Vicenta López-Cruz,1 Ma. Alejandra Hernández-Castañón,1Aurora Mendoza-Zamora,1Enrique Villarreal-Ríos,2 Ma. Angelina Gasca-Ramírez3
1Universidad Autónoma de Querétaro, Facultad de Enfermería; 2Instituto Mexicano del Seguro Social, Unidad de Investigación en Epidemiología y Servicios de Salud; 3Instituto Mexicano del Seguro Social, Hospital General Regional 1. Querétaro, Querétaro, México
Correspondence: Vicenta López-Cruz
Received: September 10th 2015
Judged: December 10th 2015
Accepted: January 27th 2016
Introduction: In nursing, professional training practice complements theory, and it is an event where stress is often involved.
Objective: To assess a support intervention for nursing students in order to face situations of stress during their first clinical practice.
Methods: Test and post-test quasi-experimental study including undergraduate students from second semester of nursing bachelor, school year 2011-2012. KEZKAZ (2003) questionnaire was applied in order to identify stress situations; then a support intervention was performed during clinical practice in which competences and handling of emotional situations were practiced. Statistical analysis was performed through Wilcoxon Rank Test for paired population. Participants were requested for their informed consent and information reliability was ensured.
Results: Regarding dimensions conforming KEZKAZ questionnaire, statistical significance (p < 0.05) was found for relationships among tutors and their partners, discomfort and uncertainty about direct health care to patients and overload of work.
Conclusions: A change in perception of students after the intervention was found, showing greater autonomy and greater certainty in their performance, as well as a reduction in the work overload perception. A great deal of support time is required in order to change dimensions involving the nurse to patient relationship.
Keywords: Psychological stress; Nursing students; Practical nursing
Stress is defined as the relationship between an individual and the environment which the individual deems overexerting. Today, stress is considered a public health problem regardless of someone’s age, gender or socioeconomic status, as it has repercussions affecting the body’s basic functions, including balance, and can cause acute diseases. It has also been identified an association with problems in the family, in social life and at work.1-7
One of the professions that addresses the health needs of the population is nursing. In nurses’ training, theory and practice complement each other to put the the student in touch with the reality of care, from which they learn in a meaningful way and acquire the skills necessary for the health field.8-14
However, the first time that nursing students perform clinical practice has often been described as very stressful. In this regard, it is noted that the areas most affected are: academic6 and clinical with 78%; followed by interpersonal with 50%; 13.6% personal; social life with 8%.15,16 Additionally, the student’s personality and encounters with suffering, disability and death in a hospital environment are important influences.11,14,17-19
Against this backdrop, it has been suggested that educational support intervention in the practical training of student nurses is needed to improve their cognitive, instrumental and attitudinal skills; and beyond that, for the student to develop strategies that allow them to cope with stressful situations during clinical practice.10,12,19-24
Therefore, this research aims to evaluate an intervention to support students in the Nursing School of the Universidad Autónoma de Querétaro to address stress in their first clinical practice.
A quantitative investigation of quasi-experimental test and posttest design was conducted on a single group. The independent variable is educational intervention.
The study population consisted of second semester nursing students at the Universidad Autónoma de Querétaro. The non-probability sampling was chosen for convenience, as 70 students enrolled and did their first clinical practice in the 2011-2012 school year.
Students of both sexes and of varied ages agreed to participate in the study. Students repeating practice and students who failed to fully answer the questionnaire or to attend 100% of the scheduled sessions were excluded.
Data collection was conducted via the KEZKAZ instrument Bilingual Questionnaire: Stressors to Nursing Students in Clinical Practice by Xabier Zupiria Gorostidi,25 who authorized its use for the present study.
This instrument has high internal consistency (Cronbach's alpha = 0.95), and includes nine different dimensions which indicate different sources of stress: contact with suffering, relationships with advisors and peers, feelings of impotence and uncertainty, lack of control in the relationship with patients, emotional involvement, damage to oneself, patients who seek intimate relationships with the student, and work overload.
The questionnaire consists of 41 items distributed in nine dimensions with Likert responses (Not at all = 0, Somewhat = 1, Very much= 2 and Extremely = 3), where the higher the value, the greater the presence of stressors.
The research was approved by the Research Committee of the Facultad de Enfermería of the Universidad Autónoma de Querétaro and the health institutions where the research was conducted.
All students with practice during the morning and afternoon shifts were invited to participate. Those who accepted were given the Bilingual Questionnaire: Stressors to Nursing Students in Clinical Practice. The questionnaire was applied in two stages. The first stage was the day before students began their clinical practice. Then, with information obtained from that pilot, the Management Skills of Second Semester Students in their First Clinical Practice program was established to advise students and address their needs. Additionally, Containing Emotions, a weekly counseling workshop with a psychologist, was scheduled during the month-long practice.
After the intervention, the KEZKAZ questionnaire was applied to identify changes in stress levels.
For the analysis, a database was developed to process information in SPSS version 20, using percentages, averages, standard deviation and the Wilcoxon signed-rank test for paired population.
At all times, the study took ethical aspects into account. Participantion was done by invitation and informed consent was requested. Students were free to leave the study if they deemed it appropriate, without any kind of reprisal under the Reglamento de la Ley General de Salud en Materia de Investigación para la Salud.26
The average age of the study population is 20.96 ± 4.43. 75.7% are female, 91.4% are single and 77.1% live with their parents. 20% both study and work, and 5.7% have one child or more.
Changes in sources of stress attributed to: work overload, feeling impotent, and relationship with advisors were found statistically significant after the intervention, (p < 0.05). In these three dimensions, there was an increase in the category Not at all (Table 1).
|Table I. Change of sources of stress attributed to: work overload, feelings of impotence and uncertainty, relationship with advisors and peers, before and after the intervention|
|Stage 1||Stage 2|
|Not at all||10.0||21.4||2.74||0.00|
|Feelings of impotence and uncertainty|
|Not at all||5.7||10.0||2.26||0.02|
|Relationship with advisors and peers|
|Not at all||21.4||37.1||1.93||0.05|
In the following dimensions: lack of training, emotional impact, lack of control with patient, and contact with suffering, there was an increase after the evaluation in the categories Not at all and Somewhat, nevertheless no significant statistical significance (p > 0.05) (Table II).
|Table II. Change of sources of stress attributed to: lack of training, emotional impact, lack of control with patient and contact with suffering, before and after the intervention|
|Stage 1||Stage 2|
|Lack of training|
|Not at all||10.0||15.7||1.85||0.06|
|Not at all||18.6||21.4||1.68||0.09|
|Lack of control with patient|
|Not at all||28.6||41.4||1.56||0.11|
|Contact with suffering|
|Not at all||22.9||27.1||1.35||0.17|
The dimensions: patient seeks intimate relationship, and damage to oneself had the least statistical significance (p > 0.05) before and after the intervention. There was no change in the percentages or the change was minimal to the Very much and Extremely categories (Table III).
|Table III. Change of sources of stress attributed to: patient seeks intimate relationship and damage to oneself, before and after the intervention|
|Stage 1||Stage 2|
|Patient seeks intimate relationship|
|Not at all||31.4||31.4||0.23||0.81|
|Damaging to oneself|
|Not at all||27.1||22.9||0.20||0.84|
After analyzing the results, we can say that students in their second semester of the nursing program at the Universidad Autónoma de Querétaro in their first clinical practice experience stress. This is consistent with research results that found lack of experience and insufficient training among nursing students.1,9,11,14,16,20
This is why it’s imporant that the student learn to adapt and manage the inevitable, to accept the limitations of their training. They should learn to live with the stress and confront situations through emotional management skills and professional training.3,10,11,16,19,22
This study’s findings show that during clinical practice, the main stressors by dimension were lack of training and feelings of impotence and uncertainty, similar to what other studies have shown,7,9,14,16,20 as well as: stress due to contact with suffering, the relationships with advisors and peers, emotional impact and overload, still-prevalent situations in the health field.
When it comes to lack of training, the student seems to be stressed at the possibility of not doing a good job. The consequences this brings on, for both patient and nursing student, have been observed in other studies.7,20 This factor seems to cease as the student gains experience and skill.
Stress from the relationship with advisors and peers may be present in up to 50% of nursing students and is related to the interpersonal area.20 Students constrained by a lack of assertiveness would certainly have to both develop social skills as well as observe differences between what they learn in school and what is done in the field. In this regard, relaxation techniques and developing tolerance to frustration could be useful. Addressing the work overload dimension, students must be taught to prioritize their activities and relax when they have the opportunity.16,20 It is necessary to discuss their concerns and fears, as well as hear from their peers that the same things happen to them.1
There is a predominance of females in the study population, but this is normal in a profession such as nursing, where the majority of employees are women.
It can be said that the stressors diminish as experience and practice increase,14 but they do not disappear. This is why it’s necessary for the student to cope with them, to reach an emotional balance, so that they have the least possible effect. Also, students must be taught to work in a team.1,9,16
This study lets us detect and analyze aspects for the enhancement of future nursing professionals’ education.14
The accompanying information allowed subjects to identify emotions in their environments, confront situations and, at the same time, cope with the emotional needs of patients under their care. For this reason, our teaching consists of developing skills and strengths which support the students. In this study, after implementing competency and emotional containment programs, some dimensions changed, although we should mention that more time is needed to achieve better results.
Given the importance of the detected stress in nursing students during clinical practice, it is considered appropriate to apply training program strategies to reduce stress, help nursing professionals react adaptively to stressful stimuli and contribute to performing their work every day effectively and without risk to their health.