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Nurse Education Today
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Perceived stress and social support in undergraduate nursing students'educational experiences
Kristen L. Reeve a, Catherine J. Shumaker a, Edilma L. Yearwood a,b,Nancy A. Crowell a,c, Joan B. Riley a,⁎a Georgetown University, School of Nursing & Health Studies, Washington, DC 20057, USAb Department of Nursing, Georgetown University, School of Nursing & Health Studies, Washington, DC 20057, USAc Human Science Department, Georgetown University, School of Nursing & Health Studies, Washington, DC 20057, USA
⁎ Corresponding author at: Human Science andNursingDNW, St. Mary's 255, Washington, DC 20057, USA. Tel.: +1
E-mail addresses: [email protected] ([email protected] (C.J. Shumaker), ely2@(E.L. Yearwood), [email protected] (N.A. Crowell),(J.B. Riley).
0260-6917/$ – see front matter © 2012 Elsevier Ltd. Allhttp://dx.doi.org/10.1016/j.nedt.2012.11.009
Please cite this article as: Reeve, K.L., et al., PeEducation Today (2012), http://dx.doi.org/1
s u m m a r y
a r t i c l e i n f oArticle history:
Accepted 15 November 2012Available online xxxxKeywords:StudentStressCopingFaculty roleSupportPsychosocialNurse education
Background: Nursing students experience high levels of stress. Coping mechanisms such as utilization ofsocial support are effective in managing the effects of stress and promoting individual well-being. The useof social support from faculty members and peers in nursing programs has not been studied sufficiently. Fac-ulty members who can perceive and understand student emotions add to the students' positive perception ofthe educational environment, making it more conducive to learning.Objectives: To identify the stress experience and use of social support as a coping mechanism in traditionaland second degree nursing students' educational experiences.Design: A mixed method study was conducted.Setting: Undergraduate nursing students at a private university.Participants: 107 baccalaureate nursing students enrolled in either a traditional (n=49) or second degree(n=58) program during the Fall 2011 semester.
Method: Five instrumentswere combined todevelop the quantitative andqualitative questions for an online survey.Results: Traditional and second degree nursing students report high levels of anxiety, worry and depression in re-sponse to stress, resulting in feelings of rejection and inadequacy. Respondents used faculty members for supportless frequently than they used their peers, spouse/significant other or parents. Second degree students and tradi-tional students differ in their level of alcohol consumption with traditional students more likely to drink heavilythan second degree students. In addition, traditional students are more likely to use fellow nursing students andother friends as social support, whereas second degree students rely more on their spouse/significant other.Conclusion: Students' high levels of maladaptive reactions to stress should encourage educators to help studentsdevelop positive coping strategies. Educators have the potential to impact the development of their students asthey transition into nurses capable of handling the rigors of the profession.© 2012 Elsevier Ltd. All rights reserved.
Introduction
Nursing students experience high levels of stress (Gibbons, 2010;Goff, 2011; Moscaritolo, 2009). As senior level traditional nursing stu-dents and their faculty, we are aware of the extremely high levelof stress students experience and the diversity of responses used tocope with stress. We are concerned about how the stress experienceof undergraduates will impact their future careers as nurses. It isimperative that faculty support nursing students to help them
epartments, 3700Reservoir Rd,202 687 4685..L. Reeve),[email protected]
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rceived stress and social supp0.1016/j.nedt.2012.11.009
develop adaptive coping mechanisms that they can employ in stress-ful situations. Development of adaptive coping mechanisms by nurs-ing students will result in students who are less likely to usemaladaptive strategies such as drinking, separating self from others,ignoring stress, anxiety and depression. Faculty members must bewilling to assist future generations of nurses survive the rigors ofnursing school and thrive in the face of challenges presented in thenursing profession. This study aimed to identify the stress experienceof undergraduate nursing students, the coping mechanisms utilizedby these students, and their reliance on various social supportsystems.
Background
It has long been perceived by nursing faculty and students thatnursing students experience higher levels of stress than other college
ort in undergraduate nursing students' educational experiences, Nurse
2 K.L. Reeve et al. / Nurse Education Today xxx (2012) xxx–xxx
students (Beck and Srivastava, 1991; Goff, 2011). Nursing studentsbelieve that they have little free time due to the demands of studying,with assignments for didactic and clinical work. Another factor con-tributing to high levels of stress is that clinical assignments requirenursing students to spend considerable time away from campus andalso requires them to be responsible for the well-being of patients(Shriver and Scott-Stiles, 2000). These activities remove studentsfrom the normal social developmental activities of their same agepeers.
Misra and McKean (2000) found that junior and senior collegestudents experience less perceived stress as compared to freshmenand sophomore students due to the development over time of im-proved coping skills. College sophomores were found to “lack moti-vation, feel disconnected and flounder academically,” frequentlyreferred to as the “sophomore slump” that can lead to high levels ofstress and depressive symptoms (Gahagan and Stuart, 2006, p.18).Second degree nursing students also experience additional stressorssince they are older than traditional students and frequently havespouses, families and other commitments, which add to the stresscaused by their studies (Goff, 2011).
Coping mechanisms such as utilization of social support have beenshown to be effective in managing the effects of stress and promotingindividual well-being (Boey, 1999; Lo, 2002; Mahat, 1998; Payne,2001; Tichy and Means, 1990). Hubbard et al. (1984) found that anincreased perceived level of social support had a direct positive asso-ciation with participation in positive health practices, including ade-quate nutrition, exercise, relaxation, safety, and health promotion.Conversely, college students with lower levels of social support smokedsignificantly more and consumed more alcohol when facing the stressof exams than those with higher levels of social support (Steptoe etal., 1996). These findings highlight the positive influence social supportcan have on healthy lifestyle choices.
Studies have examined the various social support systems nursingstudents commonly draw upon, focusing on familial and spousal sup-port; however the use of social support from faculty members andpeers in nursing education programs has not been studied sufficiently(Boey, 1999; Lo, 2002; Payne, 2001). Faculty should be aware of stu-dent stress so that they can support student growth and development(Yearwood and Riley, 2010). It is important that students perceivetheir learning environment as one built on mutual trust between fac-ulty and students because students have identified that when theyfeel safe, respected, trusted and receive frequent feedback from facul-ty members, they feel more motivated and learn more effectively(Rowbatham, 2010; Tiberius and Billson, 1991). The mutual trust cre-ated between faculty and students puts the focus on learning ratherthan teaching (Tiberius and Billson, 1991). Faculty members who per-ceive and understand the emotional needs of their students add tothe students' positive perception of the educational environment,making it more conducive to learning (Rowbatham, 2010).
Methods
Design
An institutional review board (IRB) approved this mixed methodsurvey research administered in October 2011 to baccalaureate nurs-ing students in both the traditional and the second degree programsat a private university.
Participants
Participants were 107 traditional and second degree undergradu-ate nursing students enrolled in one of five required nursing courses.One hundred seventy-five students were invited to participate and107 students completed the survey (61.1% response rate). Partici-pants included 104 women and 3 men.
Please cite this article as: Reeve, K.L., et al., Perceived stress and social suppEducation Today (2012), http://dx.doi.org/10.1016/j.nedt.2012.11.009
Data Collection
Five validated tools combined into one online survey to assesscoping mechanisms, response to stress and perceived social support.The Multidimensional Scale of Perceived Social Support (Zimet etal., 1988), Deakin Coping Scale (Moore, 2003), Social Support Ques-tionnaire (Sarason et al., 1987) and the Student Life Stress Inventory(Gadzella, 1994) were utilized. In addition, an open ended surveyitem with three questions using the Critical Incident Technique Tool(Flanagan, 1954) asked respondents to share their most stressfulclinical experience, how they responded to the stressful event, andthe persons with whom they shared the experience. The combinedtool was validated by two content experts to evaluate for reliability.
The purpose of the study was introduced by the investigators tostudents during class time. A web link was distributed to the studentsenrolled in each of the five classes, and email reminders were sentone week later and again two days before the survey closed. Informedconsent was obtained from the 107 students that participated in thesurvey prior to beginning the survey. The combined instrument wasdistributed online and was hosted by Zoomerang.com, a platformthat provided no links to identity, ensuring anonymous results. Limit-ed demographic information was collected to further ensure no link-age to results for the few male, older age or racially diverse studentparticipants. Quantitative data were obtained from all participants and62 of the participants also completed two qualitative open-endedquestions. A combination of both qualitative and quantitative mea-surements were assessed using the five validated instruments: theMultidimensional Scale of Perceived Social Support (Zimet et al.,1988); Deakin Coping Scale (Moore, 2003); Social Support Question-naire (Sarason et al., 1987); the Student Life Stress Inventory (Gadzella,1994); and Critical Incident Technique (Flanagan, 1954).
Data Analysis
Analysis of the quantitative data was performed using StatisticalPackage for Social Sciences, IBM 19.0 (SPSS, 2010). The qualitativedata regarding the most stressful clinical experience and how stu-dents coped with that situation were independently coded by fourof the researchers. Thematic analysis using Van Manen's (1990) ap-proach of extracting specific phrases or sentences was utilized. De-pendability was achieved through the independent research reviewfollowed by discussion between four of the researchers and identifi-cation and consensus about the findings.
Quantitative Results
Reaction to Stress
The students surveyed were asked to select all feelings that theyexperienced in stressful situations, including fear, anxiety, worry,anger, guilt, grief, or depression. The most commonly selected feel-ings were anxiety, worry and anger. In addition to the top three,fear and depression were frequently selected (Table 1).
Of the respondents, 95.7% (n=102) reported feeling anxiety instressful situations. In addition, worry ranked extremely high for manyrespondents, with 87.8% (n=94) of students reporting this emotion.
Feelings of depression when under stress were reported by 42.1%(n=45) of all students. This is worrisome, especially when consid-ered with the maladaptive coping strategies reported, such as sepa-rating self from others, crying, and being irritable.
Coping Strategies
The nursing students surveyed were asked to select all the strate-gies they utilize to decrease their stress including working out, hang-ing out with friends, talking to family, talking to friends, ignoring the
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Table 1Reaction to stress.
Anxiety Worry Anger Fear Depression Guilt Grief
Traditional sophomores (n=12) 100% (n=12) 83.3% (n=10) 41.7% (n=5) 41.7% (n=5) 33.3% (n=4) 25.0% (n=3) 41.7% (n=5)Traditional Juniors (n=21) 100.0% (n=21) 95.2% (n=20) 66.7% (n=14) 57.1% (n=12) 52.4% (n=11) 47.6% (n=10) 33.3% (n=7)Traditional Seniors (n=16) 93.3% (n=14) 86.7% (n=13) 46.7% (n=7) 53.3% (n=8) 46.7% (n=7) 46.7% (n=7) 6.7% (n=1)Second Degree 3rd Semester (n=31) 96.7% (n=29) 90.0% (n=27) 50.0% (n=15) 36.7% (n=11) 43.3% (n=13) 50.0% (n=15) 23.3% (n=7)Second degree 4th semester (n=27) 96.3% (n=26) 88.9% (n=24) 48.1% (n=13) 37.0% (n=10) 37.0% (n=10) 33.3% (n=9) 11.1% (n=3)
3K.L. Reeve et al. / Nurse Education Today xxx (2012) xxx–xxx
stress, feeling sad/miserable, crying, being irritable, or separating selffrom others. Students reported relying heavily on talking to friends,hanging out with friends and talking to family as strategies they felthelped decrease their level of perceived stress. In addition to thosecoping mechanisms, many students reported ignoring their stress,feeling sad/miserable, crying, feeling irritable and separating selffrom others.
Traditional students reported ignoring their stress at higher ratescompared to second degree students (Table 2). However, sophomorestudents reported low rates of ignoring their stress (16.7%, n=2) ascompared to senior students (56.2%, n=9). Reliance on talking tofamily as a coping mechanism decreased with age from sophomoreyear (91.7%, n=11) to senior year (68.8%, n=11).
Alcohol Use
Students were asked to identify the average number of alcoholicdrinks they consume each week. There is a significant difference(p=0.020) between the number of drinks traditional students andsecond degree students consume each week (Table 3). A cluster oftraditional students reported “heavy” rates of drinking (6 or moredrinks/week). Seconddegree students identifiedhavingmore “moderate”consumption of alcohol (3–5 drinks/week).
Faculty as Social Support
Students were asked questions regarding different situationsand whom they felt they would utilize for support in each situation.The four situations presented were (1) who could you trust whenyou are in trouble? (2) Who do you count on when you need help?(3) Who consoles you when you are upset? (4) Who makes you feelmore relaxed when you are under pressure? The students wereasked to select all the individuals they felt they would be able to uti-lize, including siblings, parents, spouse/significant other, nursingfriends, other friends, faculty members, spiritual advisors or no one.Both traditional students and second degree students had extremelylow levels of reliance on faculty as a social support system in thosesituations. Traditional students reported slightly higher reliance onfaculty in stressful situations as compared to second degree students,but both cohorts reported very low levels of reliance on faculty associal support (Table 4).
Table 2Coping strategies.
Talking tofriends
Hanging outwith friends
Talking tofamily
Workinout
Traditional sophomores(n=12)
83.3%(n=10)
75.0%(n=9)
91.7%(n=11)
91.7%(n=11)
Traditional juniors(n=21)
90.5%(n=19)
90.5%(n=19)
90.5%(n=19)
66.7%(n=14)
Traditional seniors(n=16)
87.5%(n=14)
87.5%(n=14)
68.8%(n=11)
62.5%(n=14)
Second degree 3rdsemester (n=31)
90%(n=27)
76.7%(n=23)
73.3%(n=23)
73.3%(n=22)
Second degree 4thsemester (n=27)
66.7%(n=18)
66.7%(n=18)
66.7%(n=18)
74.1%(n=20)
Please cite this article as: Reeve, K.L., et al., Perceived stress and social suppEducation Today (2012), http://dx.doi.org/10.1016/j.nedt.2012.11.009
Qualitative Findings
Survey participants were asked to respond with a short answerto the following prompt: “please describe the most stressful clinicalexperience you have had to date.” This question generated responsesfrom 27 second degree students and 35 traditional students, 62 re-sponses in total, 57.9% of the participants. The answers were codedfor common phrases and overarching themes were identified. Overall,students identified feelings consistent with rejection and inadequacy.However, when asked to describe persons with whom they discussedtheir experiences, the majority of students (58.1%, n=36) listed multi-ple people who constitute their support system. Furthermore, studentswere prompted to answer how they responded to the stressful event.The majority of students (51.6%, n=32) responded with upbeat andpositive phrases, and described an ongoing process of managing stressthat allowed them to continue with their nursing education.
Rejection
Students identified experiences in which they felt rejected asbeing very stressful. Rejection came from many different sources, in-cluding the staff nurse, the clinical instructor, peers, or the patient.One traditional student and six second degree students wrote aboutnegative interactions with the staff nurse they were collaborating withfor the day. Students discussed the common theme of staff nurses notwanting to work with them, and “disappearing.” One student reported,“I didn't know what nurse I was with for the day… the nurse mostlyignored me.”
Furthermore, five students described stressful experiences in whichthe clinical instructor rejected them. These respondents discussed pro-found emotional consequences from their interactions. One studentwrote, “I spent more time that semester worrying about the instructorthan I did worrying about providing good nursing care or about pa-tients.” The impact of rejection from the clinical instructor was evenmore apparent in emergency or death situations. A second degree stu-dent detailed an anxiety-producing experience in which her patientdied, and how she felt her clinical instructor ignored her distress. Shewrote, “it wasmy first patient death and I felt thatmy clinical instructordid not understand how the incident affected me.”
Twenty-seven of the 62 respondents reported utilizing their fel-low nursing students as a way to cope with their stressful situations;
g Separating selffrom others
Irritable Crying Ignoringstress
Feeling sad/miserable
33.3%(n=4)
50.0%(n=6)
25.0%(n=3)
16.7%(n=2)
25.0%(n=3)
38.1%(n=8)
28.6%(n=6)
38.1%(n=8)
19.0%(n=4)
28.6%(n=6)
50.0%(n=8)
25.0%(n=8)
37.5%(n=6)
56.2%(n=9)
31.2%(n=5)
43.3%(n=13)
30.0%(n=9)
30.0%(n=9)
33.3%(n=10)
23.3%(n=7)
29.6%(n=8)
48.1%(n=13)
40.7%(n=11)
14.8%(n=4)
29.6%(n=8)
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Table 3Alcohol use.
How many alcoholic drinks do you have a week?
None 1–2 3–5 6–8 9 or more
Traditional 14.3%(n=7)
38.8%(n=19)
14.3%(n=7)
20.4%(n=10)
12.2%(n=6)
Second Degree 15.8%(n=9)
42.1%(n=24)
33.3%(n=19)
5.3%(n=3)
3.5%(n=2)
p=0.020.
4 K.L. Reeve et al. / Nurse Education Today xxx (2012) xxx–xxx
however, a few students (3.2%, n=2) reported an opposite experi-ence of being rejected by their peers. A traditional student wroteabout feelings of self-doubt ever since a fellow student commentedthat she was “scared of her lack of clinical skills.” In addition, this stu-dent did not feel as though she could share this stressful experiencewith anyone.
Finally, students described stress when rejection came from theirpatient. A second degree student wrote about an experience whereher pediatric patient's IV infiltrated, and “the family got really upsetabout this and said that they didn't want me in the room for therest of the shift.” Another student wrote that she felt stressed “basi-cally in any situation where the patient yells at me.”
Inadequacy/Incompetence
Another main theme in the stories of students' stressful experi-ences was inadequacy. Identified stressful experiences often includedstories of struggling with the stress of being a learner. One respon-dent wrote, “I feel as if the clinical experience is inherently stressfulby virtue of the ‘unknown’. Everything is new to us as nursing stu-dents, and every semester we are given a brand new experience.”Others reported not being adequately prepared for their first clinicalexperience. One traditional student told of performing CPR for thefirst time and being “freaked out” and “really nervous.” Sophomoreswere the most likely to report feelings of inadequacy with new skillsas they are the newest to the clinical setting.
Self-doubt was also a common theme that caused students to feelinadequate. One senior traditional student stated that she had recent-ly “begun to doubt my own skills and have become less assertive dur-ing clinicals.” Another traditional student stated that instead of aspecific clinical experience being stressful, she frequently doubts her-self and wrote, “I feel as though others are smarter than me.”
Often students described feeling unprepared to be in the hospitaland overwhelmed by their responsibilities. After an anxiety-producinginteractionwith the hospital staff, one studentwrote, “the stress I expe-rienced was partly because I knew I had more responsibility as a thirdsemester nurse, but I felt incompetent to fulfill that duty.” Another re-spondent stated, “I realized I was pretty overwhelmed by some ofthe simple things I should know how to do….this made me feel prettyinadequate and worried.”
Inadequacy was also experienced after students had made errorsin the clinical setting. After administering a blood pressure medica-tion that should have been held, one student was extremely upset.She wrote, “I cried for days and considered dropping out of school.
Table 4Faculty as social support.
Trust whenyou are introuble
Count onwhen youneed help
Console youwhen you areupset
Makes you morerelaxed when underpressure
Traditional 4.1% (n=2) 6.1% (n=3) 4.1% (n=2) 16.3% (n=8)Seconddegree
0.0% (n=0) 6.9% (n=4) 0.0% (n=0) 1.7% (n=1)
Please cite this article as: Reeve, K.L., et al., Perceived stress and social suppEducation Today (2012), http://dx.doi.org/10.1016/j.nedt.2012.11.009
I self-isolated for about three days after the incident and barely talkedto anyone.”
Finally, a traditional student wrote about feeling that the cultureof nursing failed to meet her expectations. Instead of questioningher own skills, she questioned the system and the kind of care thatcan be provided to patients. She described her desire to use her nurs-ing skills to focus on the patient's humanity and reduce suffering. Herexperience during Medical/Surgical clinical disheartened her becauseshe felt as though she could not practice her personal nursing philos-ophy in that setting. “The system, the way things worked, seemed sooverwhelming and so strong, but in the opposite direction to where Iwanted to go. It caused me to really question if nursing was the rightcareer for me, and three years into my degree, I felt I had alreadysacrificed so much and wasn't sure where to go from there.”
Access to a Support System
After describing their stressful clinical experiences, students wereasked to identify persons with whom they talked about their feelings.Three senior traditional students stated that they did not share theirexperiences and feelings with anyone. However, all other studentswere able to access someone important to them and discuss their ex-perience and stress.
In general, students had multiple relationships they could dependon to help them process the stress they experienced in their clinicalassignments. Students reported that they coped by talking with aspouse/significant other (11 respondents), family member (20 respon-dents), non-nursing major friends (19 respondents), and other facultymembers (7 respondents). Twenty-seven students stated that theyshared their experience with either their clinical group or their nursingfriends. Eighteen stated that they told their clinical instructor abouttheir most stressful clinical experience. Talkingwith the clinical instruc-tor, members of the clinical group and other nursing friends as supportto copewith the stressful situationwas described as beneficial. The use-fulness of debriefing in post-clinical conference and being able to sharefeelings about the day in an open and honest manner was identified bymany students as helpful. One student wrote, “they [the clinical group]did help me reframe the day as part of a learning experience and less ofa failure.” The student who administered the medication that shouldhave been held described her experience during the debriefing, stating,“without the overwhelming support of each one of them [clinicalgroup] and the faculty member with me that day, I am not sure Iwould have been able to move forward.” Furthermore, a fourth semes-ter second degree student described the stress she felt in her capstonepracticumbecause shewasworking one-on-onewith a nurse preceptorand felt overwhelmed by being in a busy Emergency Department (ED).She reached out to another student also completing her practicum inan ED in order to share her feelings since she did not have the supportof a clinical group that is built into most clinical experiences, but notin the practicum format.
Process of Managing Stress
A third question respondents answered was “how did you handlethis stressful event?” Responses to this prompt varied; however, moststudents' descriptions ended with affirming, positive statements aboutpersisting (51.6%, n=32). Students described a multi-step coping pro-cess in which they dealt with their emotional response, engaged in aphysical activity, and decided to carry on.
After experiencing their stressful event, most students engaged ina reflective period. They processed what had happened, whether itwas through personal reflection or through engaging others in an ac-tive debriefing process. Students reported feeling better after being ableto discuss the situation with other people who understood what theywere going through. After describing an error she made, one student
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5K.L. Reeve et al. / Nurse Education Today xxx (2012) xxx–xxx
wrote, “We worked out the lessons I could take away from it and howI could regain confidence again.”
Furthermore, students engaged in a physical activity to help themactively overcome the stress they experienced. Some responses includ-ed “running,” “taking a shower,” “meditating,” and “listening to music”as helpful coping strategies.
Managing these stressful experiences is an ongoing process thatmust be continued long term. In order to have success in future clin-ical situations, students described their decisions to persist and pushthrough their feelings of rejection and inadequacy. Descriptions endedwith upbeat, positive phrases about the students' ability to persevere.Students described a conscious decision to continue with their nursingeducation, using terms such as “sticking it out,” “keeping it in perspec-tive,” and “sucking it up.” One student wrote, “It was the routine ofschool and the supportive people I told about the event that gotme through.” The student who discussed being disheartened by herMedical/Surgical clinical experience wrote about how in the end shewas given a renewed sense of “hope and drive” to achieve her visionof becoming the type of nurse she valued. These statements all recog-nize the students' abilities to undergo a stressful experience, look atit objectively, and maintain their commitment to nursing.
Discussion
The rates of anxiety, worry and depression students experiencedwere indicative of an extremely high burden of stress in all participants.Traditional students and second degree students experienced similarreactions to stress, but utilized different coping mechanisms. Stresslevel findings are inconsistent with the results of Goff (2011), whichfound that second degree students have greater stress than traditionalstudents yet they have higher levels of learned resourcefulness whichcan explain this difference (Goff, 2011). While stress provides motiva-tion in the learning environment, the excessive stress noted by thesestudents can lead to lack of engagement and confidence and decreasedperformance (Bremner et al., 2008; Chipas et al., 2012; Gibbons, 2010).
Positive coping mechanisms are of utmost importance in order toavoid the negative impacts of stress. The students from the two differ-ent programs demonstrated comparable coping mechanisms includingtalking to friends, exercise, being irritable, crying, ignoring stress, feel-ing sad/miserable, and consuming alcohol. These coping mechanismswere a combination of adaptive and maladaptive stress managementstrategies. Emotional focused coping and social support were equallyused by students facing stress in this study and in Mahat's (1998) re-search. The maladaptive coping strategies identified by these students,combined with the 42.1% of respondents who reported feelings of“depression,” raise concerns that students lack adequate copingmecha-nisms tomanage reactions to the unique experiences of being a studentnurse. Furthermore, traditional students increase their use of maladap-tive coping mechanisms, specifically by ignoring stress and feeling sad/miserable, as they advance through the program of study. Gibbons et al.(2010) linked coping by avoiding stress as strongly associated withpoor well-being. Nursing education has done little to develop curricu-lum and teach faculty to address the stress of being a student nurse.
One concerning maladaptive coping strategy our findings revealedis alcohol use behavior, particularly in traditional students. While fur-ther investigation of this issue is needed, these findings are consistentwith an earlier study by Steptoe et al. (1996), which showed a rela-tionship between poor social support and alcohol use. Nursing educa-tion has done little to address the worrisome phenomenon of alcoholuse among undergraduate nursing students.
A review of the literature identified a “sophomore slump” causedby a sudden decrease in social support that had been in place duringfreshman year, apprehension about the future, and the demands ofrequired classes (Gahagan and Stuart, 2006). Our research revealedthat sophomore respondents experienced increased levels of irritabil-ity and grief and talked with their parents as a means of support at
Please cite this article as: Reeve, K.L., et al., Perceived stress and social suppEducation Today (2012), http://dx.doi.org/10.1016/j.nedt.2012.11.009
higher rates as compared to other cohorts. Additionally, only 16.7%of sophomores ignored their stress as compared with 56.2% of seniortraditional students. This recognition of stress in sophomores revealsa unique opportunity for faculty to reach students early on in theirnursing education and teach positive coping strategies. Throughthese interactions, faculty can and should develop trusting relation-ships with students and serve as important assets in their students'social support system. Sophomore year therefore represents a primeopportunity for faculty action to help students develop positive cop-ing strategies.
Alarmingly low numbers of students reported being able to trustfaculty when they are in trouble, count on faculty when they needhelp, depend on faculty to console them when they are upset, or ac-cess faculty to make them feel less stressed when under pressure.These levels were substantially lower than the utilization of peers,family, and spouse/significant other, which is consistent with earlierfindings (Mahat, 1998).
The underutilization of faculty as a source of support for nursingstudents should concern nursing educators. Nursing faculty have thepotential to positively or negatively impact students' perception of thechallenges and rewards of professional nursing (Alpers et al., 2012).Nursing programs need to recognize sources of stress and demandson students and make programmatic changes to reduce students' dis-tress and enhance learning (Gibbons et al., 2009).
Conclusions and Recommendations
Nursing students experience high levels of stress due to the rigor-ous academic and emotional demands placed on them when theybegin to take responsibility for patient care. That stress impacts thestudent experiences while they are in school and may later impacttheir lives and journeys as professional nurses. Gibbons, Dempster andMoutray concluded that the well being of nursing students “has a directbearing on theirfitness to practice and on patient safety” (2010, p. 630).
Faculty can intervene to help students by understanding the de-mands on students and by providing the needed support and guid-ance to enhance student development and learning. Shaban et al.(2012) found that an excessive amount of assignments and studyingled to significant stress in Jordanian students. Gibbons et al. (2009)concluded that a measurable tool for stress evaluation should beused with all nursing students in order to promote course changesthat take into account students' distressing experiences.
Furthermore, faculty can make small changes in their interactionswith students to improve student confidence and promote supportivestudent faculty relationships (Yearwood and Riley, 2010). When stu-dents rated social support as an “uplifting” factor, they had higher scoresof well-being (Gibbons et al., 2010). Teachers can provide social supportby giving students timely and constructive feedback. Faculty also needto be aware of their own coping style in order to understand howtheir attitudes and relationships impact student coping skills (Gibbonset al., 2010).
Another suggestion for faculty to help students cope with thestress of clinical is to promote a collaborative environment amongstudents, faculty and the clinical staff. Decker and Shellenbarger(2012) notes the importance of creating a positive workplace envi-ronment for students. This can be done by the instructor modelingeffective communication, the instructor informing the staff nursesabout student skill levels, and the instructor setting realistic goalsfor clinical experiences. A consistent recommendation is the importanceof faculty advocacy for students. Finally, it is important to note that theacademic community has a responsibility to promote coping andwell-being in nursing students. Chipas et al. (2012) argue that the nurs-ing education community should include curriculum components oncoping mechanisms and communicating with difficult people. Profes-sional nurses working in complex health care systems need effective
ort in undergraduate nursing students' educational experiences, Nurse
6 K.L. Reeve et al. / Nurse Education Today xxx (2012) xxx–xxx
coping strategies to deliver safe and high quality care and preventburnout.
This paper adds to the literature the critical role of nurse educatorsto recognize the stress their students experience and understand itssignificance for educational and professional success. Moreover, fac-ulty need to recognize the unique and significant opportunities theyhave to serve as important assets in their students' support systems.Faculty in traditional and second degree baccalaureate nursing pro-grams can and should take steps to help students cope successfullywith stress during their undergraduate education.
Future research needs to be conducted in a variety of nursing ed-ucation programs. Research studies are needed to address how betterto build supportive faculty–student relationships, how to identify thecoping strategies that work best for students, and how to teach facultyto encourage positive coping behaviors.
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