CHAPTER II

REVIEW OF LITERATURE

Review of literature is a critical summary of research on a topic of interest

generally prepared to put a research problem in context to identify gaps and weakness

in prior studies so as to justify a new investigation. Literature reviews play a critical

role for nurses seeking to develop an evidence based practice. It can inspire new

research ideas and help to lay the foundation for studies.

Literature review is an essential step in the whole process of research. It is

done in order to broaden understanding and create an insight in the researcher

regarding the selected area. It also helps to select the appropriate methodology, tool

development and analysis.15

Review of literature for the study presented under the following headings.

2,1 Literature related to stress and coping

2.2 Literature related to studies on stress and coping among student nurses

2.3 Literature related to studies on the effectiveness of coping strategies

among student nurses

2.4 Conceptual Frame Work

2.1 Literature related to stress and coping

For the last five decades the term stress has enjoyed increasing popularity in

the behavioral and health sciences. It first was used in physics in order to analyze the

problem of how manmade to carry heavy loads and resist deformation by external

focus. In this analysis, stress referred to external pressure or force applied to a

structure, while strain denoted the resulting internal distortion of the object In the

29
transition from physics to the behavioral sciences, the or psychological demands on

an individual. The external forces that impinge on the body are called stressors.77

Stress is a natural phenomenon that everyone experience in his or her life

time22 and is caused by stress causing factors or stressors.23 Ram Chandra Rao spoken

about concept of stress in India. He suggests that there are two Sanskrit words ‘klesa’

and ‘duhkha’, which are the causes of stress. Several studies have shown that stress is

harmful for mental and physical health24. Constant stress brings about changes in the

balance of hormones in the body which may lead to the situation or thought that

makes us feel frustrated, angry, nervous, or anxious.25

Stressors are often thought of as being external. However, Vogel and Bower78

explained that stress can also manifest from within the mind of the individual. We

create our own stress, make our own stressful events, and cause our own diseases.

These processes are based on specific genetic vulnerabilities, individual experiences,

and environmental circumstances. Therefore, not only are we responding to stressors

as part of everyday life, but we also are responsible for manifesting stress based on

how we perceive and interpret our experiences. The degree to which an individual is

susceptible to the effects of stress and how it manifests in a person’s life is variable by

the nature and extent in which it is experienced.

Seyle79 viewed stress as a response to noxious stimuli or environmental

stressors and defined it as the “nonspecific response of the body to noxious stimuli.

Thus, he defined stress as a response, and it became the dependent variable in stress

research. His work focused on describing and explaining a physiological response

pattern known as the general adaptation syndrome (GAS) that was focused on

retaining or attaining homeostasis, which refers to the stability of physiological

systems that maintain life (e.g., body temperature, heart rate, glucose levels). The

30
following are the basic premises of his theory: (a) The stress response (GAS) is a

defensive response that does not depend upon the nature of the stressor; (b) the GAS,

as a defense reaction, progressed in three well-defined stages (alarm, resistance, and

exhaustion); and (c) if the GAS is severe enough and/or prolonged, disease states

could result in death or the so-called diseases of adaptation.

In his early work, Selye79 proposed that cognitive variables such as perception

played no role in contributing to the initiation or moderation of the GAS. In his 1983

edition he80extended his thinking to include both negatively and positively toned

(eustress) experiences that could be contributed to and moderated by cognitive fac-

tors. It is important to note, however, that Selye’s basic theoretical premise that stress

was a physiological phenomenon was not altered. In the absence of a modification of

his theory, it was not possible to explain psychological stress. This could not be done

in the context of a theory that was strictly limited to physiology and neglected

cognitive-perceptual factors. In fact, problems inherent in a normative or generalized

response theory were demonstrated when Mason81 disconfirmed the non-specificity of

physiological responses to noxious stimuli in rats and monkeys.

As a social-personality psychologist, Richard Lazarus82 became interested in

explaining the dynamics of troublesome experiences. He developed and tested a

transactional theory of stress and coping He believed that stress as a concept had

heuristic value, but in and of it was not measurable as a single factor. Lazarus

contended that stress did not exist in the event but rather is a result of a transaction

between a person and his or her environment. As such, stress encompasses a set of

cognitive, affective, and coping factors.

In 1966, Lazarus79 identified two forms of coping: direct action and palliative.

In 1984, Lazarus and Folkman changed the names of these two forms to problem-

31
focused and emotion-focused, respectively. Problem-focused coping strategies are

similar to problem-solving tactics. These strategies encompass efforts to define the

problem, generate alternative solutions, weigh the costs and benefits of various

actions, take actions to change what is changeable, and, if necessary, learn new skills.

Problem-focused efforts can be directed outward to alter some aspect of the

environment or inward to alter some aspect of self. Many of the efforts directed at self

fall into the category of reappraisals—for example, changing the meaning of the situ-

ation or event, reducing ego involvement, or recognizing the existence of personal

resources or strengths.

Emotion-focused coping strategies are directed toward decreasing emotional

distress. These tactics include such efforts as distancing, avoiding, selective attention,

blaming, minimizing, wishful thinking, venting emotions, seeking social support,

exercising, and meditating. Similar to the cognitive strategies identified in problem-

focused coping efforts, changing how an encounter is construed without changing the

objective situation is equivalent to reappraisal. The following are common examples:

“I decided that something a lot worse could have happened” or “I just decided there

are more important things in life.” Unlike problem-focused strategies, emotion-

focused strategies do not change the meaning of a situation directly. For example,

doing vigorous exercise or meditating may help an individual reappraise the meaning

of a situation, but the activity does not directly change the meaning. Emotion-focused

coping is the more common form of coping used when events are not changeable 79
80
Another important construct in Lazarus’s transactional model is emotion—

specifically emotions that are considered to be stress emotions. These include, but are

not limited to, anxiety, fear, anger, guilt, and sadness Lazarus (2000) presents cogent

arguments for the explanatory power of the cognitive theory of emotion. Although

32
thoughts precede emotions, (that is, emotions are shaped by thought processes)

emotions can in turn affect thoughts. The primary appraisal of threat and the specific

meaning of the situation to the person triggers a particular stress emotion consistent

with its meaning. Lazarus and Lazarus and Folkman link stress-related variables to

health-related outcomes. All of the constructs in their transactional model, when taken

together, affect adaptational outcomes. The theorists propose three types of

adaptational outcomes: (a) functioning in work and social living, (b) morale or life

satisfaction, and (c) somatic health. They view the concept of health broadly to

encompass physical (somatic conditions, including illness and physical functioning),

psychological (cognitive functional ability and morale—including positive and

negative effects regarding how people feel about themselves and their life, including

life satisfaction), and social (social functioning).

Sarafino and Ewing102 emphasize being able to assess and reduce student's

stress is of paramount importance to college counseling and health centers. They

emphasize the role that stress can play in causing psychological and physical illnesses

such as hypertension, headaches and even the common cold. Their research focused

on life event stress and the stress of daily “hassles”. Life events referred to major

changes in ones life such as employment, personal relationships or health. The term

“hassles” referred to common annoyances or irritants such as misplacing items, time

pressures or interpersonal conflicts. Results were related to frequency, perceived

unpleasantness and the process of rumination, or as they term it “dwelling”. Their

research validated that many times the severity of the perceived stress is often

dependent on the individuals' coping skills. Also, students that dwell on stressors and

problems will often continue to experience chronic anxiety and strain after the actual

stressor is no longer present91.

33
Stress, Coping, and Health Outcomes as Defined in Stress Theories

Scientific view Conceptualization of Conceptualization of Health outcomes

stress coping
Response based Stress is the There is no On the basis of the
(Selye, 1956, 1983) nonspecific response conceptualization of assumption that each
to any noxious coping per se. person is born with a
stimulus. The Instead, Selye used finite amount of
physiological the concept of energy and that each
response is always the “resistance stage,” the stress encounter
same regardless of purpose of which is to depletes energy stores
stimulus— the resist damage (this that cannot be
general adaptation concept is part of the rejuvenated, it was
syndrome (GAS). GAS). proposed that stress
causes “wear and tear
on the body” that can
result in various
diseases based on the
person’s genetic
propensity.

Stimulus based The term stress is Coping is not A summative

(Holmes & Rahe, synonymous with defined. accumulation of
1967) “life event.” Life adaptation efforts
events are “stress” over a threshold level
that require makes a person
adaptation efforts. vulnerable to
developing a physical
or mental illness
(operationalized as
disease) within 1
year.

Transaction based The term stress is a Coping is Adaptational health

(Lazarus, 1966; “rubric” for a conceptualized as outcomes are
Lazarus & Folkman, complex series of efforts to ameliorate conceptualized as
1984) subjective the perceived threat short term and long
phenomena, including or to manage stress term.
cognitive appraisals emotions (emotion- Short-term outcomes
(threat, harm, and focused coping and include social
challenge), stress problem-focused functioning in a
emotions, coping coping). specific encounter,
responses, and morale in the positive
reappraisals. Stress is and negative affect
experienced when the during and after an
demands of a encounter, and
situation tax or somatic health in
exceed a person’s symptoms generated
resources and some by the stressful
type of harm or loss is encounter.
anticipated. Long-term outcomes
include social
functioning, morale,
and somatic health.
Both short-term and
long-term health
outcomes encompass
effective, affective,
and physiological
components

34
 Although Jones and Johnston’s research study did not focus directly on stress

and coping related to clinical experiences, it provided useful information about coping

among student nurses in general. First year students in their study reported mainly

academic items such as fear of failing, long hours of study and lack of free time as

their main sources of stress. The authors of this study examined the use of coping

methods in relation to the level of distress experienced by student nurses. Students

whose level of distress was lower used problem-focused coping methods, whereas the

students, who experienced higher level of distress, engaged in non-direct (or emotion-

focused) coping methods such as hostility or wishful thinking63.

According to the Neuman Systems Model,111 “Nursing is prevention as

intervention” The concepts prevention and intervention include three components:

primary prevention, secondary prevention, and tertiary prevention. Primary

prevention is the process through which client-client system stability is accomplished.

Intervention may begin at any point when stressors are either suspected or identified.

Primary intervention is used when the stressor has not invaded the normal line of

defense and has not produced symptoms of anxiety. Secondary prevention should be

initiated when a stressor invades the normal line of defense or when a primary

intervention is not implemented or is unsuccessful. The goal of secondary intervention

is to achieve client-client system wellness by strengthening the line of resistance to

promote reconstitution.112 Tertiary prevention as intervention is implemented during

reconstitution in an attempt to return the clientclient system to wellness with a focus

on maintenance .Strategies to decrease undergraduate nursing student anxiety in the

clinical learning environment are considered primary and secondary interventions

because strategies can be initiated at the start of a clinical rotation as a preventative

measure or at the time a student is identified as experiencing anxiety.111

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2.2. Studies related to stress

Descriptive cross-sectional study was conducted to determine sources of stress

and coping strategies in student nurses studying at the Iran Faculty of Nursing &

Midwifery. All undergraduate student nurses enrolled in years 1-4 during academic

year 2004-2005 were included in this study. Results of the study revealed that first

year student nurses are exposed to a variety of stressors. The results also provided

important clues for establishing a student support system during the first year and

improving it throughout nursing school is necessary to equip student nurses with

effective coping skill.27

There are many sources of stress in college students. Ross, Niebling and

Heckert55 used the Student Stress Survey to identify the major sources of stress in this

population. The researchers surveyed 100 undergraduate students at a mid-sized

midwestern university. The survey consisted of 40 items that were divided into four

categories of potential sources of stress. These categories included interpersonal

sources of stress, intrapersonal sources of stress, academic sources of stress and

environmental sources of stress. The interpersonal sources of stress were the result of

interactions with others such as a fight with a girlfriend or boyfriend or trouble with

an individual's parents. The intrapersonal source of stress indicated a change within

the individual such as sleeping or eating habits. Academic sources of stress identified

school related activities such as an increase in workload, difficulty in assignments and

examinations or transferring schools. Lastly, environmental sources of stress were

related to problems outside of the school area such as difficulties with a vehicle or

computer. Additionally, the categories were subdivided into daily annoyances such as

financial difficulties or major life events such as a divorce, death in the family, change

in alcohol or drug use. The top five sources of stress identified in this study were a

36
change in sleeping habits, vacations and breaks, a change in eating habits, new

responsibilities and increased class workload These results indicate that three of the

top five stressors of college students are intrapersonal. The researchers recommend

further study,as these results identify the frequency of stressors rather than the

severity of the perception of stress and the ensuing impact upon the individual.

A descriptive study was to identify stressful events of first-year Nepalese

student nurses in the clinical setting and to determine how they cope with the stressful

events. The sample consisted of 104 student nurses who had been in the clinical

setting for 6 to 8 weeks. Four stressful events identified were: interpersonal

relationships, initial experiences, feeling helpless, and demeaning experiences. The

most frequently reported stressful event was interpersonal relationship (50%). Eight

categories of coping from students' description were problem-solving, accepting

responsibility, seeking social support, self-control, tension reduction, avoidance,

wishful thinking and negative feelings. The majority of students utilized the "seeking

social support" category of coping.100

A relationship between stress in college students and poor health behaviours

has been documented in several studies In a study by Hudd SS, Dumlao J and Muray

D et al,94 145 undergraduate students were surveyed in an attempt to answer three

important questions. These questions were: 1). Are students in certain demographic

groups more prone to experience higher levels of stress than others? 2). Is there a

relationship between stress and healthy or unhealthy behaviours? and 3). Do students

experiencing high levels of stress have lower levels of self-esteem and perceive

themselves to be less healthy? The results of the survey indicate that women are

stressed more often than men. Results also indicate that students that report higher

stress levels are more prone to unhealthy behaviours such as poor dietary habits, poor

37
sleeping habits and less exercise. Interestingly, there was no reported difference in the

two groups in alcohol consumption. It was also found that students reporting higher

stress levels perceive themselves to be less healthy and less satisfied with a variety of

life factors such as their grade point average, weight and fitness level. This

dissatisfaction with various life factors may lead to decreased self-esteem. It was not

clear, however, if the high levels of stress reduce one's self esteem or whether the low

self-esteem contributes to the stress levels that one perceives. The researchers

recommend that universities design programs in time management and coordinating

multiple tasks that would be adapted to the needs of students as they progress through

their academic careers.

Sundaram S28 conducted a comparative study on stress among 30 first year

and 30 fourth year B.Sc student nurses in Chennai. The study revealed that the first

year B.Sc. Student nurses had comparatively more stress and less coping than the

final year B.Sc. Student nurses. The researcher suggests orientation classes for the

newcomers and to conduct well organized guidance and counselling services to help

the student nurses to carry on their course of study with less stress and adequate

coping.

Pagana93 surveyed 262 baccalaureate student nurses and found that personal

inadequacy and a fear of making mistakes were constant stressors. Lindop92 identified

conflict between the ideal and real clinical practice was also a source of stress. He

also found that time management problems, when trying to complete nursing tasks,

added to a student's perception of stress. Bell,6 found that anxiety and stress could

interfere with learning a complex, psychomotor skill.

Parkes KR examines stressful episodes reported by student nurses (N = 150)

interviewed during the early stages of their training at two general hospitals. The

38
approach is qualitative rather than empirical, and the paper focuses on how students

perceive and interpret the day-to-day demands and frustrations they encounter in the

course of their work in the wards. The episodes were classified into six major content

areas. Three of these (the care of dying patients; interpersonal conflicts with other

nurses; and insecurity about professional skills and competence) were found to

account for two-thirds of the total episodes reported. The types of episodes are

discussed in the context of literature findings relating to nursing stress. Underlying

factors common to many episodes were the inadequate support and guidance given by

senior nurses and clinical tutors, coupled with the students' lack of experience and the

demanding nature of the ward environment. Ways in which adverse effects of stress

among student nurses might be alleviated, including improving communication skills,

enhancing social support, and the use of stress management techniques, are discussed

in the light of this material Level of stress and coping strategies used by nursing

interns.82

A correlation can be found between a student's academic stress and the

individual's anxiety, time management and leisure satisfaction was conducted by

Misra and McKeann40 to investigate the interrelationship among these variables in

249 undergraduate university students. It was hypothesized that a student's academic

stress would show a positive correlation with anxiety and a negative correlation with

self-reported time management behaviors and leisure satisfaction. The research

supported that effective time management skills seem to lower academic stress and

anxiety. However, a strong correlation between leisure satisfaction and perceived

academic stress was not demonstrated. It does appear that women have higher

perceived stress levels than men, even though they reported higher effective time

management skills. Additionally, students in the freshman and sophomore classes

39
reported much higher stress levels than juniors or seniors. The researchers attribute

this fact to the lack of strong social support networks and that freshman and

sophomores have not yet developed the coping skills of junior and senior students.

Therefore it is recommended that faculty should encourage all students to attend time

management seminars as well as stress management programs, early in their academic

careers.

Yang Luo, Honghong Wang36, conducted a correlation study on 288 college

student nurses, to explore the factors affecting student nurses’ psychological status,

and the interactions between mental symptoms and stressful factors, coping style and

social support in their early clinical experiences. The result of this study was that

positive correlations were found between stressful events, negative coping styles,

while negative correlations related to positive coping style, social support. They also

found that stressful factors, negative coping style and social support all have main

effects on mental symptoms. In order to improve the psychological condition of

student nurses, the authors suggest that, apart from reducing the stress incidents and

avoiding negative coping, it is very necessary to enhance the social support systems

and to encourage them to adopt the positive coping styles.

A cohort study was carried out in order to evaluate the evolution of student

nurses’ perception of stressors associated with clinical practice by Xabier Zupiria,

Gorostidia, Xavier Huitzi, Egilegorb, Mari Jose Alberdi Ericec et al.84 Sixty-nine

students answered the KEZKAK questionnaire at four stages of their studies. The

most powerful stressors identified by students both at the beginning and at the end of

their studies were: lack of competence, uncertainty, being harmed by the relationship

with patients, emotional involvement, lack of control in relationships with patients,

contact with suffering, relationships with tutors and companions, and overload.

40
Nevertheless, most of the stressors were found to lose stressor power during the

course of nursing training. The researchers emphasized that interventions are

necessary for helping student nurses to overcome their stress related to clinical

experience.

Descriptive cross-sectional study was conducted to determine sources of stress

and coping strategies in student nurses studying at the Iran Faculty of Nursing &

Midwifery. All undergraduate student nurses enrolled in years 1-4 during academic

year 2004-2005 were included in this study. Results of the study revealed that most

students reported "finding new friends" (76.2%), "working with people they did not

know" (63.4%) as interpersonal sources of stress, "new responsibilities" (72.1%),

"started college"(65.8%) as intrapersonal sources of stress more than others. The most

frequent academic source of stress was "increased class workload" (66.9%) and the

most frequent environmental sources of stress were being "placed in unfamiliar

situations" (64.2%) and "waiting in long lines" (60.4%).Interpersonal and

environmental sources of stress were reported more frequently than intrapersonal and

academic sources. Mean interpersonal (P=0.04) and environmental (P=0.04) sources

of stress were significantly greater in first year than in fourth year students. Among

coping strategies in 12 areas, the family problem solving strategies, "trying to reason

with parents and compromise" (73%) and "going along with family rules" (68%) were

used "often or always" by most students. To cope with engaging in demanding

activity, students often or always used "trying to figure out how to deal with

problems" (66.4%) and "trying to improve themselves" (64.5%). The self-reliance

strategy, "trying to make their own decisions" (62%); the social support strategies,

"apologizing to people" (59.6%), "trying to help other people solve their problems"

(56.3%), and "trying to keep up friendships or make new friends" (54.4%); the

41
spiritual strategy, "praying" (65.8%); the seeking diversions strategy, "listening to

music" (57.7%), the relaxing strategy "day dreaming" (52.5%), and the effort to "be

close with someone cares about you" (50.5%) were eachused "often or always" by a

majority of students. Most students reported that the avoiding strategies "smoking"

(93.7%) and "drinking beer or wine" (92.9%), the ventilating strategies "saying mean

things to people" and "swearing" (85.8%), the professional support strategies "getting

professional counseling" (74.6%) and "talking to a teacher or counselor" (67.2%) and

the humorous strategy "joking and keeping a sense of humor" (51.9%) were used

"seldom or never".First year student nurses are exposed to a variety of stressors.

Establishing an student support system during the first year and improving it

throughout nursing school is necessary to equip student nurses with effective coping

skills. Efforts should include counselling helpers and their teachers, strategies that can

be called upon in these students' future nursing careers.27

Another descriptive cross-sectional study was conducted to determine sources

of Stressors and coping strategies among 273 Baccalaureate Student nurses. The

results of the study showed that 40.2% of student nurses who reported high stress

most of them in mild levels (31.8%). Findings also indicated that student nurses

experienced high stress levels over prolonged periods that exceeded stress levels in

prior life events.85

Another study about sample survey on the aspects of nurse education

programmes that frequently cause stress to student nurses. The result indicated that

stress exists for students in both the clinical and academic aspects of the programme.

Financial constraints and academic-related concerns emerged as the most stressful

areas for the students. A third of the students reported that relationships with teachers

and staff on the ward cause some degree of stress. Factor analysis revealed that five

42
factors emerged as sources of stress. Firstly, `academic' stress factors. The second and

third components concern relationships, the former involving teaching-related staff,

and the latter involving the clinical experience. The last two components suggest that

finance and death of patients are independent sources of stress.86

A study was conducted to determine the levels of affective distress, sources of

stress and coping strategies among 220 first-year student nurses in Tayside, Scotland.

The result of the study showed that, 50.5% of students in cohort 1 and 67.9% of

students in cohort 2 suffered significant affective distress. The study also concluded

that distressed students reported the same sources of stress as the non-distressed

students, but suffered them more intensely. The use of fantasy and hostility was

associated with high levels of distress and stress, in both groups. This screen of first-

year student nurses suggests that there is a problem with student distress around an

initial series of general/surgical and psycho-social ward placements.87

A study was conducted in Ramban medical centre, Israel to identify nursing

student`s perceptions of stress in their initial clinical setting experience. The method

adopted was exploratory longitudinal study by using stress scale which include six

subscales. The stress scale was administered three times during the clinical experience

to 46 students. The result revealed that, there is significant difference in pre-clinical

stress level and the actual level of stress in the clinical setting.88

A study was to understand the living experience of nursing student`s coping

with the demands of their clinical practice. The method adopted was Husserl an

phenomenological approach and the data revealed several strategies that, 14 student

nurses utilized to cope with the demands of their undergraduate clinical programme.

The result of the study revealed that, the students having a strong determination to

complete their course and talking things over with family, friends and other students

43
as a means of coping, helped them to get relief from stress and also considered other

nursing could really understand the feeling and experience of being as 'student

nurse'.89

A study was conducted in Ireland to examine the stress experiences and

coping abilities of student nurses. A survey design was adopted, as method and done

it in a large Dublin teaching hospital. A questionnaire was used to assess the stressors

pertaining the student nurses. It included clinical stress, academic stress, coping and

personal factors. The results indicated that the level and intensity of academic

workload, the theory practice gap and poor relationship with clinical staff and patients

leading to stressors. Student adopted short term emotion focused coping strategies to

deal with stress. The study recommended that the provision of adequate support

services from a clinical and academic section, a lecture-practitioner model of

education delivery which helps in developing student`s self awareness skills and

reduction of stress.51

A study to identify experiences that led to both distress and eustress and to

make recommendations to help students cope with course demands.. A series of focus

groups were carried out with a volunteer sample of final year student nurses (n = 16)

in the United Kingdom. The data were thematically analysed. Findings showed that

the themes identified were clinical experience, support, learning and teaching

experience and course structure. There were experiences within each that were

perceived as sources of distress and eustress. Many of the sources of distress concur

with earlier findings but they are more likely to be experienced and commented on

because the demands of present-day programmes and the profile of many student

nurses mean that more effort is invested in meeting educational demands. The

experiential learning and patient-care opportunity that placements provided was an

44
important source of eustress. Conclusion. Students who coped well drew on effective

support networks and adopted a positive, optimistic perspective towards programme

issues. Effective educators did not offer more time than those perceived as less

effective but seemed more effective at tuning into students’ concerns, showing more

empathy and offering clearer guidance.90

A research was conducted using the grounded theory to investigate how

Iranian student nurses manage their time according to the circumstances and obstacles

of their academic field method. Twenty-one student nurses were purposefully chosen

as participants. Data was collected through semi-structured interviews and analyzed

using the method suggested by Corbin and Strauss. One of the three processes that the

student nurses used was “unidirectional time management.” This pattern consists of

accepting the nursing field, overcoming uncertainty, assessing conditions, feeling

stress, and trying to reduce stress and create satisfaction. It was found that students

allotted most of their time to academic tasks in an attempt to overcome their stress.

The findings of this study indicate the need for these students to have time for the

extra-curricular activities and responsibilities that are appropriate to their age.98

A study done by Tayebeh Mirzaei103 to investigate how Iranian student

nurses manage their time according to the circumstances and obstacles of their

academic field. Research was conducted using the grounded theory method. Twenty-

one student nurses were purposefully chosen as participants. Data was collected

through semi-structured interviews and analyzed using the method suggested by

Corbin and Strauss. One of the three processes that the student nurses used was

“unidirectional time management.” This pattern consists of accepting the nursing

field, overcoming uncertainty, assessing conditions, feeling stress, and trying to

reduce stress and create satisfaction. It was found that students allotted most of their

45
time to academic tasks in an attempt to overcome their stress. The findings of this

study indicate the need for these students to have time for the extra-curricular

activities and responsibilities that are appropriate to their age.

A descriptive study was performed to explore sources of stress and coping

strategies among AU student nurses by Patra Phuekphan A.108 Data were collected

from 154 student nurses who enrolled in year one to four in academic year 2008. Two

measurements, including Student Stress Survey and Adolescent Coping Orientation

for Problem Experiences Inventory, were modified and employed. Descriptive

statistics were applied for data analysis by using SPSS version 15.0. Results revealed

that finding new friends and work with the unfamiliar people were ranked as the main

sources contributing interpersonal stress; intrapersonal sources of stress represented

by outstanding personal achievement and speaking in the public; academic stressors,

the highly reported stressor were associated with using second language and

increasing new responsibilities; and placed in unusual situation was environmental

stressor. Furthermore, coping strategies that students always used to overcome stress

composed of developing self-reliance and being humorous.

2.3 Studies related to effectiveness of coping strategies among student nurses

Bittman BB, Synder C, Bruhn KT., Liebfried F,Stevens SK, Westengard J29

conducted a prospective cross over study, to examine the impact of a 6-session

Recreational Music-making (RMM) protocol on burnout and mood dimensions as

well as Total Mood Disturbance (TMD) in 75 first year associate degree student

nurses from Allegany college of Maryland. Burnout and mood dimensions were

assessed with the Maslac Burnout Inventory and the profile of Mood States

respectively. This study shows that a statistically significant reduction of multiple

burnout and mood dimensions as well as total mood disturbance scores in first year

46
associate degree student nurses. All this study finding shows importance and

effectiveness of stress management program on student nurses.

A quasi-experimental study was conducted by Ram Kumar Guptha105 to

determine the effectiveness of yoga nidhra on stress level among student nurses (30 in

study group and 30 in control group) in selected nursing institutes of Pune, India.

Findings related to effectiveness of yoga Nidra show that the mean post –test stress

level of the experimental group was lower than the mean pre-test stress level. Keeping

in view of the study, the following recommendations are made: A study can be done

using other alternative methods or techniques. It is also recommended to develop and

implement policies to promote mental well-being of students. This will not only assist

in the prevention of mental health problems but also contribute to a healthy working

environment and reduced levels of stress.

A study was conducted by Macini J, Clegg R30 to determine the effectiveness

of a stress management programme and also to determine personal and professional

stressors experienced, and coping strategies adopted by graduate student nurses. The

stress management programme consisted of practice of relaxation response, imagery,

and diaphragmatic breathing and the subjects were 30 female graduate student nurses.

The method adopted was experimental study in which the students were randomly

assigned to an experimental and a control group .The data collection consisted of

blood pressure measurements, weekly Palmar Sweat Prints(PSP) and a weekly Self-

Report(WSR). The result suggested that the control group reported significantly less

strategies for coping with stress than the experimental group.

A study was conducted by van der JJ Klink RW Blonk, AH Schene and van

Dijk FJ95 to determine the effectiveness of occupational stress-reducing interventions

and the populations for which such interventions are most beneficial. Methods of

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Forty-eight experimental studies (n = 3736) were included in the analysis. Four

intervention types were distinguished: cognitive-behavioral interventions, relaxation

techniques, multimodal programs, and organization-focused interventions. Results

showed that a small but significant overall effect was found. A moderate effect was

found for cognitive-behavioral interventions and multimodal interventions, and a

small effect was found for relaxation techniques. The effect size for organization-

focused interventions was nonsignificant. Effects were most pronounced on the

following outcome categories: complaints, psychologic resources and responses, and

perceived quality of work life. It was concluded that Stress management interventions

are effective. Cognitive-behavioral interventions are more effective than the other

intervention types.

The study results of Davazdahemami et al31 titled as “reviewing the

effectiveness of stress management training in cognitive-behavioral technique on

blood sugar and depression of patients with type II diabetes” indicated that stress

management training program could reduce the depression mean score of the patients

in the follow-up step, which this reduction was significant as compared with the

control group.

A study aimed to determine the effect of a cognitive-behavioural stress

management training program by Babak Moeini96 based on PRECEDE model on

stress reduction among nurses. In this quasi-experimental study, which was conducted

among 58 female nurses in Hamadan, northwest Iran were enrolled in the study and

were divided into two equal groups included 29 nurses from one Hospital and 29

nurses from the other as intervention and control groups respectively. The data

collection tool was a self-administered questionnaire including demographic

characteristics and nursing stress scale (NSS). In addition, a questionnaire based on

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PRECEDE model was used in order to assess predisposing, reinforcing and enabling

factors. The intervention was a training program including five sessions during three

weeks in which relaxation and problem-solving training was thought. A pre-test and a

post-test were performed 1.5 months apart. The t-test, Mann Whitney and Willxocon

statistical tests were used for data analysis at 95% significant level using SPSS

13Results shown that the baseline score average of job stress was 113.0 and 109.8 for

intervention and control groups respectively (P=0.250). After intervention, score

average of job stress decreased to 94.0 in experimental group while that of control

group remained relatively unchanged (109.2), (P<0.001). A significant difference was

found in PRECEDE model constructs and stress management behaviours in

intervention group compared to control group after training interventions (P<0.001).

Jain S, Shapiro S, Swanick S and Roesch SC et al.97 conducted a randomized

controlled trial to examine the effects of a 1-month mindfulness meditation versus

somatic relaxation training as compared to a control group in 83 students. Results

showed that hierarchical linear modelling reveals that both meditation and relaxation

groups experienced significant decreases in distress as well as and increases in

positive mood states over a time, compared with the control group (p<.05 in all

cases). There are no significant differences between meditation and relaxation on

distress and relaxation on distress and positive mood states over time.

An experimental study was conducted to assess the effectiveness of 10

sessions, 5 week stress management program among 18 student nurses of Texas

Women’s University, Canada. It included sessions on progressive relaxation, deep

muscle relaxation and visual imagery. 10 student nurses served as the experimental

group and the remaining as the control group. State and trait anxiety measures were

taken prior to midterm and final examinations. The results revealed that, the stress

49
management group effectively reduced trait anxiety (P < 0.05), while the control

group’s levels remained relatively unchanged. The experimental group showed a

reduction in state anxiety from the mid semester to final examinations, while the

control group showed a slight increase in the same. It was concluded that stress

management program is an effective way to reduce stress among student nurses.99

A study was done by Hamdan-Mansour AM, Puskar K, Bandak AG107 to

examine the effectiveness of cognitive behavioral therapy (CBT) with university

students suffering from moderate to severe depressive symptoms in Jordan. Eighty-

four university students were recruited and assigned randomly to control and

intervention groups. Intervention impact was assessed on measures of depressive

symptoms, perceived stress, and coping strategies at three time points; baseline,

postintervention, and 3-months postintervention. The interventional model used was

the Modified Teaching Kids to Cope (MTKC), and the control group received no

treatment. Overall, using CBT showed a significant improvement in the outcome

measures. At postintervention, students had lower scores on perceived stress, lower

depressive symptoms, less use of avoidance coping strategies, and more use of

approach coping strategies. The findings are discussed in terms of treatment

implications and recommendations for use at academic and health care settings.

A study done by Richman CL, Brodish J, Haas F, Billings C104 to examine

the effect of designated interventions in nursing practice problems on levels of

burnout in nurses. A battery of tests measuring burnout, self-esteem, depression,

personal accomplishment, depersonalization, and emotional exhaustion were given to

nurses in experimental and control groups. Pre and post-test data were gathered for

both groups. The treatment included a 2-day conference which was designed as a

respite experience to address problems specific to the nursing profession. Results

50
indicate significantly less burnout, less frequency of depersonalization, and

significantly greater frequency of personal accomplishment in the scores of the

experimental group relative to the control group. This study shows that specific

interventions can be used to benefit the emotional well-being of nurses by providing

them with a respite opportunity and the skills to manage key stressors in their

professional environment.104

The investigating and assessing the effects of relaxation training on the levels

of state anxiety concerning first year female student nurses at their initial experience

in clinical setting. This research is a quasi experimental study that was carried out in

nursing and midwifery faculty of Tehran university of medical sciences .The sample

of research consists 60 first term female student nurses were selected through

convenience and random sampling. 30 of them were the experimental group and 30 of

them were in control group. The Instruments of data-collection has been a

questionnaire which consists of 3 parts. The first part includes 10 questions about

demographic characteristics the second part includes 20 question about anxiety (test

‘Spielberg‘ ). The 3rd part includes physiological indicators of anxiety (BP, PR, body

temperature). The statistical tests included t-test and fisher test, Data were analyzed

by SPSS software. The statistical test illustrates a significance difference between two

groups of test and control after the training (p=0.01)106

2.4 Conceptual framework

Conceptual framework for the present study is based on Imogene King’s Goal

attainment Model (1981). King’s goal attainment theory is based on the concepts of

personal, interpersonal and social system including perception, judgment, action,

reaction, transaction and feedback.

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 PERCEPTION: INTERACTION & COMMUNICATION
Student nurses commonly experience stress, hence RESEARCHER -ASSESS THE STUDENT
stress reduction measures need to be taken STRESS AND COPING AND TEACHING TO
EXPERIMENTAL GROUP ON SELECTED
COPING STRATEGIES
STUDENTS - RESPOND TO STUDENT STRESS
JUDGEMENT : AND COPING SCALE AND PRACTICES
Awareness is needed to reduce the level of stress ADAPTIVE COPING BEHAVIOURS
and to improve the adaptive coping abilities
NURSE
RESEARCHER

ACTION:
Plan to assess the level of stress and coping & MUTUAL GOAL TRANSACTION
to teach selected coping strategies SETTING POST TEST
DIFFERENCE IN
TO REDUCE STRESS LEVEL OF STRESS
LEVEL BY AND COPING AFTER
ACTION: PRACTING TEACHING COPING
ADAPTIVE COPING STRATEGIES
Giving consent to participate and practice
MEASURES
adaptive coping
STUDENT
NURSES IN
INTERVENT
IONAL AND JUDGEMENT :
CONTROL Stress can be reduced by appropriate NEGATIVE OUTCOME
POSITIVE OUTCOME
management
REDUCTION OF STRESS AND STRESS AND MALADATTIVE
INCREASE OF COPING COPING REMAINS SAME OR
BEHAVIOURS EXAGGERATE
PERCEPTION :
Stress is a physical and psychological factor it
deteriorates health. So it needs to be managed Included in the study

Not included in the study

FEED BACK

FIGURE 2.2. CONCEPTUAL FRAME WORK BASED ON IMOGENE KINGS MODEL (1981)
Perception:

A person imports energy from the environment and transforms processes and

stores it. This includes perception, judgment and action on the part of the nurse

investigator as well as the patients.

The nurse researcher perceives the stress as a commonly problem faced by

student nurses.

Student nurses perceive that stress is a psychological factor which deteriorates

health condition and so it has to be managed appropriately.

Here the nurse researcher analyses the area of action to be carried out for the

student nurses and the student nurses express the need for the action.

Nurse researcher judges that practicing adaptive coping strategies may reduce

the stress of the student nurses. Judge that stress can be controlled by effective

management.

Action:

Here, the nurse researcher takes the actual action for the perceived need and

the student nurses takes action by keeping themselves ready to receive the action.

The nurse researcher develops stress and coping scale to assess the levels of

stress before and after intervention.

Mutual goal setting:

Here, the nurse researcher and the student nurses identify a common goal that

is to obtain relief from stress and practise adaptive coping

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Interaction and Communication:

Interaction: Refers to the verbal and nonverbal behaviour between an

individual and the environment or between two or more individuals, it involves goal-

directed perception and communication.

Communication: According to the Imogene King, communication refers to

transmission of information from one person to another either directly (face to face)

or indirectly (telephone call or written message). Communication is the information

component of transaction.

In this study, the nurse researcher conducts pre-test to both experimental and

control group and then gives stress management to experimental group followed by

post-test I&II to both the groups.

Student nurses respond to stress and coping scale and practices adaptive

coping Hence they interact and communicate.

Transaction:

It is a process of interaction between a person and environment for the purpose

of goal attainment. It is the mutually identified goals of two or more individuals

In this study, difference in the post test level of stress and coping strategies

was assessed after implementing coping strategies to the student nurses.

Feed Back:

The outcome may be either positive or negative. If the outcome is negative

then the nurse researcher rearranges the situations where the process recycles.

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Positive outcome:

Reduction of stress and increased coping level of student nurses

Negative outcome:

Stress level and coping remains same or exaggerated in the student nurses

54