MEDICAL COLLEGES OF NORTHERN PHILIPPINES

Alimannao Hills, Peablanca, Cagayan

STRESSORS AND STRESS MANAGEMENT IN THE CLINICAL SETTING IDENTIFIED BY
LEVEL III BACHELOR OF SCIENCE IN NURSING STUDENTS


A Research Presented To The
Faculty and Staff Of The
Medical Colleges of Northern Philippines


In Partial Fulfilment of the Requirements in Nursing Research


By:
Sheena Mae B. Acoba
Roberto V. Alonzo
Riva Tiara Clarisse T. Aranas
Philip D. Simangan
William P. Apostol
Maryrose R. Vinarao
Margie G. Cunanan
Jolly Dave M. Ancheta
Denice Fayne A. Tahiyam
Daphne Kae B. Madriaga
Catherine U. Mendoza
Caroline D. Uy
Carmen Agnes G. Miguel





CHAPTER I:
INTRODUCTION
All human beings are part of a greater whole. When one person is
affected, all of humanity is affected. These effects can be either
positive or negative. Nursing is a profession that understands holism
and looks at individuals holistically. As caregivers, it is essential
for nurses to care for themselves in order to give fully to those they
serve. Unmanaged stress can adversely affect the caring process.
Students of nursing appear to experience an increased level of stress.
Management of stress is a tool that is invaluable to the profession of
nursing. According to Pryjmachuk (as cited in American Holistic Nurses
Association [AHNA], one third of nursing students experience stress
severe enough to induce mental health problems such as anxiety and
depression. Although this has been the trend, it does not need to
continue.
In a more specific perspective of stress and stressors, Hamaideh
noted that university students are prone to stressors due tithe
transitional nature of university life. Based on a national study of
more than 300,000 freshmen at more than 500 colleges and universities
in the America by Santrock, todays college students experience more
stress and are more depressed than in the past because of the growing
expectations from them such as the pressure to succeed, finding
employment after graduation and achieving a sense of financial
stability. Universities offer numerous programs to study and one of
the most stressful programs offered is the nursing course as stated by
Comeau. In the nursing curriculum according to Snell, students invest
longer hours and have greater emotional demands than most other
students. Other than the usual stress, such as paper works, tests,
exams, final grades, class environment, professors and competition,
nursing students experience clinical-related stress such as constantly
having to deal with patients pain, anxiety and death, as well as
giving emotional support to patients families and even the disruption
of the circadian rhythms in effect of shift work (Gross, 2007). High
levels of stress are believed to affect students health as well as
their academic performance that is why issues on stress should be
managed. Generally, people handle stress through coping as constantly
changing cognitive and behavioural efforts to manage external and/or
internal demands that are appraised as taxing or exceeding the
resources of the person. Comeau suggested that to achieve an effective
nursing program, stress management workshops should be provided during
the academic year, adding that implementing techniques to cope with
stress in a nursing program has an effect on retention and
performance. Key benefits of learning stress coping techniques as
nursing students include the promotion of these tools among clients
during hospital exposure as well as in the future practice of the
profession thus contributing to the care of their clients.
Because nursing students experience much stress, an ever growing
body of literature regarding the stresses of nursing supports the need
to include stress management education in curricula, Nursing curricula
is filled with the necessary elements of preparing competent nurses.
This presents the challenge of including yet another component into
nursing curriculum. Although this is a challenge, over-coming this
challenge is a must. The need for stress management techniques for
nursing students is necessary to prevent burnout and also to prevent
nurses from leaving the profession. The stress that nursing students
carry can only be of harm to the profession in the long-term.
Being part of the population of modern nursing students and
recognizing the prevalence of stressors in the nursing program, the
researchers, through this study, aim to identify the stressors that
significantly affect the third year nursing students of Medical
colleges of Northern Philippines in the clinical setting. Furthermore,
the study seeks to determine if these stressors have a positive or
negative effect in the academic pursuit of the respondents in the
nursing course. With the identification of the stressors that are
taxing to the nursing students, administrators may be given insight to
the plight of the students. Appropriate interventions or modifications
may then be done to address the issue thus promoting a better learning
environment, an essential factor for improvement in the students
learning and performance.
STATEMENT OF THE PROBLEM

Nursing students experience different levels of stress. According
to Beddoe & Murphy, nursing students report very high stress levels
that are at times higher than those of students in other health
professions. Nursing students have attributed stress to academic and
interpersonal circumstances. This stress may affect performance and
ability to care for patients and self.

This study sought to identify the stressors and how they manage
such perceived by the Level III Bachelor of Science in Nursing (BSN)
Students in the clinical setting; specifically it pursued the
following objectives:

1. To determine the profile of the respondents in terms of age and
gender;
2. To determine and rank the identified stressors in the clinical
setting;
3. To identify the stress management utilized by the respondents to
stressors;
4. To determine whether the stressors are perceived by the respondents
as challenges or threats; and
4. To determine if there is a significant difference on the identified
stressors and stress management by the respondents when grouped
according to their profile.

HYPOTHESIS
There is no significant difference on the identified stressors
and stress management by the respondents when grouped according to
their profile.
SIGNIFICANCE OF THE STUDY
The findings of the investigation would be beneficial to the
following:

The researchers, conducting this kind of study will bring a learning
experience for them. It will hand them the pulse of the Level III
nursing students when it comes to managing their stress during their
clinical exposures, which was hardly known without survey.
The nursing students, who may acquire greater insights of the
stressors and challenges they may encounter during exposure on
clinical areas. This knowledge will give them better and wider
perspective about their profession and aid them in enhancing
their coping abilities and self-confidence.
The Clinical Instructors, the findings 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. Furthermore, 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.
With the result of the study, the The School Administrators and
Faculty will become more aware of the sources of stress of the
students in the clinical setting and thereby have a significant basis
to come up with appropriate interventions to properly manage the
stress experienced by the students thus promoting better performance.
It also gives them the chance to improve the quality of nursing
education for the benefit of the students and the institution as well.
The parents: this study will give insights to the parents about the
stressors encountered by their child and to prepare them or strengthen
them by providing emotional and moral support or in any ways that will
help them to cope.

The study will provide the future researchers baseline data as they
conduct further investigations on the stressors that nursing students
encounter.
SCOPE AND LIMITATION OF THE STUDY

This study is entitled Stressors and Stress Management in the
Clinical Setting Identified by Level III Bachelor of Science in
Nursing Students. The study focuses on stressors as perceived by
nursing students in the clinical setting. Stressors from other aspects
such as from the academic/classroom setting or from interpersonal
relationships (family or peer-related) were not considered in the
study. The respondents are the third year or Level III nursing
students officially enrolled in the second semester of school year
2012-2013 at the Medical Colleges of Northern Philippines.



DEFINITION OF TERMS

To convey clearly the meaning of the words used in the study, the
researchers defined the terms used operationally, as follows:

Clinical Setting- pertains to the hospital setting wherein
students apply and practice what they have learned in terms of
rendering nursing services and focusing on the holistic being of
the patient.

Clinical Instructors- refer to the person who impart knowledge
and skills to students

Related Learning Experience- refers to exposure of the nursing
students in different hospital wards or areas as well as in
different types of hospital services in order to broaden learning
while undergoing Related Learning Experience program by the
institution

Coping Mechanism- refers to the adaptation to stress events during and

Stress Management- refers to the act or art of managing the whole
system of care and treatment of the respondents during and after stress

Nursing Students- refer to the students enrolled in nursing
course

Medical Colleges of Northern Philippines is a college that
provides instructional training in some health allied courses
like Bachelor of Science in Nursing in Peablanca, Cagayan.

Stressors- pertains to factors affecting the performances of the
nursing students
CHAPTER II
REVIEW OF RELATED LITERATURE
Significant information on previous research related to the
stress in clinical setting is included in the review of the
literature. Within the context of the clinical learning environment,
what is known about stress, stressors and stress management in
relation to clinical setting from research studies is discussed and
analyzed. Related research on the variables of age and gender is
presented. As a result of this study on how nursing students manage
their stress in the clinical setting, unique insights into the
dynamics of this relationship may be gained.

FOREIGN LITERATURE AND STUDIES

Stress is a disruptive condition that occurs in response
to adverse influences from the internal or external
environments. (p. 78). It is a state produced by a change in
the environment that is perceived as challenging, threatening
or damaging to a persons dynamic balance or equilibrium. The
change or stimulus that evokes this state is a stressor. The
nature of stressor is variable; an event or change that is
stressful for one person may not be stressful for another, and
an event that produces stress at one time and place may not do
so at another time or place. A person appraises and copes with
changing situations. The desired goal is adaptation or
adjustment to the change so that the person is again in
equilibrium and has the energy and ability to meet new demands.
This is the process of coping with the stress, a compensatory
process that has physiologic and psychological components.
(p.79)
Anxiety, frustration, anger and feelings of inadequacy,
helplessness or powerlessness are emotions often associated
with stress (p.91). After recognizing a stressor, a person
consciously or unconsciously reacts to manage a situation. The
physiologic response to a stressor, whether physical or
psychological, is a protective and adaptive mechanism to
maintain homeostatic balance of the body. When stress response
occurs, it activates a series of neurologic and hormonal
processes within the brain and the body systems. The duration
and intensity of the stress can cause both short-term and long-
term effects. A stressor can disrupt homeostasis to the point
where adaptation to the stressor fails and a disease process
results (p.81). (Smeltzer,S.C.,et.al.2010)
Kozier, B., et. al.(2008) defined Stress as a condition in
which the person experiences changes in the normal balanced
state. A Stressor is any event or stimulus that causes an
individual to experience stress. When a person faces stressors,
responses are referred to as coping strategies, coping
responses or coping mechanisms. There are many sources of
stressors: internal Stressors (originate within a person such
as infection or feelings of depression), External Stressors
(from outside the individual such as death in the family or
pressure from peers), Developmental Stressors (occur at a
predictable time throughout an individuals life like
retirement or reduced income in older adults) and Situational
Stressors (unpredictable and may occur at any time during life
like marriage or illness). Stress can have physical, emotional,
intellectual, social and spiritual consequences. Usually the
effects are mixed, because stress affects the whole person.
Physically, stress can threaten a persons physiologic
homeostasis. Emotionally, it can produce negative or
nonconstructive feelings about the self. Intellectually, stress
can influence a persons perceptual and problem-solving
abilities. Socially, stress can alter a persons relationships
with others. Spiritually, stress can challenge ones belief and
values.
Rebecca J. Frey (2009) said that the stress in humans
result from interactions between persons and their environment
that are perceives ad straining or exceeding their adaptive
capacities and threatening their well-being. The element of
perception indicates that human Stress Response reflects
differences in personality, as well as differences in physical
strength or general health. Risk factors for stress-related
illnesses are a mix of personal, interpersonal and social
variables. These factors include lack or loss of control over
ones physical environment and lack or loss of social support
networks. People who are dependent on others (e.g. children or
the elderly) or who are socially disadvantaged (because of
race, gender, and educational level or similar factors) are at
greater risk of developing stress-related illnesses. Other risk
factors include feeling of helplessness, hopelessness, extreme
fear, anger, and cynicism or distrust of others.
Walter Canon (2009) said that the human body reacts either
positively or negatively to as stress facto producing two kinds of
possible reactions. When the human body tries to flee from stressful
situation, negative reaction is exhibited. Positive reaction comes
about when the body makes the principle of homeostasis apply to
overcome stressful situation which is known as Adaptation or Coping.
He advocated that while the concepts of stress are absolute fact, its
presence and intensely receptions are relative in accordance with the
physical and psychological make-up of the individual. All people,
therefore, experience stress but the way stress is present and is
handles by each individual is unique for each other. A little
difficulty is hardly felt by another.
Stress can be defined as the brains response to any demand. Many
things can trigger this response, including change. Changes can be
positive or negative, as well as real or perceived. They may be
recurring, short-term, or long-term and may include things like
commuting to and from school or work every day, travelling for a
yearly vacation, or moving to another home. Changes can be mild and
relatively harmless, such as winning a race, watching a scary movie,
or riding a rollercoaster. Not all stress is bad. All animals have a
stress response, which can be life-saving in some situations. When you
face a dangerous situation, the pulse quickens, a person breathes
faster, muscles tense, the brain uses more oxygen and increases
activityall functions aimed at survival. In the short term, it can
even boost the immune system. However, with chronic stress, those same
nerve chemicals that are life-saving in short bursts can suppress
functions that arent needed for immediate survival. The immunity is
lowered and the digestive, excretory, and reproductive systems stop
working normally. Once the threat has passed, other body systems act
to restore normal functioning. Problems occur if the stress response
goes on too long, such as when the source of stress is constant, or if
the response continues after the danger has subsided.
(http://www.nimh.nih.gov, 2012)

Stressors in Clinical Settings

A multitude of factors has been linked to students experiences
of stress and anxiety in a clinical setting. Themes that emerged from
a review of the literature include: a) interpersonal relationships
with nursing staff and the socialization process; b) relationships
with medical staff, c) relationships with clinical teachers; d)
feelings of incompetence and inadequacy; e) a lack of knowledge needed
to perform clinical procedures; and e) the fear of making mistakes and
possibly harming patients. Besides the stressors related directly to
the clinical setting, students are often dealing with life events
outside nursing which may lead to psychological stress (Watson,
Gardiner, Hogston, Gibson, Stimpson, Wrate and Deary, 2008). In
addition, as theories discussed above suggest, personal traits also
influence how the person perceives stressful situations and how they
cope with it.



Relationships with nursing staff and socialization process

Development of professional relations with staff members is part
of the socialization process. In the literature review, students
identified interpersonal encounters as a source of stress, especially
when students did not feel welcomed or supported by nursing staff.
This in turn often led to poor learning outcomes.
Nursing students evaluated their clinical experience as negative
when nursing staff was not interested in mentoring (Papp, Markkanen
and Von Bonsdorffif ; 2009). Other research studies found that nursing
students often had difficulty coping with unhelpful staff and being
ignored by them (Melincavage, 2008). Melincavage discovered that
students felt anxious when staff nurses were inconsiderate of
students inexperience, which in turn influenced students feeling of
incompetence. In LaFaucis (2009) study, nursing students reported
that being treated as a nuisance by cranky and non-responsive staff
nurses hindered their learning experiences. In a qualitative study by
Shipton (2010), nursing students described some of the actions and
attitudes of nursing staff as stressful, and nurses were described as
nasty, not wanting to be bothered or demeaning (p. 246). The
nursing students in one study (Levett-Jones, Lathlea, Higgins &
McMillan; 2009) described nursing staff as unfriendly, hostile,
indifferent, unreceptive, and unapproachable. Their feelings of
inclusion/exclusion affected directly their sense of belongingness and
subsequently increased their anxiety, capacity and motivation to
learn.
In a qualitative research study by Gibbons, Dempster and Moutray
(2007), many nursing students had a feeling of being criticized
rather than supported by nurses on the unit (p. 286). They felt that
nurses focused more on students weaknesses (or what they did not do)
rather than on their strengths. In some studies, students felt
stressed when nurses had unrealistic expectations of their clinical
abilities ( Melincavage, 2008).
As students often change their clinical settings, many find that
the unfamiliarity of clinical setting is stressful (Kim, 2008). It
stressed the importance of fitting in and learning the rules of the
wards. They identified the transient nature of their experiences as a
source of stress.
There are numerous studies which report positive outcomes when
students develop good relationships with nursing staff. Chesser-Smyth
(2007) reported factors identified by students which contributed to
their increased confidence level, increased self esteem, and decreased
anxiety which subsequently facilitated their learning. These were:
acquisition of knowledge; receptive, respectful and supportive staff;
and feeling as part of the team which all gave indication that
successful socialization process facilitated learning in clinical. In
the study by Levett-Jones et al. (2009) nursing students reported that
when they felt welcomed by nursing staff it motivated them to learn.
In the study by Papp et al. (2010) nursing students felt appreciated
when students felt to be a part of the nursing care team.
In addition to contending with exams, grades, long hours of
studying, work, family and other personal commitments you are also
faced with the challenges of clinical practice. Clinical practice has
been identified as one of the most anxiety producing components in
nursing programs. Lack of experience, fear of making mistakes,
difficult patients, discomfort at 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 beginning student nurse. (Sharif &
Masoumi, 2007).

Relationships with Medical Staff

The literature review revealed many research studies reporting
that nursing students find communication with medical staff stressful.
Many participants recalled that the interactions with physicians were
often unpleasant and anxiety provoking.
Several studies (Kim, 2008) identified talking with physicians as
anxiety-producing. In a study by Clarke and Ruffin (1992) when
students were asked to rate the interpersonal interactions on a stress
scale, the interaction with medical staff was rated highest.

Relationships and Interactions with Teachers

Clark (2008) conducted a qualitative research study on students
perceptions of faculty incivility. Students in the study gave examples
of teachers treating students unfairly; teachers behaving in demeaning
and belittling ways towards students; and students being pressured by
teachers to conform to unreasonable demands. These teacher behaviours
made students feel powerless, helpless, traumatized, angry, and upset.
Similarly in LaFaucis (2009) study, nursing students felt that being
exposed to clinical instructors who instilled fear and intimidation in
them hindered their learning.
In the research study by Shipton (2010), nursing students
appraised as stressful the following actions of the clinical faculty:
clinical evaluations, waiting on clinical instructor, being observed
by a clinical instructor. In the study by Tiwari, Lam, Yuen, Chan,
Fung and Chan (2007), nursing students described their clinical
assessment as very stressful. Clinical teachers in this study were
concerned about the student anxiety they witnessed during their
assessments. A majority of students and clinical teachers agreed that
the assessments influenced student learning and students spent all of
their energy on passing assessments at the expense of learning other
things.

Feelings of Inadequacy and Lack of Knowledge

The lack of clinical knowledge or skills to accomplish a task or
to perform clinical procedures has been linked to stress and anxiety
in many studies. Chesser-Smythe (2008) found students felt
particularly vulnerable at the beginning of each rotation when they
described themselves as knowing little and feeling useless (p. 323).
Kim (2008) found that 77% of nursing students in their last
semester of the program reported uncertainty about their clinical
skills and doubts about personal adequacy as beginning staff nurses
(p. 150). These feelings of inadequacy and uncertainty about their own
clinical skills were associated with high anxiety. Nursing students in
Magnussens and Amundsons (2007) study reported feelings of
inadequacy and unpreparedness for clinical experience. Their teachers,
they reported, often put them on the spot and expected them to have
knowledge about all aspects of care (p. 265). Many students had the
sense of knowing so little, when the professional demands would be so
great even at the end of the program (p. 264.

Patients

The literature review shows that nursing students often get a
sense of satisfaction from interactions with patients. Although
interactions with patients are not often reported in studies as
anxiety provoking, nursing students identify a few situations which
are quite stressful. The identified situations are mainly dealing with
terminally ill and dying patients and handling emergencies and
situations in which there is a possibility change in the patients
condition. In Cook s study, situations perceived by nursing students
as challenging were dealing with very ill patients and having to deal
with emergencies such as cardiac arrests. Similar findings were
reported where nursing students identified fear of making a mistake or
harming a patient as a source of stress in clinical (Kim 2008).

Effects of Stress on Clinical Learning

Given the review of the literature on sources of stress and
anxiety experienced by nursing students during their clinical
rotations, and the theoretical review of the effects of high emotional
states on learning, one can expect that the learning process would be
negatively influenced under excessive amounts of stress and anxiety in
nursing students. A few studies below provide examples of the effects
of stress and anxiety on learning in clinical rotations.
Many studies identify difficult relations with staff as
influencing stress on student learning or performance. Anxiety related
to work overload, both in academics and clinical led to great stress,
fatigue and lack of sleep (Elgicil & Yildirim Sari, 2007). Hamill
(2010) studied stressors and coping methods used by 2nd year nursing
students. She described the use of mainly problem-focused coping
methods and 29 attributed it to students being more assertive and more
confident at the end of the 2nd year of the program. Besides problem-
focused coping, students also reported using emotion-focused coping
methods such as: binge eating; sitting in a bath and having a good
cry; being irritable; discussing stressors with peers; socializing;
resorting to alcohol. One of the common coping mechanisms which all of
the students in this study used was physical exercise.
Wang Letzkus (2007) reported qualitative findings which included
the following:
(a) Students interpreted flexibility on the part of their clinical
instructors to be a caring act;
(b) Junior nursing students perceived a broader range of the types of
caring behaviors than did seniors; and
(c) Nursing students found that working with uncaring RN staff members
to be stressful.
Clawson Roe (2009) reported data on research with baccalaureate
junior and senior nursing students and clinical faculty as it related
to stress and caring in the clinical setting. According to Clawson
Roe, baccalaureate nursing students perceived stressors as a challenge
in the presence of a caring instructor. Conversely, when clinical
instructors demonstrated caring behaviors less frequently, nursing
students perceived stressors as a threat or as harm (Clawson Roe,
2009). In the studies conducted by Wade (2007), Wang Letzkus (2005),
and Clawson Roe (2009), age and gender were not included as variables.
Sources of student stressors identified by Clawson Roe were as follow:
(a) coursework, (b) time, (c) being unsure, (d) fear, (e) educator,
and (f) clinical environment. Clawson Roe (2009) reported the
perception of stressors as a threat or challenge was highest in
beginning level students. According to Clawson Roe, stress perceived
as a threat related to a fear of failure. Conversely, stressors
perceived as a challenge related to managing the coursework and time
management (Clawson Roe,2009). According to Clawson Roe, beginning
nursing students perceived their clinical educator as less of a
stressor than their fear of failing, harming a patient or meeting
their own expectations (p. 227).
Moscaritolo (2009) reviewed qualitative studies on undergraduate
diploma, associate and baccalaureate programs and identified factors
associated with stress and anxiety in the clinical learning
environment. According to Moscaritolo, the following were the most
common factors contributing to stress and anxiety for nursing
students: (a)their first clinical experience, (b) fear of making
mistakes, (c) performing clinical skills,(d) faculty evaluation, (e)
lack of support by nursing personnel, and (f) connecting theory with
practice. Moscaritolo reported high levels of anxiety in nursing
students led to interference with learning. On the other hand, some
anxiety was inevitable and facilitated motivation and improved
performance (Moscaritolo, 2009). Kubes (2010) study found that
caring, nurturing teaching behaviors had a significant influence on
learning (p.85).Kube reported that nursing students stress and
anxiety in a clinical setting was reduced by the caring actions of
their clinical instructors.




Gender and Stress
While both men and women recognize the impact stress can have on
physical health, men appear to be somewhat more reluctant to believe
that its having an impact on their own health. Likewise, men put less
emphasis on the need to manage their stress than women do. Yet men are
more likely than women to report being diagnosed with the types of
chronic physical illnesses that are often linked to high stress levels
and unhealthy lifestyles and behaviors, signalling that there may be
some important gender differences when it comes to stress management.
(American Psychological Association, 2010).
There was a paucity of research on whether age plays a role in
student perception (Langford, 2007). Age as a variable was included in
light of the increasing entry of older age students into second degree
nursing programs. Gender was included based on the growing number of
males entering nursing programs and gender differences cited in the
literature (Smith, 2009). Gender may influence nursing students
management with stress.
Nursing evolved as a female dominated field of practice with a
small number of nurses reported as male. Historically, the majority of
men entered nursing as a second career (Smith, 2009). Some nursing
schools targeted the male population starting at the grade school
level to change the image of nursing as a female profession and to
address the nursing shortage of males in nursing (Burton, 2011). Some
studies addressed the need for recruitment and retention of male
nursing students and exploration of factors which influenced male
attrition (Brady & Sherrod, 2008). According to Anthony (2008) the
attrition rate for male nursing students in a large mid-Western
nursing program, ranged between four percent and seven percent. To
date, national statistics on male attrition were not published.
Several studies also addressed the perceptions of male nursing
students. Identification of influencing life stressors to success
within a nursing program was one if the identified perception. (Bell-
Scriber, 2008).
According to Ann Marriner Tomey et. al,(2009),stress is a part of
every students daily life. Leaving home, daily managing finances,
living with roommates and juggling work, classes and relationships all
contribute to the normal stress of being a student. In addition, it is
not uncommon for students to feel stressed and anxious about wasting
time, meeting high standards or being lonely. Stress can come from
exciting or positive events. Falling in love, preparing to study
abroad or buying a car can be a stressful as fewer happy events. One
of the most important things you can do is to recognize when stress
levels are building. The amount of stress that you can tolerate before
you become distressed varies with your life situation and your age. A
critical first step in coping with stress is taking stock of stressors
in life. Whenever stress is present, your body reacts. It acts like an
alarm system that prepares your body to defend yourself. A little
stress is good. It helps you to think faster and harder and makes you
put that extra bit of effort to meet the challenges of life.
Carson et al. believed that nurses with high self-esteem will
have lower levels of stress and burnout and better coping skills than
those with low self-esteem (cited in Gross and Kinnison, 2007).Since
nursing is a stressful program to study. Comeau (2009) suggested
coping techniques such as time management, better sleeping habits,
general health improvement, and support system with family and
friends, and stress management within the nursing curriculum. Academic
institutions can institute stress management techniques like massage
therapy, meditation, yoga, dance and art therapy activities within
their orientation program.

Local Literature and Studies

According to Calderon, people who experience a high level of
stress for a long time and who cope poorly with this stress may become
irritable, socially withdrawn and emotionally unstable. They may also
have difficulty concentrating and solving problems. Some people under
intense and prolonged stress may start to suffer from extreme anxiety,
depression or other severe emotional problems.
Odrigo G. Ancheta stated Stress gives us energy to cope with the
demanding activity of life. It is true that stress is a normal
constant part of life because it involves changes, challenges and
emotions. Try to imagine life without stress; you would not have any
challenges to affect your emotions and anything new and exciting. It
gives us energy because it involves physical and emotional activities.
Stress might be considered as a problem because we often bear about
stress in negative light that people may also associate bad
experiences with stress.
According to Cuevas,P.F., et. Al., (2007), stress is not
only inevitable and essential but also normal part of life.
However, normal does not mean necessarily mean healthy. It
triggers hormones that change the way body works and feels.
These changes are natures way of helping the person cope with
perceived threats. Some cope with stress by behaving in a way
that is unhealthy like drinking, smoking or overeating. This is
the reason why it is important to manage stress appropriately
in order to avoid the unhealthy effects of inappropriate coping
mechanisms.
Fortunately, stress management is largely a learnable
skill. It is not possible to live without stress but one can
learn ways to handle the stress of daily life efficiently. It
is also important to remain attentive to negative stress
symptoms and to learn to identify the situations that evoke
them. When these symptoms persist, the risk for serious health
problems is greater because stress can exhaust the immune
system. Recent research demonstrates that 90% of illness is
stress-related. Meditation, self awareness, time management,
siesta (taking a nap or short rest), stretching, sensation
technique (touch therapy), sports, socials, music, talking to
someone, stress debriefing and smile were identified as stress
management techniques.
Bersabe (2008) recommended stress management to resist and cope
with stress as follows: satisfying relationships/ social network,
humor, hobbies, strong sense of self and optimism, consulting a
specialist (psychiatrist, support group), and physical health and good
health habits.
Another local study in relation to stress was done by Bayogos, S.
et.al. (2007) which was on the level of stress experienced by third
year student nurses on their first clinical exposure, it was found
that the respondents during their first clinical exposure seldom
experienced personal-related, hospital facilities- related, peer-
related and family-related stresses.


THEORETICAL/CONCEPTUAL FRAMEWORK
This study is anchored on Betty Neumans Systems Model, a model
based on the concept of stress and reaction to stress. This nursing
theory views nursing as being responsible for developing interventions
to prevent or reduce stressors on the client or to make them more
bearable for the client. Neuman believes that every person develops
set of responses to stress that constitute the normal line of defense.
This line of defense helps to maintain health and wellness. However,
when physiological, psychological, socio-cultural, developmental, or
spiritual influences are unable to buffer stress, the normal line of
defense is broken, and disease can result. (Perry, 2009).The model
emphasizes the importance of accuracy in assessment and interventions
that promote optimal wellness using primary, secondary, and tertiary
prevention strategies. According to Neumanstheory, the goal of
primary prevention is to promote client wellness by stress prevention
and risk factors reduction. Secondary prevention occurs after symptoms
appear. The nurse determines the meaning of the illness and stress to
the client and the clients needs and resources for meeting them.
Tertiary prevention begins when the client system becomes more stable
and recovers. At the tertiary level of prevention the nurse supports
rehabilitation processes involved in healing, moving the client back
to wellness and the primary level of disease prevention(Perry, 2009).
Basing on Neumans goal of primary prevention, the study on the
stressors in the clinical setting as identified by third year nursing
students will be conducted. It is perceived to promote wellness among
the students when the stressors that significantly affect them are
identified thus foundation for stress prevention and management is
established.
The research paradigm is shown in Figure 1. This included the
input, the process and the output. The input contains the profile of
the Level III BSN students, the different stressors they encountered
and the different management they perform to alleviate them. In the
process, questionnaires will be distributed and observations were
conducted to gather pertinent information. It also includes the
analysis and evaluation of the gathered data and information from
respondents using statistical treatment such as getting the mode,
average mean, weighted mean, percentage, and t-test. The output
consists of the findings about the stressors, perception of the
stressors and stress management and in relation to age and gender.
















Respondents
Profile The
Different
Stressors
Encountered By
the respondents
in the Clinical
Setting

Perception of
Stressors
(challenging or
Threatening)

Different
Stress
Management
Performed By
the respondents

Significant
difference on
the identified
stress
management by
the respondents
when grouped
according to
their profile


DISTRIBUTION OF
QUESTIONNAIRES

OBSERVATION


ANALYSIS AND
EVALUATION
USING
STATISTICAL
TREATMENT
- PERCENTAGE
- AVERAGE
MEAN
- WEIGHTED
MEAN
- T-TEST
- ANOVA


Determination of
the following:

stressors in
the clinical
setting

stress
management
utilized

whether the
stressors as
challenges or
threats

if there is a
significant
difference on
the identified
stress
management by
the
respondents
when grouped
according to
their profile.

INPUT PROCESS OUTPUT


Figure 1. Paradigm of the study. Stressors and stress management in
the clinical setting identified by Level III Bachelor of Science in
Nursing Students.




Chapter III
RESEARCH METHODOLOGY
This chapter presents the method of research used, instruments,
the sources of data and the procedures used in gathering of data
employed by the researchers.

RESEARCH DESIGN

A descriptive quantitative research design is used to explore
stressors, perception of the stressors whether challenging or
threatening, and stress management in the clinical setting identified
by the respondents. Descriptive research examines a situation as it
is and does not involve changing or modifying the situation under
investigation nor is it intended to determine cause and affect
relationships .Leedy and Omrod state that surveys are used to
describe the incidence, frequency, and distribution of certain
characteristics in a population (p. 108). According to Leedy and
Ormrod, the design of the survey involves the provision of questions
to willing participants, summarizes their responses with percentages,
frequency counts, or more sophisticated statistical indexes; and then
draws inferences about a particular population from the responses of
the sample (p. 184).
This study identifies, describes and explores nursing students
stressors and stress management on their clinical exposure or Related
learning Experience which included gender and age as variables. Two
instruments and a demographic data form will be administered by pen
and paper to a sample of willing participants in Alimannao Hills,
Peablanca, Cagayan. Results are to be analyzed statistically and
report in narrative or table format. Researchers may also deal with
comparison and contrast or the discovery of existing relationships
between events and groups.
This quantitative method describes and explores nursing students
stressors encountered how they manage stress in their clinical
exposure and their relationship with age and gender in an objective
empirical-based way. However, the survey instruments originate from a
naturalistic paradigm. A naturalistic paradigm, according to Polit and
Beck, produced findings based on the individuals involved in the
phenomenon of interest. The phenomenon of interest is the nursing
students specified stressors and their behaviors on managing those
identified in the clinical setting.
The two survey instruments used in this study are based on
qualitative and quantitative studies. By using a survey instrument
developed from a naturalistic paradigm, the construct validity of the
instrument captures data reflective of the phenomenon of interest.
This may strengthen the content and construct validity of a
quantitative instrument. According to Creswell, quantitative research
problems are designed to describe trends by looking at the tendencies
and variations in tendencies in participant responses. Nursing
students answers may be influenced by the variables of age and
gender. In the research design of this study, the views of male and
female nursing students from different age groups are included. The
researchers use questionnaire as the primary tool in gathering data.
This is made from created materials and statements that could generate
the desired result when the respondents follow correctly the direction
given. The researchers formulate questions based on their readings
from books, manuals, journal and experiences as nursing students. The
questionnaires are first drafted for the approval of their adviser and
other members of the faculty knowledgeable to the topic.

SAMPLING DESIGN
The researchers use the Level III BSN nursing students of Medical
Colleges of Northern Philippines as their respondents who are
randomly selected from four sections. They are chosen using
single random sampling, each number of the population has an
equal chance to be included in the sample gathered. Their reactions,
opinions and answers are to be analyzed and reported.

SECTION POPULATION NUMBER OF RESPONDENTS
Gold 39 36
Silver 33 30
Bronze 41 37
Jade 37 34
Total 150 109




DATA GATHERING PROCEDURE

The researchers surfed through the internet to look for related
and relevant topics, to look for previous researches conducted by
experts or other person, be it local or worldwide. The researchers try
to look in some related literatures and studies. This is for the
researchers to reprove, look for new reasons and to understand stress
by nursing students in the clinical setting. The researchers conducted
an actual survey in a local college at Peablanca, Cagayan. The target
population were the junior BSN students. The respondents must answer
given questionnaires honestly. After gathering data, the researchers
tallied and came up with results.
The researchers floated questionnaires for them to gain the
respondents perception and identification of the stressors and stress
management they utilize.


STATISTICAL TREATMENT OF DATA

After the distribution, collection and completion of
questionnaires, the researchers tally gathered data and
use central tendency measures (average mean, weighted mean),
percentage, t-test and interpretation and ranking. The following
formulas are to be used:
For the percentage
(%) = rf x 100
Where:
% = percentage
rf = relative frequency

For the Average Mean

X = x
n
Where:
X = average mean
x = sum of scores or measures
n = Total number of respondents

For the Weighted Mean
Formula: WX = fx
N
Where: WX---Weighted Mean
fX---Summation of Frequency
N----Total Population

For t-test

t = X1 X2


The researchers used ranking to determine the position of each
variable.






Finally, the findings were summarized and compared with each
work; conclusions were drawn, and recommendations were formulated.


ANALYSIS OF VARIANCE

DATA ANALYSIS PLAN
In determining the profile of the respondents, frequency
distribution and percentage are used.
To describe and characterize the stressors, weighted mean is
used.
In determining the significant difference on the stress
management utilized by the respondents when grouped according to their
profile, T-test is used in gender and Analysis of variance is used for
Age.
NUMBER VALUE E (DoR) INTERPRETATION
4.20 TO 5.00 5 ALWAYS
3.40 TO 4.19 4 OFTEN
2.60 TO 3.39 3 SOMETIMES
1.80 TO 2.59 2 SELDOM
1.0 TO 1.79 1 NEVER
CHAPTER IV
PRESENTATION, ANALYSIS, AND INTERPRETATION OF DATA

This chapter presents the data gathered in this study which has
been carefully presented, analyzed, and interpreted. These data are
gathered by the researchers to 109 junior nursing students
enrolled at the Medical Colleges of Northern Philippines, second
semester, and school year 2012-2013.

Table 1.1
Distribution of Respondents According to Age
AGE (YEARS
OLD)
FREQUENCY PERCENTAGE Rank
18 8 7.34 4
19 63 57.80 1
20 22 20.18 2
21 16 14.68 3
Total 109 100.00
Mean=19.43

Table 1.1 shows the profile of the 109 respondents in terms of their
age. There are 8 or 7.34% of the respondents who are 18 years old
which ranked as number fourth; 63 or 57.80% of the respondents were 19
years old which ranked first; 22 or 20.18 % were aged 20 years which
ranked second, and 16 or 14.68%of the respondents were 21 years old
and ranked third.
The data indicate that the respondents are at the right age to
consider them as mature individuals capable of identifying and
managing stress. It also shows that the majority of the respondents
are 19 years old.

TABLE 1.2 1Distribution of Respondents According to GENDER
GENDER FREQUENCY PERCENTAGE RANK
MALE 29 26.31 2
FEMALE 80 73.39 1
Total 109 100.00
Table 1.2 presents the data of the 109 respondents in terms of their
gender. There were 29 or 26.31% of the respondents were male while 80
or 73.39% of the respondents were female.
This indicates that majority of the students enrolled in
BSN are female.
Table 1.3 Weighted Mean and Descriptive Values of Stressors
STRESSORS Weighted
mean
Rank

Descriptive
Interpretation
1.uninterested/unapproachable/unreceptive
staff nurse
3.53 24 Often
2. unrealistic expectation of clinical
abilities
3.80 23 Often
3. fear of making mistakes 4.34 4 Always
4.being treated as nuisance in the area 4.21 8 Always
5. unfamiliarity of the clinical area 4.67 1 Always
6. uncertainty on own clinical skills and
knowledge
4.40 3 Always
7. lack of clinical knowledge or skills
to accomplish a task or perform
procedures
4.28 5 Always
8. assigned to two or more patients 4.24 6 Always
9. bedside conference 4.17 9 Often
10. charting 4.06 12.5 Often
11. standing for long hours 4.43 2 Always


Table 1.3 The stressors in the clinical setting identified by the
respondents are reflected in table 1.3 with their corresponding
weighted mean and descriptive interpretation, points garnered and
overall rank.
12. difficult patient (very ill,
emergencies, disbelief, etc.)
4.06 12.5 Often
13. significant others of the patient 3.86 21 Often
14. interaction with the physician/intern 3.91 18 Often
15. clinical instructor treating students
unfairly.
3.81 22 Often
16. clinical instructor behaving in
demeaning and belittling ways toward
students.
3.90 19.5 Often
17. being pressured by clinical
instructor/staff nurse/physician/intern
4.22 7 Always
18. waiting on clinical instructor. 3.95 14 Often
19. being observed by staff nurse or
clinical instructor.
3.99 13 Often
20. relationship with duty mate. 3.92 17 Often
21. uncaring and/or moody clinical
instructor.
3.87 20 Often
22. connecting theory with practice (i.e.
ideal procedures are not observed in the
area)
3.90 19.5 often
23. rotation examination. 3.94 15 Often
24. oral report or oral revalida in the
area.
4.08 10 often
25. preparing for case presentation. 3.93 16 often
26. on the spot making of requirements
(NPC, DAR, LFD, Case Analysis, etc)
4.07 11 Often

The individual rankings done by each respondent were then subjected to
a point system established by the researchers. Unfamiliarity of the
clinical area ranked first with a weighted mean of 4.67 , standing for
long hours with 4.43 weighted mean, . uncertainty on own clinical
skills and knowledge with 4.40 ranked third, fear of making mistake
with 4.34 ranked fourth, lack of clinical knowledge or skills to
accomplish a task or perform procedures with 4.28 as fifth, assigned
to two or more patients with 4.24 ranked sixth, being treated as
nuisance in the area with 4.21 and being pressured by clinical
instructor/staff nurse/physician/intern with 4.22 ranked 7
th
and
interpreted as always.

This indicates that majority of the study participants felt that
in terms of knowledge they were not prepared to deal with complex
patient cases in clinical setting. Many doubted themselves and many
were overwhelmed by the amount of knowledge that one needed in order
to work safely with patients. Physically, majority of the respondents
find it difficult to care while standing for too long hours and have
to take care to different patients at the same time. Respondents were
negatively affected by the environment they practiced in, which
affects their learning outcomes.

Bedside conference got a weighted mean of 4.17 and ranked as 9
th
most
stressful, oral report or oral revalida in the area with 4.08 ranked
10th, on the spot making of requirements (NPC, DAR, LFD, Case
Analysis, etc)with 4.07 as eleventh, charting and difficult patients
(very ill, emergencies, disbelief, etc.) with 4.06 as twelfth, being
observed by staff nurse or clinical instructor with 3.99 as 13
th
,
waiting on clinical instructor with 3.95 as 14
th
, rotation examination
with 3.94 as 15
th
, preparing for case presentation with 3.93 as 16
th
,
relationship with duty mate with 3.92 as 17
th
, with 3.91 as 18
th
,
clinical instructor behaving in demeaning and belittling ways toward
students and connecting theory with practice (i.e. ideal procedures
are not observed in the area) with 3.90 as 19
th
, uncaring and/or moody
clinical instructor with 3.87 as 20
th
, significant others of the
patient with 3.86 as 21
st
, clinical instructor treating students
unfairly with 3.81 as 22
nd
, unrealistic expectation of clinical
abilities with 3.80 as 23
rd
,and uninterested/unapproachable/unreceptive
staff nurse ranked last with 3.53. All of them were interpreted as
often. This indicates that majority of the respondents are still
having difficult time in socializing and establish harmonious
relationship with other members of the health care team, dutymates,
patients and their significant others and as well as with the Clinical
Instructors. Activities and requirements during the exposure were also
found stressful.
The interpersonal relationship with healthcare professionals was a
source of stress among the participants. The process of socialization
into the unit and into the team of nurses was difficult for many and
it depended in large part on the behaviors and on the professionalism
of individual nurses and doctors/interns. Some students experienced
unwelcoming environments in which the nurses were not interested in
teaching and helping them. Some clinical instructors way of approach
and inappropriate communication style was a source of stress. Constant
evaluation process in clinical made the respondents feel stressed. A
majority of the respondents may feel that the responsibility placed on
them was overwhelming and that teachers had unrealistic expectations
of them. They might feel like they were not given opportunity to be
students as they believed teachers expected them to be perfect.
Activities to be accomplished on time cause the respondents stress.
Patients and their significant others were considered as another
significant source of stress in the clinical setting because some of
them had a negative attitude, were uncooperative in their care, and
unapproachable. Also, the critical condition of some patients worried
and instilled fear in some respondents. Group mates were at times also
a source of stress because of the different personalities that
sometimes clashed
Table 1.3 Distribution of Perception of the Stressors
PERCEPTION FREQUENCY PERCENTAGE RANK
Challenging 88 80.73 1
Threatening 21 19.27 2
Total 109 100

Table 1.3 shows the Distribution of Perception of the Stressors .After
the identification of stressors in the clinical setting, the
respondents were then asked about their coping towards their
stressors. They were asked to identify whether they see their
stressors as challenges or threats. The respondents see the stressors
identified in a positive way.



Table 1.4 Weighted Mean and Descriptive Values of Stress Management
STRESS MANAGEMENT WEIGHTED
MEAN
Rank Descriptive
Interpretation
1. I adjust to the environment or situation. 4.02 7 Often
2. I allot ample time to prepare. 3.81 11 Often
3. I confront the patient. 2.80 27 Sometimes
4. I study and read to be more knowledgeable. 3.76 12 Often
5. I manage my time. 4.09 5 Always
6. I accept the situation. 4.19 3 Often
7. I take a shower to feel good. 3.93 8 Often
8. I do household chores. 3.11 19 Sometimes
9. I eat my favorite food. 3.55 16 Often
10. I take a nap/sleep. 4.39 2 Always
11. I express my feelings. 3.83 10.5 Often
12. I go out to the mall. 2.07 36 Seldom
13. I go out to park. 2.13 35.5 Seldom
14. I go to spa and get a massage. 1.46 38 Never

Table 1.4 presents the stress management performed by the
r e s p o n d e n t s t o h a n d l e a n d a l l e v i a t e t h e i r s t r e s s .
15. I surf the internet. 2.93 24 Sometimes
16. I simply smile. 3.68 15 Often
17. I laugh at it. 3.73 13 Often
18. I listen to music. 4.15 4 Often
19. I just think positively. 4.59 1 Always
20. I read magazines, newspapers and the like. 3.29 18 Sometimes
21. I reflect on what happened. 3.70 14 Often
22. I just relax. 3.07 20 Sometimes
23. I go shopping. 3.02 21 Sometimes
24. I enjoy pleasurable activities like drawing,
playing instruments, etc.
2.99 22 Sometimes
25. I engage myself in sport. 2.49 31 Seldom
26. I curse. 2.36 33 Seldom
27. I do physical exercises (jogging, aerobics,
etc.)
3.83 10.5 Often
28. I turn to my friends. 3.90 9 Often
29. I watch the television or listening to the
radio.
3.49 17 Often
30. I write it down on my journal/ LFD. 2.92 25 Sometimes
31. I drink alcoholic beverages. 2.91 26 Sometimes
32. i smoke. 2.51 30 Seldom
33. I pity myself. 2.44 32 Seldom
34. I ignore it. 2.55 29 Sometimes
35. I consult a specialist. 2.96 23 Sometimes
36. I pray to God. 4.08 6 Often
37. I would get angry/frustrated/depressed. 2.68 38 Sometimes
38. I reason out and answer back to defend myself. 2.28 34 Seldom
39. I take medication for relief. 2.13 35.5 Seldom
40. I simply stay at the corner of my room and
cry.
1.92 37 Seldom
a significant difference on the identified stressors and stress
management by the respondents when grouped according to their profile.


Table 1.5
Analysis Of Variance on the Significant Difference the Identified
Stressors and Stress Management by the Respondents
when Grouped According to their Profile

Sources

SUM OF
SQUARES
Df MEAN
SQUARE
F P DECISION
Between
Groups
22833.435 40 570.836 338.894 .oooE+00 Accept
Ho at .05
level Within
Groups
7458.569 4428 1.684
Total 30292.004 4468

The table above shows that the probability between and
within groups is 0.00E+00, hence the Ho is accepted: There is no
significant difference on the identified stressors and stress
management by the respondents when grouped according to their
profile.







Chapter V
This chapter presents the conclusion and the recommendations made
by the researchers based on the analysis of gathered and collated
data.

Conclusion
The null hypothesis: There is no significant difference on the
identified stressors and stress management by the respondents when
grouped according to their profile is accepted.
It was evident from the data gathered that when grouped according
to age group, the respondents have similar coping
strategies/mechanisms to address stress. Although each of the
respondents may have different tolerance threshold levels, they
address similar stressors almost the same way.
The top stressor among students is the fear of committing
errors; most of those who have this first on their list use positive
thinking as a coping mechanism or as a stress management.
Majority of the respondents take the stressors as mere
challenges. Therefore, these stressors may be positively contributing
to their successes at achieving their goals; albeit it may also be
negative once their maximum tolerance is broken. Say for instance
fear, it may induce anxiety. Anxiety when unmanaged/mismanaged may
cause debilitating effect to the individual.

Recommendations:
Stress management is essential in maintaining balance. Stressors
when become compounded may cause burn out and eventually psychological
disturbance that may lead to the alteration on the normal
functioning/role performance of the individual. It is recommended
therefore that each individual adapts appropriate stress management
techniques each time they feel stressed. It is important that the
management to be employed should post minimal risk; i.e. the benefits
must outweigh the risks involved. Ultimately, the end goal of stress
management is to promote relaxation of the different faculties of the
human being, thereby maintaining homeostasis in both internal and
external milieu. The most important consideration when choosing stress
management technique is safety.











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