CHAPTER I

THE PROBLEM AND ITS SETTING

Background of the Study

Stress stalks nurses long before they begin working in the hospitals. Tension and pressure

are also frequent companions of nursing students. In addition to contending exams, grades, long

hours of studying, work, family and other personal commitments student nurses are also faced

with the challenges of clinical practice. An American study of stress among health care

professions ranked Nursing at the top.

Alarming as different studies show but higher levels of stress had been exhibited within

the four walls of the nursing profession. According to Sharif & Masoumi (2005), lack of

experience, fear of making mistakes, being evaluated by faculty members, worrying about giving

patients the wrong information, or medication and concern about possibly harming a patient are

just a few of the stressors for the novice nurse.

Preparing to become a nurse was found to be significantly emotionally stressful and a

possible risk to the well-being of students (Tully, 2005). Nursing student who fulfill their clinical

practices are exposed to symptoms specific to nursing in the field of stress (Pades Jimenez and

Homar Amengual, 2006).

Initial clinical experience for new nursing students can be stressful and intimidating,

particularly for young students having no prior healthcare experience (Sprengel and Job, 2005).

Additionally, characteristics of nursing profession are significantly and directly related to human

health. Therefore, nursing students need to be aware and to be able to utilize the nursing

theoretical aspects for high quality clinical practicing. Moreover, nursing shifts and ward

rotations, in order to fulfill the patient’s needs 24 hours a day also expose nursing students to
stress that directly effect their adaptation (Lambert et al., 2007a; 2007b; Xianyu and Lambert,

2006).

The standards used by the researchers in selecting the main problem are the researchers’

personal experiences in the clinical area gave a good insight and became an inspiration towards

coming up with this kind of investigation, the abundance of studies, concepts and information

about the independent variable of the study which is stress and third, is the application of the

knowledge that will be construed from the study that would be of significance to develop

competent teaching skills among clinical instructors making learning a pleasurable experience.
Statement of the Problem:

The main problem of this research is the “Perceived Effects of Stress on the Clinical

Performance of Level III and IV Nursing Students of CEFI” specifically to answer the following

sub problems:

1. What is the demographic profile of the respondents in terms of:

1.1 Age

1.2 Sex

1.3 Year Level

1.4 Clinical Area

2. What are the common stressors frequently encountered by the Level III and IV students in

the clinical setting?

3. To what extent do the Level III and IV students perform the basic nursing activities even

under stress?

4. What are the perceived effects of stress in the clinical performance of Level III and IV

nursing students?

5. What are the coping mechanisms utilized by the respondents to alleviate stress?
Theoretical Framework

The theoretical framework used to guide this study is based upon the concepts of stress,

adaptation, and coping. There are three assumptions inherent in this research. The first is that

stress is inherent in every phase of life. The second is that stress is a subjective and individual

reaction to both positive and/or negative experiences in one's environment. The third assumption

is that individuals must learn to adapt to or cope with stress in order to survive.

Stress

Stress arises from any interaction between an individual and the environment when the

individual perceives the situation as threatening, challenging or possibly damaging. Essentially,

the individual perceives that a situation may tax or exceed the individual’s resources. Hans Selye

conducted the initial research on stress. Selye's work was based on the premise that any activity

or emotion can cause stress, which will require ome type of change or adaptation from the

individual. The definition of stress used by elye is "the non-specific response of the body to any

demand,” Selye's theory supports that some stress is necessary to maintain life, but if the non-

specific response places increased demands for adaptation, the effects on the individual may be

damaging or excessive. After conducting extensive animal and human research, Selye identified

a predictable pattern of responses to stress that he termed the general adaptation syndrome

(GAS). He identified three stages to this syndrome. The first stage is the alarm stage that is the

immediate stress response. The individual perceives a stressor that causes the body to begin a

physiological response. This response is automatic and unconscious. It is at this point that the

individual initiates the flight or fight response to the stimuli. The second stage is the stage of

resistance. This is the stage where adaptation and coping occur. After using a large amount of the
individual's available energy, the body enters the last stage. This third and final stage is termed

exhaustion.

Role Theory

One area identified frequently in relation to students is the stress that occurs during role

transition (Nunnery, 1997). A role is a position that one assumes that has expected and actual

behaviors that are prescribed by society. These behaviors are termed "norms" and are the

standards or guidelines that govern an individual's actions within that role (Hardy, 1978). Often,

students will experience stress related to their prescribed roles in the form of role stress, role

strain, role conflict and role ambiguity or incompetence. Role stress is perceived when role

demands are difficult or impossible to meet. Role strain is the subjective response an individual

experiences as a result of role stress (Hardy, 1978). This response often includes frustration,

anxiety or tension. Role conflict can result when role expectations are contradictory or mutually

m exclusive (Hardy, 1978). Role overload occurs as a result of multiple role demands. Research

indicates that many students perceive increased stress because of multiple role demands

(McBride, 1997; Ross, Niebling & Heckart, 1999). Nunnery (1997) states that functioning in

multiple roles can be instrumental in redefining one's identity, but can also lead to negative

consequences. Many students have roles such as wife, husband, mother, father, breadwinner and

so forth. All of these roles compete for energy and time. Adding the role of student to an already

taxed individual can lead to excessive role strain and conflict.

Role incompetence occurs when an individual's resources are inadequate, or believed to be

inadequate, relative to the demands of the role. Role incompetence can result from several

different situations. In many cases, students entering college have doubts as to their ability to

complete their educational requirements. Jones and Johnston (1996) found that one of the main
sources of stress in nursing students is the fear of failing. Beck (1995) states that grade anxiety

and the fear of "will I make it?" is a constant drain on student's energy and resources.

Additionally, Wilson (1994) found that a major source of nursing student's stress is the fear that

they will harm a patient through their lack of knowledge or inexperience. Pagana (1988) found

that a significant source of stress for nursing students is the role expectations placed upon them.

Nursing students often feel inadequate to meet these expectations. The fact that they are students

learning to be a nurse and not an actual nurse is often forgotten. Many students state that they are

expected to make decisions that they do not have the experience or knowledge to make. Coping

Discussion of stress and adaptation requires careful analysis of the concept of coping.

Lazarus (1977) defines coping as a reaction to stressors. This reaction is the individual's attempt

to master conditions of harm, threat or challenge (Goosen & Bush, 1979). Coping mechanisms

are "those direct, active tendencies aimed at eliminating a stressful event," The process of coping

may consist of a rather large array of overt and covert behaviors. The process of coping is a very

complex response that occurs when an individual attempts to remove stress or what is perceived

as a threat from one's environment. The actual reaction one has to an environmental event is as

important as the event itself (Garland & Bush, 1982). Therefore, not only does one's coping

ability have implications for mental and physical health, but the person's state of health can also

affect one's ability to cope. Lazarus (1977) divides coping into two main categories, direct action

and palliation. Direct action refers to the individual's attempt to change the environment or

stressor. Palliation, on the other hand, refers to the individual's attempt to moderate the demands

made by the stressor or tolerate the subjective symptoms produced by the stressor.

Lazarus (1977) further divides palliation into two subgroups. One subgroup is directed at

the symptoms and includes the use of alcohol, tranquilizers or muscle relaxation techniques. The
second subgroup is termed intrapsychic modes and refers to the use of unconscious defense

mechanisms such as denial or distancing. Consequently, the individual may deal with stress

through several methods including removing the stressor through manipulating the environment,

developing specific responses to help deal with the stressor or seeking diversion from the

stressor. Lazarus and Lanier (1978) further studied the concept of coping and divided the coping

choices into instrumental coping (problem-focused) and palliative (focused on regulating the

emotional response). Instrumental choices included information gathering, problem-solving,

communication, social skills training, time management, mobilizing supports and direct efforts at

changing the environment. Palliative techniques included denial, diverting attention, searching

for meaning, emotional distancing, expressing affect, cognitive re-labeling and relaxation

training (Schmitz, 1995).

Studies by Pearlin (1990) and Pearlin and Schooler (1978) were among the first to

address the interaction of the individual and the environment. They identified coping as a

behavior that is a protective mechanism that functions in three ways. First is by attempting to

eliminate or modify the situation that is giving rise to the problem. Second is to perceptually

control the meaning of the experience in a manner that neutralizes the problematic character of

the situation. The third is to attempt to keep the emotional consequences of the situation

manageable. These researchers believe that all coping behaviors can be categorized into these

three areas. The research by Roth and Cohen (1986) on coping identified two basic orientations

to stress - approach and avoidance. These orientations refer to the cognitive and emotional

activity that is oriented either to or away from a threat. Approach strategies refer to attempting to

take appropriate action to either change a situation or to make it more controllable. On the other

hand, avoidance strategies attempt to protect the individual from the overwhelming power of the
stressor by distancing the individual from the experience. Neither approach nor avoidance is

determined to be the most effective coping style.

According to the authors, the coping behavior must be matched with the potential

rewards available in relation to the demands. Approach strategies allow for direct action and

attempt to change the situation, allowing the individual to take more control. On the surface, this

sounds more effective than avoidance. However, the student that continually copes by studying

long hours, getting little rest and neglecting their family or personal needs is not necessarily

coping effectively. Approach strategies generally seem to be more effective when an individual

has more power or control over a situation (Smitz, 1995).

Avoidance or distancing are behavior patterns that are thought to be more passive and are

often thought of as weak or ineffective. In some cases, avoidance can be important to allow

assimilation of a stressful situation until the individual can gain more control or acceptance. This

can be especially effective in a situation where an individual has no control such as disease (Roth

& Cohen, 1986) or if the stressor involves chronic, high stress difficulties (Lennon, 1987). It is

important, however, that avoidance or denial is used only to facilitate assimilation since denial

can cause negative consequences. First, denial may cause the individual to not perceive or take

advantage of opportunities to correct a stressful situation. An example of this would be students

that will not take advantage of student services such as counseling or tutoring. Second, denial

can lead to unconscious build up of pressure in the active memory, which can cause

psychological intrusions such as nightmares, foreboding thoughts or negative feelings (Roth &

Cohen, 1986).

This framework can be used as a guide to evaluate student's response to stress.

may experience stress, perceive it as a challenge and will be motivated to work harder and

increase his or her learning. Other students will perceive stress more as a threat and learning may

be hindered. Hefferin (1982) supports this theory. She states that more competent students will

react to stress with anxiety. The more capable student is stimulated by this anxiety and will strive

to gain mastery over the situation. The less able students, however, will blame themselves for

classroom failures and blame others for failures in interpersonal relationships. Therefore, it is

important for administrators and faculty to understand the types of stress students perceive and to

implement strategies to deal with this stress.

 Stressors
 Effects
 Coping
Mechanism

FIGURE 1: Conceptual Framework of the study

Figure 1 discussed about stressors, effects and coping mechanisms of level III and IV

nursing students of Calayan Educational Foundation Inc. The second figure shows the process

and what the result of work of level III is and IV nursing students when they are under stress and

how they cope with it. The last figure is the output where we can give information, educate and

communicate by distributing materials where they can find ways to manage stress.

Scope and Limitation

of Level III and IV school year 2010-2011. It also investigated the contributing factors and its

effects to the respondents’ clinical performance and the respondents’ way on how to manage or

alleviate stress. A sample population of fifty six student respondent of Calayan Educational

Foundation Inc. was utilized by the researcher. Only five students from MaryHill College

Lucena City were used for pilot testing.

Significance of the Study

The value of this research With this information, it can help students by making careful

planning a basic part of their daily routine, to set personal and professional goals by establishing

priorities, practicing good health habits, improving their self esteem and teach themselves to

identify stress and how to manage it by not affecting their clinical performance during exposure

in the hospital.

Nursing students

may acquire greater insights of the stressors, problems and challenges they may

encounter all throughout their clinical performances which is part of their chosen career. This

knowledge will give them better and wider perspective about their profession and aid them in

enhancing their coping abilities and self-confidence.

Clinical Instructors

may provide them understanding why nursing students behave like they do. This study

will also provide them hints of what remedial measures they need to institute to lessen the

learning difficulties of their students while undergoing clinical exposure. Further, it will
eventually help them to build a better relationship with the students, promote educational growth,

and improve human and public relations with the identified clinical area of operation.

School administrators and faculty

who may help to work out solutions and course of action that will improve the students’

performance and to lessen their burden in their clinical duties while on the learning process. It

also gives them the chance to improve the quality of nursing education for the benefit of the

students and the institution as well.

Definition of Terms

Throughout this study the following terms will be used and for the convenience of the

readers of this study, the following are defined as follows:

Clinic or Clinical Area

Defined as either the field of principal professional clinical activity or the primary area

of responsibility, depending on the profession.

Level III Nursing Students

Students that study a nursing profession and does a duty in the clinical area for at least 19

hours a week.

Level IV Nursing Students

Students that study a nursing profession and does a duty in the clinical area for at least

24 hours a week.
Stress

a normal physical response to events that make you feel threatened or upset your balance

in some way.

Related Learning Experience

this pertains to the clinical exposure, which the nursing students have to undergo. It is

required to all nursing students in order for them to have an in depth and meaningful experience

and easily appreciated when they are already in actual hospital situation.