lower 2 weeks later in the experimental group compared with pretest (t = 6.00, p < .001). Additionally, there were significant differences in anxiety level between the groups after 2 weeks (t = 2.35, p = .020) and after 4 weeks (t = 4.78, p < .001). Discussion The purpose of this study was to identify the effects of a web-based nursing process documentation program on the stress and anxiety levels of nursing students during their clinical practicum. Previous studies have consistently reported that nursing students experience high levels of stress and anxiety (Galbraith & Brown, 2011; Melincavage,
11.75 (
The Effects of a Web-Based Nursing Process Documentation Program on Stress and Anxiety of Nursing Students in South Korea Eunjoo Lee, RN, PhD, and Hyun Kyung Noh, MSN, RN Eunjoo Lee, RN, PhD, is a Professor at the Research Institute of Nursing Science, College of Nursing, Kyungpook National University, Deagu, Korea, and Hyun Kyung Noh, MSN, RN, is an Assistant Professor at the Department of Nursing, Hosan University, Gyeongsan, Gyeongsangbuk-do, Korea.
Search terms: Anxiety, Korean nursing student, stress, web-based nursing process documentation program Author contact: [email protected], with a copy to the Editor: [email protected]
AIM: To examine the effects of a web-based nursing process documentation system on the stress and anxiety of nursing students during their clinical practice. METHODS: A quasi-experimental design was employed. The experimental group (n = 110) used a web-based nursing process documentation program for their case reports as part of assignments for a clinical practicum, whereas the control group (n = 106) used traditional paper-based case reports. Stress and anxiety levels were measured with a numeric rating scale before, 2 weeks after, and 4 weeks after using the web-based nursing process documentation program during a clinical practicum. The data were analyzed using descriptive statistics, t tests, chi-square tests, and repeated-measures analyses of variance. RESULTS: Nursing students who used the web-based nursing process documentation program showed significant lower levels of stress and anxiety than the control group. CONCLUSION: A web-based nursing process documentation program could be used to reduce the stress and anxiety of nursing students during clinical practicum, which ultimately would benefit nursing students by increasing satisfaction with and effectiveness of clinical practicum.
Nursing education has undergone many changes in the last decade with the adoption of information technology (Ozturk & Dinc, 2014). The integration of well-designed educational programs into nursing education is necessary to provide a basis for the competent future nurses (Button, Harrington, & Belan, 2014; Choi, 2003). Clinical practicum is an essential part of nursing education, as it provides nursing students with the opportunity to improve their ability to integrate theory and practice (Becker & Neuwirth, 2002; Moscaritolo, 2009). Through clinical practice, nursing students learn how to provide high-quality care for patients and learn about unique perspectives in the nursing profession (Elcigil & Sari, 2007; Lave & Wenger, 1999; Papp, Markanken, & Von Bonsdorff, 2003).
© 2015 NANDA International, Inc. International Journal of Nursing Knowledge Volume 27, No. 1, January 2016
Although clinical practice is an integral component of nursing education, nursing students generally suffer from a high degree of stress and anxiety during this component of their education (Galbraith & Brown, 2011; Melincavage, 2011; Moscaritolo, 2009; Shipton, 2002). Beck and Srivastava (1991), in a descriptive correlational study, found that undergraduate nursing students considered clinical practice to be the most stressful and anxiety-provoking aspect of the undergraduate nursing program. Jones and Johnston (1997) also reported that nursing students experienced higher levels of stress than did students in other health-related fields. If nursing students experience emotional impairment, such as stress and anxiety, their experiences in clinical practicum will be negatively affected,
35
The Effects of a Web-Based Nursing Process Documentation Program thus resulting in decreased academic performance and learning and poor coping skills (Beddoe & Murphy, 2004; Melincavage, 2011; Shields, 2001). This will, in turn, impair their professional lives and affect the quality of care provided once they become nurses (Evans, 2001; Leveck & Jones, 1996). Therefore, nursing educators should identify causes of stress and anxiety experienced by nursing students in clinical practice, and identify effective strategies to relieve this stress and anxiety, in order to cultivate professionalism in nursing and better quality of nursing care in the future. Many previous studies have reported that lack of knowledge, unfamiliar situations, fear of making mistakes, a gap between theory and practice, faculty evaluation, and ambiguous roles as nursing students in clinical settings were the main reasons for stress and anxiety (Elcigil & Sari, 2007; Han & Lee, 2012; Moscaritolo, 2009; Park & Kim, 2000). Among these factors, excessive amounts of assignments, such as preparing case studies and presenting case study results to clinical instructors and faculty members, were always ranked highly as the causes of stress and anxiety (Han & Lee, 2012; Kim, 1997; Park, Kim, Kim, Kim, & Park, 2005). These assignments caused anxiety because nursing students had difficulty selecting correct diagnoses, interventions, and expected outcomes due to a lack of knowledge and clinical experience (Lee & Lee, 2004; Yang, 1999). In addition, nursing students encountered patients with diverse health problems, but lacked critical thinking skills to collect, analyze, connect, and synthesize patient data, making them more anxious and stressed (Suliman & Halabi, 2007). The nursing process, which involves selecting correct diagnoses, interventions, and outcomes, is a basic and central component of patient care and all nursing care, and involves scientific and systematic solutions to nursing problems based on critical thinking (Lunney, 2008). Using this process, nurses can diagnose and treat patients for present or potential health problems, provide individualized care, offer continuity of care, and develop professionally (Johnson et al., 2006). The process also provides a tool to evaluate the effectiveness of nursing interventions, define the independent function of nurses, and enhance professional autonomy (Johnson et al., 2006). Therefore, application of the nursing process model to patient care has been accepted for clinical practice by the Korean Nurses Association as well as the American Nurses Association (ANA, 2014; The Korean Nurses Association News, 2001). A web-based nursing process documentation system that adopts standardized nursing languages (SNLs), such as the NANDA-I, Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC), could be an effective tool to reduce stress and anxiety levels in nursing students by providing a logical way to proceed through each step of the nursing process. Farren (2010) reported that SNLs not only aided in the ease of use of the nursing process model, but also promoted decision making in nursing students during clinical practicum by guiding criti-
36
E. Lee and H. K. Noh
Table 1. Research Design Posttest
Experimental Control
Pretest
Treatment
2 weeks
4 weeks
Q1 Q2
X
Q2 Q2
Q3 Q3
Q1, Q2, Q3, questionnaire survey; X, web-based nursing process documentation program.
cal thinking. Another study reported that using SNLs reduced nursing recording time and improved nursing documentation quality (Bulechek, Butcher, & Dochterman, 2008; Lunney, 2008; Moorhead, Johnson, Maas, & Swanson, 2008). However, most studies related to electronic nursing process programs were performed with nurses (Kelley, Brandon, & Docherty, 2011; Korst, Eusebio-Angeja, Chamorro, Aydin, & Gregory, 2003; Mahler et al., 2003; Robles, 2009), not nursing students. No studies have yet examined whether web-based nursing process documentation programs using NANDA-I, NIC, and NOC (NNN) linkages influence the stress and anxiety levels of nursing students during clinical practice. Therefore, the purpose of this study was to identify the effects of a web-based nursing process documentation program on the stress and anxiety levels of nursing students during their clinical practice. Through this research, we can develop better strategies to promote positive clinical training and effective nursing education by decreasing stress and anxiety among nursing students in clinical practice. Methods Study Design and Sample A quasi-experimental design was used in this study (Table 1). Study participants were nursing students enrolled in 3 years of nursing college (diploma program) in order to become registered nurses in Korea. The study employed a convenience sample of 216 second-year nursing students in K province of South Korea. Previous studies have reported that the second year is when nursing students start clinical practice, and that these students have higher stress than do students in subsequent years (Admi, 1997; Jones & Johnston, 1997; Suliman & Halabi, 2007). A sample size of 212 was calculated using G*Power version 3.1 (Franz Faul, Universitat Kiel, Germany), according to an effect size of 0.15, alpha of 0.05, and power of 0.80. These data demonstrate that our study sample size was appropriate. Instruments Web-based nursing process program. This study was conducted using a web-based nursing process documentation system, which integrated the SNLs of NANDA-I, NOC,
E. Lee and H. K. Noh
The Effects of a Web-Based Nursing Process Documentation Program
and NIC. In the web-based nursing process documentation system, a total of 202 NANDA-I nursing diagnoses and their related signs and symptoms (NANDA International, 2009), 542 nursing interventions with more than 9,000 nursing activities (Bulechek et al., 2008), and more than 2,000 nursing indicators belonging to 385 nursing outcomes (Moorhead et al., 2008) were integrated in English terminology with Korean translations. To complete the nursing process using the web-based nursing documentation system, nursing students input patient demographics, such as age, sex, admission date, insurance type, medical diagnosis, and type of operation. Then, students choose nursing diagnoses either from those categorized into the domains and classes of the NANDA-I taxonomy structure, or by using a search engine that required typing in the NANDA-I label. After nursing diagnoses are selected, their defining characteristics and related factors are displayed. Students can choose these by clicking the button corresponding to each defining characteristic and related factor. After choosing nursing diagnoses, students choose nursing outcomes, which are categorized by the domains and classes of the NOC taxonomy structure. After choosing appropriate nursing outcomes, students choose indicators and assess patient status using a 5-point Likert scale. After choosing the nursing outcomes and their indicators, students choose nursing interventions, which are categorized by the domains and classes of the NIC taxonomy structure. Thus, nursing diagnoses, outcomes, and interventions are selected in order (Bulechek et al., 2008; Moorhead et al., 2008). This program is available at http://medinfo.knu.ac.kr/ nursingprocess, and a paper on the development process was published in Korea previously (Hong & Kim, 2011). Questionnaire. Questionnaires developed in this study measured participants’ demographic characteristics and levels of stress and anxiety. Stress and anxiety levels were measured using a numeric rating scale (NRS). The score range of the NRS is from 0 to 100, and higher scores indicate that nursing students felt more stress and anxiety during their clinical practice. Data Collection This study was conducted after approval from the institutional review board of Kyungpook National University Medical Center. For data collection, the researcher directly visited three diploma nursing schools located in K province and asked for their participation in the study. After receiving approval, the researcher visited the nursing students and explained the research purpose and procedure, as well as their right to withdraw from the study at any time. The total number of nursing students registered in clinical practice was 227, and the number of nursing students who were willing to participate in the research was 223. Nursing students were assigned to either the experimental
(n = 115) or the control (n = 108) groups by the hospital in which they were doing clinical practice. However, seven students (five experimental and two control) did not complete all three questionnaire administrations; thus, a total of 216 students were included in the final sample. Finally, 110 nursing students completed case reports using the webbased nursing process documentation program (experimental condition), and 106 students completed their case reports using traditional paper-based methods (control condition). Completing the case report based on nursing process model is one of the mandatory assignments of any nursing students in South Korea. Therefore, it would not put any extra burden on nursing students participating in the study. The rate of participation in the study was 96.9%. Students were assigned by clinical practicum hospital to prevent diffusion effects among participants. The hospitals where clinical practicum was completed included two university-affiliated hospitals, two general hospitals, one women’s clinic, and one psychiatric special hospital. Questionnaires were administered three times during the study: at pretest (baseline), 2 weeks after the intervention, and 4 weeks after the intervention. Baseline stress and anxiety were measured 2 weeks after the first clinical practicum to allow nursing students to become oriented to clinical practice. The first questionnaire was distributed by the researcher directly to both the control and experimental groups. Immediately after the baseline data collection was complete, students in the experimental condition received 60 min of instruction from the researcher on how to use the SNLs of NANDA-I, NOC, and NIC, as well as how to complete care planning for patients using the web-based nursing process documentation program. They also practiced how to use the web-based nursing process documentation program in the computer lab for 20 min. The second and third questionnaires were distributed to the representatives of students, and then the representative students distributed the questionnaire to the participants to remove any pressure from the researcher or course instructors. After completing the questionnaires, participants returned the questionnaires to the representative students, and the representative students handed them out to the researcher. To remove any other effects to the participants, the researcher did not contact the participants during the study except for the instruction for the SNL and how to use web-based nursing process documentation system. In addition, extra instructions or special instructions were not provided to both the control and experimental groups during the study, which may influence the anxiety and stress level of the participants. Data Analysis Data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows version 19 (SPSS Inc., Chicago, IL, USA). Descriptive statistics, appropriate to the level of measurement, were used to describe the study
37
The Effects of a Web-Based Nursing Process Documentation Program
E. Lee and H. K. Noh
Table 2. Homogeneity Test Between the Experimental and Control Groups (N = 216) Experimental (n = 110)
Control (n = 106)
Variables
M ± SD or n (%)
M ± SD or n (%)
t or χ2
p
Age Gender Male Female Stress Anxiety
20.03 ± 1.779
20.40 ± 1.787
0.40 1.59
.692 .113
9 (8.18%) 101 (91.82%) 65.82 ± 16.66 59.55 ± 19.55
15 (14.15%) 91 (85.85%) 64.34 ± 20.38 59.53 ± 20.16
0.59 0.07
.561 .995
variables. Independent t tests, chi-square tests, and repeated-measures analyses of variance were used to assess the mean differences between the experimental and control groups. A p value of .05 was set for statistical significance. Results Characteristics of the Sample and Homogeneity Test of Variables In total, 216 students were enrolled in the study. The experimental group included 110 students and the control group included 106 students. The mean age of the experimental group was 20.03 years and that of the control group was 20.40 years. Most participants were female, both in the experimental group (91.82%) and the control group (85.85%). A homogeneity test was performed to examine the variables that may have resulted in differences in stress and anxiety levels between groups. There were no significant differences between groups in age (t = 0.40, p = .692) or gender (χ2 = 1.59, p = .113). In addition, there was no significant difference between groups in stress (t = 0.59, p = .561) or anxiety levels (t = 0.07, p = .995) (Table 2). Effect of Using the Web-Based Process Documentation Program on Stress Level The mean scores for stress of the experimental and control groups are presented in Table 3 and Figure 1. There were significant differences between the two groups (F = 8.03, p = .005), within groups over time (F = 67.66, p < .001), and an interaction between time and group (F = 11.75, p < .001) for stress level. In the control group, the mean score for stress decreased from 64.34 to 60.94 after 2 weeks. After 4 weeks, the mean score for stress was 53.58. This score was compared with the score at pretest and after 2 weeks, which showed that the changes in score were 10.76 and 7.36, respectively. In the experimental group, after 2 weeks, the mean score for stress changed from 65.82 to 55.91. After 4 weeks, the mean score for stress was 39.82. This score was compared
38
with the score at pretest and after 2 weeks, which showed that the changes in score were 26.00 and 16.09, respectively. In the control group, stress level was significantly lower after 4 weeks compared with at pretest (t = 4.48, p < .001), but there was no significant change after 2 weeks (t = 1.84, p = .069). In contrast, in the experimental group, stress level was significantly lower after 2 weeks compared with the pretest (t = 6.93, p < .001). Additionally, there were significant differences in stress level between the groups at 4 weeks (t = 5.19, p < .001). Effect of Using the Web-Based Process Documentation Program on Anxiety Level Mean scores for anxiety of the experimental and control groups are presented in Table 4 and Figure 2. There was a significant difference between the two groups (F = 8.53, p = .004), within groups over time (F = 46.80, p < .001), and for the interaction between time and group (F = 9.03, p < .001) for anxiety level. In the control group, the mean score for anxiety decreased from 59.53 to 57.50 after 2 weeks. After 4 weeks, the mean score for anxiety was 51.32. In the experimental group, after 2 weeks, the mean score for anxiety decreased from 59.55 to 51.09. After 4 weeks, the mean score for anxiety was 39.09. In the control group, anxiety was significantly lower after 4 weeks than at pretest (t = 3.43, p = .001), but there were no significant changes after 2 weeks (t = 1.05, p = .295). In contrast, anxiety was significantly lower 2 weeks later in the experimental group compared with pretest (t = 6.00, p < .001). Additionally, there were significant differences in anxiety level between the groups after 2 weeks (t = 2.35, p = .020) and after 4 weeks (t = 4.78, p < .001). Discussion The purpose of this study was to identify the effects of a web-based nursing process documentation program on the stress and anxiety levels of nursing students during their clinical practicum. Previous studies have consistently reported that nursing students experience high levels of stress and anxiety (Galbraith & Brown, 2011; Melincavage,
11.75 (
