A study to explore the coping strategies for the anxiety & perceived stress

among the nursing students during clinical training at Jaipur, Rajasthan.

Author : Ms. Neeshu Singh, Dr. Paramjit Bawa, Mr. Misbah Moin, Prof. (Dr.) Geeta
Chaudhary
Affiliation: Research Scholar Himalyan University, Research Guide Himalyan University,
College of Nursing AMU, S.N. College of Nursing SGNR.
Corresponding Author: Prof. (Dr.) Geeta Chaudhary
Corresponing email id : [email protected] , [email protected]

Abstract

Clinical training represents a stressful experience for the many nursing students. The levels of
stress and anxiety may differ during students’ educational training, depending on their ability
to embrace behavioral strategies for coping with stress, and other factors. This study aimed to
find the relationship between anxiety, perceived stress, and the coping strategies used by
nursing students during their clinical training. A cross-sectional correlational descriptive
approach is adopted for the present study. Total 190 nursing students enrolled in the Nursing
department of NIMS University, Jaipur, Rajasthan. Participants provided data on background
characteristics and completed the following instruments: the Perceived Stress Scale; the
State-Trait Anxiety Inventory and the Coping Behavior Inventory. Relationships between
scores were examined using Spearman’s rho.
The finding of the study shown that the mean age of participants was 20.71 ± 3.89
years (range 18–26 years). Approximately half of the students (47.92%) indicated a moderate
level of stress with a mean Perceived Stress Scale score of 22.78 (±8.54). Senior nursing
students perceived higher levels of stress than novice students. The results showed a
significant correlation for perceived stress and state anxiety (r = 0.463, p < .000) and also for
trait anxiety (r = 0.718, p < .000). There was also a significant relationship between the total
amount of perceived stress and the following domains of the coping behaviour inventory:
problem solving (r = −.452, p < .01), self-criticism (r = .408 p < .01), wishful thinking (r
= .459, p < .01), social support(r = −.220, p < .01), cognitive restructuring (r = −.375, p < .01),
and social withdrawal (r = .388, p < .01). In the current study, the coping strategy most
frequently used by students was problem-solving, followed by social support and cognitive
restructuring. Finding concluded the Nursing students show a moderate level of stress, in
addition to this there was a significant correlation with anxiety. Nursing teachers and clinical
Instructors/Mentors should be encouraged to develop programs to help prepare nursing
students to cope with the challenges they are about to face during their clinical Postings.
Keywords: Clinical training, Coping, Perceived Stress, Anxiety, Behaviour, Cognitive
Introduction

Research on level of stress among health professionals is an issue of current interest [1]. This
is not only due to the many causes of fundamental stress referred by healthcare professionals,
but also because it is worth considering the negative and chronic effects of stress over time
[2].
In nursing, the subject of stress has received much attention in the literature, and remains to
be the topic of many research studies [3, 4]. The practical training of a nurse’s education has
been reported to be much more stressful than academic training. Also, the perceived lack of
knowledge and skills are considered to be one of the common stressors for many nursing
students [5]. Additionally, the first experience in clinical practice includes stressors such as
fear of making mistakes, having to handle emergency conditions, irregularities in clinical
practice and visiting specific units [6].
Generally, nursing students do not have the same accountability and responsibility in the
individual care of patients in hospital as registered nurses, though they are exposed to some
of the same stressors.
Low or moderate levels of stress may boost students’ motivation, leading to greater
perseverance when studying and achieving future goals [7]. On the other hand, high levels of
stress can have a negative influence on students, leading to depression and despair, and hence
affecting students’ health and academic level [8]. Stress is unavoidable and, in most cases, it
is difficult to overcome, however, a good coping strategy may help students to improve their
academic results [9].
Need of the study
Coping mechanisms are crucial when trying to deal with the stress and anxiety that nursing
students face on a daily basis. Longitudinal studies have shown that stress levels in nursing
students may increase or decrease during their educational training depending on coping
behavior strategies adopted by the students. However, as observed by Jimenez et al. , these
differences about stress levels over the course of professional training should be considered
with caution, as different programs exist in each country. Though some studies identify the
first or second year as being the most stressful for students , for others, the third year is the
most stressful due to the clinical duties. However, other studies show that stress levels
increase according to the training or the academic year or decrease as the student becomes
more trained [10]. In addition these differences, coping strategies vary according to the
characteristics of the individual and the context where the stressors are found. Hence, the
main aim of this study was to find the relationship between anxiety, perceived stress and
coping strategies used by nursing students during their clinical training. Besides, we
accomplished a comparative analysis between perceived stress and coping strategies by
gender, course and clinical placement, based on the available literature.

Research design, setting and sample

A cross-sectional, descriptive, correlational design was used. Graduate-level students were
enrolled from the College of Nursing of NIMS University 2020-21 academic Session. During
the first year, nursing students only have academic subjects (theoretical-practical taught in the
classroom setting). These classes take place at the college & Labs with little exposure to
clinical area, and, at this point students have no direct contact with patient in hospital settings.
After the first year, once the basic core subjects are taught, the students begin their clinical
placements. These begin in the Second year and are completed in the fourth year, with
subjects that are entirely care-based and which take place at the hospital. During these 3
years, students alternate clinical placements with academic subjects.

The Inclusion criteria for this study were as follows:

a. All participants were students enrolled in an academic year of the nursing degree
course taught at the university (except first year students).
b. Participants must have been present in the classroom when the researcher visited to
collect data.
Sample Size: A prior sample size calculation was not performed for this study, rather the
sample size was based on the entire population of students, The population of nursing
students studying at the university was 340 students, of these, 115 were excluded because
they did not fulfil the inclusion criteria; thirty-three did not participate in the research and,
finally, 192 students agreed to participate and complete the self-administered questionnaire.
The response rate was 85.33%.
Data collection instruments
Data were collected from the students in the study group using a 20- min online self-
report questionnaire comprising the following information:
a. Demographic characteristics:
b. Perceived stress scale (PSS). The PSS-14 was designed for measuring the degree to
which daily life situations are evaluated as stressors. The European Spanish version
PSS (14-item) has demonstrated adequate reliability (internal consistency, alpha
= .81). Study demonstrated an alpha =. 87. The range for total scores on the PSS-14
was from 0 to 56. Stress scores below the 25th percentile (0 to 17) were interpreted as
low stress, scores between the 25th and 75th percentile (18 to 28.5) were interpreted
as moderate stress and scores above the 75th percentile (28.6 to 56) were interpreted
as high stress. On the Stress Survey, each item’s mean stress rating was calculated.
An item with an average of 5 was interpreted as causing “severe stress”, 4 as causing
“a lot of stress”, 3 represented “moderate stress”, 2 was “a little stress”, and 1
equalled “no stress”.
c. The State-Trait Anxiety Inventory (STAI): Internal consistency coefficients for the
Spanish version scale range from .86 to .95. In our sample we obtained an alpha of
0.91 for STAI State and an Alpha of 0.86 for STAI trait. The STAI has 40 items with
20 items allocated to each of the subscales, based on a 4-point Likert format (score
from 0 to 3). The range of scores for each subscale is 0–60, in which higher scores
indicate greater anxiety.
d. The Coping Strategy Inventory (CSI) is a self-report questionnaire designed to assess
coping thoughts and behaviors in response to a specific stressor. The internal
consistency coefficients were between .63 and .89 and between .64 and .85 in our
sample for each primary subscale. The CSI has 40 items, each item on the CSI may be
scored using a 5-point Likert format (scores from 0 to 4), with the total score ranging
 from 0 to 160. This questionnaire contains eight primary subscales. These are:
problem solving, self-criticism, expression of emotions, wishful thinking, social
support, cognitive restructuring, problem avoidance, and social withdrawal.
Statistical data analysis
Data analyses were carried out using the Statistical Software Package for the Social
Sciences (SPSS) version 23.0. Data were examined by calculating the means, standard
deviation (±SD), absolute and relative fre
Quencies and percentages, in order to generate a descriptive statistical analysis. In
order to measure the internal consistency and homogeneity of the three questionnaires, the
Cronbach’s alpha test was performed, accepting a coefficient ≥ 0.70 as an ideal value. The
individual analysis of each item was carried out using the homogeneity index which was
assessed using the Spearman correlation coefficient. Each item that obtained a coefficient >
0.30 was considered useful for evaluating the attribute. Additionally, no items failed to fulfil
this condition.
Correlations and regression analysis

Non parametric tests were used for the comparison of means between groups
according to gender, course, clinical placement and previous training in health sciences.
Correlations between the scores of the different scales used were assessed using the
Spearman’s rho correlation coefficient. The accepted confidence interval was 95% and the
significance level for all analyses was set at p < .05;
Changes in R2 were reported after each step of the regression model to further determine the
association of the additional variables. The significance criterion of the critical F value for
entry into the regression equation was set at p < .05, and was considered significant in all
tests.

Table 1 Means, standard deviation and skewness and kurtosis of the participants’
scores for perceived stress (PSS), anxiety (STAI) and dimensions of coping (CSI)
Constructs Dimensions M SD Min Max Skewness Kurtosis

Stress Perceived stress 22.78 8.53 5 47 .303 .155

Anxiety Anxiety state 17.63 9.01 3 54 .894 .813

Anxiety trait 20.13 8.73 4 46 .541 −.126

Coping Problem solving 15.08 3.43 4 20 −.450 −.072

Self-criticism 6.54 4.56 0 20 .484 −.152

Expression of emotion 9.88 4.37 0 20 −.127 −.406

Wishful thinking 9.45 5.15 0 20 .248 −.863

Social support 13.9 4.61 0 20 −.708 .067

Cognitive restructuring 12.51 3.78 2 20 −.212 −.188

Problem avoidance 7.36 1.62 3 13 −.018 .560

Social Withdrawal 6.28 3.70 0 19 .495 .012

N = 192; Skewness Standard Error = .175; kurtosis Standard Error = .349
The mean age of participants was 20.71 ± 3.89 years (range 18–26 years). Most students were
female (86.5%) and 17.7% of the students had previous training in health sciences. Up to
52.1% of students were undergoing their first clinical placement in the second year. The
mean PSS score was 22.78 (±8.54), indicating a moderate level of stress. Furthermore, the
stress scores ranged from 5 to 47 out of a possible 56. In our study, most participants
(47.92%) indicated a moderate level of stress. The Anxiety state score was 17.64 (±9.01)
classified as ‘no problem’ with a minimum score of 3 and maximum of 54 and Anxiety trait
of 20.13 (±8.74) classified as ‘mild anxiety’ with a minimum score of 4 and maximum score
of 46.

Table 2 Comparison of the level of stress and anxiety classified by type of clinical
placement

STAI STATE PERCEIVED STRESS

(Mean ± SD) (Mean ± SD)

Geriatrics 16.18 ± 7.53 24.35 ± 8.65

Mental health 19.40 ± 10.72 25.40 ± 6.87

Primary care 15.9 ± 8.75 22.33 ± 7.30

Internal medicine 16.14 ± 7.75 21.13 ± 9.08

Specialized services 23.77 ± 11.16 23.64 ± 9.00

Mother-child health 18.27 ± 7.92 24.09 ± 7.03

TOTAL 17.64 ± 9.01 22.79 ± 8.54

Regarding the type of clinical placements, no significant differences were found when
comparing the mean perceived stress (p = .352) using the ANOVA. However, significant
differences were identified in relation to anxiety state (p = .002). When comparing clinical
placements two by two, statistically significant differences were identified between Primary
Care and Special Services (15.9 ± 8.75 vs 23.77 ± 11.16, p = .006), Geriatrics and Special
Services (16.18 ± 7.53 vs 23.77 ± 11.16, p = .004) and Internal Medicine and Special Services
(16.14 ± 7.75 vs 23.77 ± 11.16, p = .001). Up to 100% of the students who displayed severe
anxiety in the state STAI were in specialized services

Table 3 Bivariate analysis of the mean score for the dimensions of the CSI compared by
academic year and gender

Gender (M, SD) U p value Year (M-SD) U p value

Problem Female 15.22 ± 3.42 1828.50 .208 2nd 15.33 ± 3.49 4192.50 .287
solving
Male 14.23 ± 3.50 3rd 14.83 ± 3.39

Self-criticism Female 6.59 ± 4.61 2051.00 .684 2nd 5.98 ± 4.35 3952–50 .091

Male 6.27 ± 4.30 3rd 7.16 ± 4.74

Expression of Female 10.23 ± 4.34 1432.01 .006** 2nd 10.14 ± 4.28 4390.00 .584
 Gender (M, SD) U p value Year (M-SD) U p value

emotion Male 7.61 ± 3.98 3rd 9.60 ± 4.48

Wishful Female 9.59 ± 5.25 1911.00 .348 2nd 8.62 ± 5.28 3610.50 .010*
thinking
Male 8.58 ± 4.51 3rd 10.36 ± 4.90

Social support Female 14.14 ± 4.65 1594.00 .032* 2nd 14.01 ± 4.65 4465.00 .725

Male 12.38 ± 4.15 3rd 13.78 ± 4.60

Cognitive Female 12.68 ± 3.87 1703.50 .083 2nd 12.51 ± 3.83 4543.50 .883
restructuring
Male 11.42 ± 3.07 3rd 12.51 ± 3.76

Problem Female 7.47 ± 1.56 1647.00 .048* 2nd 7.47 ± 1.71 4270.00 .382
avoidance
Male 6.69 ± 1.89 3rd 7.25 ± 1.52

Social Female 6.27 ± 3.66 2135.50 .932 2nd 5.50 ± 3.30 3509.00 .004*
withdrawal
Male 6.34 ± 4.03 3rd 7.13 ± 3.94
*p < .05; ** p < .01; U = U Mann Whitney
The CSI displays significant differences between gender for the dimensions Expression of
emotion, Social support and Problem avoidance, as, in all cases, the mean of these scores was
higher among female students. However, for the total score, despite the fact that the mean
score was higher in women (23.22 ± 8.55) than in men (20 ± 8.04), significant differences
were not found regarding gender (p = .069) for the total score. Regarding the students’
academic year, the dimensions that were found to be statistically significant were wishful
thinking and social withdrawal. The total mean score of the test for students in their second
year was 21.30 ± 8.65 and the total mean score for students in their third year was 24.40 ±
8.16, the statistical analysis was significant (p = 0.009)

Table 4 Spearman’s correlation coefficient between perceived stress, STAI state and
trait and dimension of CSI

1 2 3 4 5 6 7 8 9 10

1. Perceived stress

2. Anxiety state .463**

3. Anxiety trait .718** .264**

4. Problem solving −.452** .050 −.180*

5. Self- criticism .408** .144* .316** −.281*

*

6. Expression of emotion −.086 .051 −.063 .269** .059

7. Wishful thinking .459** .078 .313** −.142 .534** .196**

8. Social support −.220** .031 −.088 .439** −.042 .591** .085

9. Cognitive −.375** .003 −.145* .573** −.214** .298** −.071 .471**

restructuring

10. Problem avoidance .105 .423** .461** .053 .168* .106 .120 .004 −.053

11. Social Withdrawal .388** .138 .289** −.266** .396** −.104 .424** −.275** −.115 .091
* p < .05. ** p < .01
A Spearman’s rho correlation was used to investigate the relationship between total perceived
stress and anxiety (state and trait) and the PSS score with the total score on the CSI and all
subscales. The results displayed a significant correlation for the total on the PSS and the state
STAI (r = .463, p < .01) and for the total PSS and the trait STAI (r = .718, p < .01). Regarding
the perceived stress and the coping strategies, the results revealed a significant relationship
between the total perceived stress and the following domains of the CSI: problem solving (r
= −.452, p < .01), self-criticism(r = .408 p < .01), wishful thinking (r = .459, p < .01), social
support (r = −.220, p < .01), cognitive restructuring (r = −.375, p < .01), and social withdrawal
(r = .388, p < .01).
Table 5 Summary of Stepwise Regression Analyses to determine predictors of Perceived
stress

Independent Variables B SE B β t

Step 1

Anxiety trait .709 .049 .726 14.56**

Step 2

Anxiety trait .609 .049 .624 12.32**

Wishful thinking .440 .084 .266 5.26**

Step 3

Anxiety trait .550 .049 .564 11.28**

Wishful thinking .436 .080 .263 5.47**

Cognitive restructuring −.475 .105 −.211 −4.53**

Step 4

Anxiety trait .474 .053 .486 8.98**

Wishful thinking .445 .078 .269 5.72**

Cognitive restructuring −.485 .102 −.215 −4.75**

Anxiety state .153 .046 .162 3.30*

Step 5

Anxiety trait .439 .054 .450 8.15**

Wishful thinking .444 .077 .268 5.79**

Cognitive restructuring −.300 .124 −.133 −2.41*

 Independent Variables B SE B β t

Anxiety state .161 .046 .170 3.52**

Problem solving −.364 .142 −.147 −2.56*

R = .528 for step 1; R = .588 for step 2; R = .628 for step 3; R = .649 for step 4; R2 = .661
2 2 2 2

for step 5. * p < .05; **p < .01

For the first step, the adjustment index of the model was significant F (1, 191) 212.186, p
< .01 and the anxiety trait variable was a significant predictor of the perceived stress scale (β
= .726, t = 14.56, p < .01).
The significant variables included in the second model were: anxiety trait (β = .624, t =
12.32, p < .01) and wishful thinking (β = .266, t = 5.26, p < .01), the adjustment was F (2, 191)
134.82, p < .01.
For the third model, the significant variables were: anxiety trait (β = .564, t = 11.28, p < .01),
wishful thinking (β = .263, t = 5.47, p < .01), cognitive restructuring (β = −.211, t = − 4.53, p
< .01) and the adjustment was: F (3, 191), 106.01 p < .01.

For the fourth model anxiety trait (β = .486, t = 8.98, p < .01), wishful thinking (β = .269, t =
5.72, p < .01), cognitive restructuring (β = −.215, t = − 4.75, p < .01), and anxiety state (β
= .162, t = 3.30, p < .05) were significant variables, and the adjustment was: F (4, 191)
86.44, p < .01.

For step 5: anxiety trait (β = .450, t = 8.15, p < .01), wishful thinking (β = .268, t = 5.79, p
< .01), cognitive restructuring (β = −.133, t = − 2.41, p < .05), anxiety state (β = .170, t =
3.52, p < .01), and problem solving (β = −.147, t = − 2.56, p < .05) were significant variables,
furthermore the adjustment was: F (5, 191) 72.53, p < .01. The fifth model explained 66.1%
of the variance in perceived stress, representing the model with the best fit.
Implications for nursing education
Research findings are in line with previous research, highlighting that the study of coping
strategies appears instrumental for the prevention of stress. Moreover, it is essential for
training in these strategies to begin within the university facilities. These programs could help
prepare nursing students to cope with the challenges they are about to face during their
clinical rotations.
Limitations
This study has limitations that must be considered when interpreting these results. First, these
findings cannot be generalized, as the study was conducted in nursing students of only one
University and therefore, the socio-demographic structure of the sample was not necessarily
the same as other faculties in Rajasthan.
Conflict of Interest
No conflict of interest in the present study as it was self-financed
Ethical Clearance:
Ethical Clearance was obtained from the Ethical board of Nims University and written
consent was obtained from all the participants
Conclusion:-
On the basis of the study finding researcher recommend that the teaching of positive coping
strategies should be implemented in the nursing curriculum prior to clinical placements.
Qualitative research focused on the student’s perception on their clinical experience may be
helpful for developing an effective clinical teaching strategy in nursing education.

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