Scholarly article on topic 'Perceived stress among Macao nursing students in the clinical learning environment'

Perceived stress among Macao nursing students in the clinical learning environment Academic research paper on "Educational sciences"

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Abstract of research paper on Educational sciences, author of scientific article — Ming Liu, Ken Gu, Thomas K.S. Wong, Min Z. Luo, Men Y. Chan

Abstract Objective This study aimed at investigation of the stress perceived by Macao nursing students in the clinical learning environment. Methods A cross-sectional research was designed and 203 nursing students in a public higher education institute were recruited. The Stressors in Nursing Students Scale-Chinese Version (SINS-CN) was used to measure nursing students' stress. Data analysis includes descriptive analysis and analysis of variance. Results The overall SINS-CN mean score was 3.33 (SD = 0.49), while the scores for different dimensions were: clinical, 3.44 (SD = 0.54), education, 3.35 (SD = 0.62), finance and time, 3.31 (SD = 0.72), confidence, 3.21 (SD = 0.60), and personal problems, 3.03 (SD = 0.68). Among 10 most common stressors, four belong to the clinical dimension, four to the education dimension, one to the confidence dimension, and one to the finance & time dimension. Analysis for factors associated with stress indicated that no statistical significance was found in most demographic variables, except year two students' stress scores were significantly lower than those of students in other years (p values were between 0.000 and 0.026). Conclusions Macao nursing students, to some extent, experienced stress in clinical learning environment and the stress level was higher than that of Hong Kong nursing students. The most common stressors were related to clinical and educational dimensions. The study suggests that teaching and learning modalities and the workload of nursing students should be reviewed.

Academic research paper on topic "Perceived stress among Macao nursing students in the clinical learning environment"

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Original Article

Perceived stress among Macao nursing students in ^ the clinical learning environment

Ming Liu a, Ken Gu a'*, Thomas K.S. Wong b, Min Z. Luo a, Men Y. Chan a

a School of Health Sciences, Macao Polytechnic Institute, Rua De Luis Gonzaga Gomes, Macao b Knowledge Transfer and Consultancy Company Limited, Hong Kong

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ARTICLE INFO

ABSTRACT

Article history:

Received 29 December 2014 Received in revised form 21 April 2015 Accepted 24 April 2015 Available online 14 May 2015

Objective: This study aimed at investigation of the stress perceived by Macao nursing students in the clinical learning environment.

Methods: A cross-sectional research was designed and 203 nursing students in a public higher education institute were recruited. The Stressors in Nursing Students Scale-Chinese Version (SINS-CN) was used to measure nursing students' stress. Data analysis includes descriptive analysis and analysis of variance.

Results: The overall SINS-CN mean score was 3.33 (SD = 0.49), while the scores for different dimensions were: clinical, 3.44 (SD = 0.54), education, 3.35 (SD = 0.62), finance and time, 3.31 (SD = 0.72), confidence, 3.21 (SD = 0.60), and personal problems, 3.03 (SD = 0.68). Among 10 most common stressors, four belong to the clinical dimension, four to the education dimension, one to the confidence dimension, and one to the finance & time dimension. Analysis for factors associated with stress indicated that no statistical significance was found in most demographic variables, except year two students' stress scores were significantly lower than those of students in other years (p values were between 0.000 and 0.026).

Conclusions: Macao nursing students, to some extent, experienced stress in clinical learning environment and the stress level was higher than that of Hong Kong nursing students. The most common stressors were related to clinical and educational dimensions. The study suggests that teaching and learning modalities and the workload of nursing students should be reviewed.

Copyright © 2015, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author.

E-mail address: kengu@ipm.edu.mo (K. Gu). Peer review under responsibility of Chinese Nursing Association. http://dx.doi.org/10.1016/jijnss.2015.04.013

2352-0132/Copyright © 2015, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Stress refers to a dynamic interaction between the individual and the environment [1]. This interaction may lead to cognitive, emotional and behavioral alteration [2]. Nursing as a caring profession has been known to be a stressful occupation [3]. Nursing students who engage in a wide range of clinical duties during their learning in clinical settings share similar stressors as professional nurses experience. In addition, nursing students also have stress related to their educational studies and personal/social experience [4]. Stress can be deleterious to individuals and lead to physical and psychological distress [5]. This psychological distress may hamper students' academic performance and hence impede their pursuit of the nursing career temporarily or permanently [6]. What is more, stress and psychological distress may have negative effects on nursing graduates in the workforce [7].

Existing evidence indicates that nursing students have higher levels of stress than students in other disciplines [8,9], but stress varies at different education levels of nursing students and different nursing programs [7,10,11]. Common sources of stress in nursing students basically include: a) academic-related concerns such as workload, lack of knowledge, examination, teaching style; b) clinical practice for example, lack of competence, taking care of death and dying, shifting, supervision, assessment; c) relationships with others (clients, peers, teachers or other health professionals) [12]; and d) personal factors such as gender, age, new surroundings away from home, family structure, financial burdens and job roles [4,7,13].

Study on nursing student stress in the Macao Special Administrative Region of Republic of China (Macao SAR) is very limited. Vong and colleagues used a convenience sampling method to recruit 77 nursing students to complete a self-developed scale of nursing student stress [14]. The psychometric properties of the scale were not presented. The results indicated that the average level of stress was moderate and the clinical practice and academic workload were the first and second ranked stress factors. Another unpublished study was conducted by Li [15]. Its main purpose was to explore the effect of personal characteristics of nursing students on stress and coping strategies [15].

There are two nursing education agencies in Macao, a charity agency which was founded in 1923 and a government-funded agency, founded in 1964 [16]. Together with Macao's political system, the Macao nursing education system has experienced remarkable changes in the past 15 years since the return of Macao's sovereignty from Portugal to the People's Republic of China (PR China) in 1999. Nursing education has been transformed from hospital-based training to tertiary education based, from a three-year diploma program to the"3 + 1" supplementary bachelor degree (three-year diploma plus one-year of supplementary study), and then to the current four-year baccalaureate degree program [16].

Simultaneously, clinical practice has been reformed from supervision and assessment of students by clinical nurses to one that typifies the cooperative work of the nursing faculty and clinical nurses [16]. The advantage of doing this is ensuring the quality of students' learning in clinical practice.

However, it may cause more stress to students. In an Annual School-Student Dialog in one of the public universities in Macao, some nursing students reported that 'they are overloaded with work because assignments and assessment usually come from both nursing faculty and clinical supervision nurses'. Another unpublished report from the Student Affairs Office indicated that among 18 different disciplinary programs, the nursing program students ranked the highest in 'Level of Academic Challenge' [17].

In addition, students may be overwhelmed by and feel stressed in Macao's complex multicultural clinical environment. Although about 95% of the population is Chinese [18], Macao was a Portuguese colony for more than 400 years, resulting in a very multicultural society. The original multi-culturalism has been compounded in recent years by a dramatic increase of immigration and tourism, making the healthcare services situation even more complicated and challenging [19]. A simple example is the increasingly multilingual environment, where three languages (Chinese, Portuguese and English) consisting of four dialects (Cantonese, Mandarin, Portuguese and English) are in daily use in clinical settings. Nursing students often report experiencing difficulty in such a multilingual working environment. Therefore, it is important for us to understand the stress perceived and stressors experienced by our nursing students so that we can prevent the undesirable impacts incurred in the current situation of healthcare provision in Macao. The general aim of this study was to investigate the stress perceived by Macao nursing students in the clinical learning environment. The specific objectives of the study were: a) to measure the level of stress perceived by nursing students; b) to identify the sources of nursing student stress in the clinical learning environment; and c) to analyze the factors that are associated with stress experienced by nursing students.

2. Methods

2.1. Study design

The study was a cross-sectional descriptive design using self-administered questionnaires for data collection.

2.2. Setting and sample

The study took place in a public higher education institution in Macao SAR. All students studying in the nursing program were recruited to minimize sampling error. The total number of nursing students was 231. Excluding 20 students who participated in the instrument test-retest reliability study, there were 211 participants in the main study.

2.3. Ethical consideration

Approval was sought from the Research Ethics Committee of the study setting before conducting the study. Permission for using the questionnaire was granted by the original corresponding author. All participants were assured of anonymity and confidentiality. A signed consent form was obtained from

those who were willing to participate in the study before data collection.

2.4. Measurements/instruments

Data collection instruments included the demographic profile and the Stressors in Nursing Students Scale-Chinese Version (SINS-CN). The validity of the SINS-CN has been established in a previous study and the internal consistency with Cronbach's a is >0.7 [20]. The original SINS-CN is a 43-item, self-administered questionnaire covering clinical, confidence, education and financial sources of stress [20]. The questionnaire uses a five-point Likert scale from 1 'being not at all stressful' to 5 'being extremely stressful' [20]. The validated version among Macao nursing students consists of 43-item with five dimensions with Cronbach's a 0.96 for overall scale and 0.67-0.94 for sub-dimensions [21]. A test-retest reliability with 2-week interval was 0.82 for the overall instrument and 0.70-0.88 for the sub-dimensions [21].

2.5. Data collection/procedure

The researchers delivered the questionnaire to all 211 participants at the end of a single semester at the point in time when each level of students finished their clinical placement. The completed questionnaires were collected from the returning boxes after two weeks. These questionnaires and data sheets were stored in a locked cabinet.

2.6. Data analysis

The Statistical Package for the Social Sciences (SPSS version 20) was used in performing data analysis. Descriptive statistics were used to analyze the socio-demographic data and stress level as well as the common stressors of students. Post hoc was used to compare the mean scores of the five factors among the four years of students.

3. Results

3.1. Demographic characteristics of participants

Totally, 203 valid responses were obtained with a 96% valid return rate. Demographic characteristics of participants were presented in Table 1.

3.2. Level of stress and common stressors

The overall SINS-CN mean score was 3.33 (SD = 0.49), while the scores for different dimensions were: clinical, 3.44 (SD = 0.54), education, 3.35 (SD = 0.62), finance and time, 3.31 (SD = 0.72), confidence, 3.21 (SD = 0.60), and personal problems, 3.03 (SD = 0.68). The ten most highly scoring common stressors perceived by students are presented in Table 2. Among them, four stressors belonged to the clinical dimension (items 3, 9, 24, 39), four to the education dimension (items 1, 4, 7,18), one to the confidence dimension (item 33), and one to the finance and time dimension (item 22).

Table 1 - Demographic data (n = 203).

Demographic characteristics No. %

Gender

Male 45 22.2

Female 158 77.8

Mean = 20.8 (SD = 2.9)

Year of students

Year 1 54 26.6

Year 2 53 26.1

Year 3 53 26.1

Year 4 43 21.2

Religions

No religion 173 85.3

Christians 14 6.9

Catholics 8 3.9

Buddhists 8 3.9

Parents' marriage status

Married 173 85.2

Single 11 5.4

Divorced 19 9.4

Family household monthly income (MOP)a

<10,000 3 1.5

10,000-20,000 21 1O.3

20,000-30,000 95 46.8

30,000-40,000 68 33.5

>50,000 MOP 16 7.9

a MOP: Macao Pataca (1 US $ = 8.OOMOP).

3.3. Factors associated with stress

The researchers further explored the demographic variables which might affect the students' stress. However, no statistical significance was found in most variables except year of study. The p-values were found significant in the statistic results between year of study and total mean score and each of the five dimensions. In further analysis for multi-group comparison, we found year two students' stress scores (including the five dimensions) were significantly lower than those of students in other years (with p values between 0.000 and 0.026), as shown in Table 3.

4. Discussion

4.1. Level of stress and common stressors

The results revealed that Macao nursing students, to some extent, experienced stress in the clinical learning environment and the stress level was higher than that of Hong Kong nursing students [22]. Macao and Hong Kong have a lot of similarities in terms of nationality, political system, social structure and economy; however, nursing education is, to some extent, different. Nursing in higher education in Hong Kong is quite mature, while in Macao it is still in its transition period to a four-year tertiary education degree with an extensive clinical practice component [19]. Moreover, the arrangement and management of clinical placement might

Table 2 - Common stressors perceived by nursing students (N = 203).

Item No Stressors Rank Mean (SD)

9 Fear of making a mistake in clinical placements 1 4.00 (0.93)

3 Having too much clinical responsibility 2 3.86 (0.71)

22 The lack of free time 3 3.79 (0.98)

33 Fear of failing in the course 4 3.77 (0.94)

1 The amount of classwork material to be learned 5 3.75 (0.73)

7 Examinations and placement gradings 6 3.67 (0.94)

24 Criticism from peers or senior staff 7 3.66 (0.94)

18 Having too much to learn 8 3.65 (0.89)

39 Feeling responsible for what happens to patients 9 3.63 (0.88)

4 The difficulty of the classwork material to be learned 10 3.50 (0.73)

have attributed to the level of stress reported in the results. The multicultural and complex clinical environment certainly had an impact on the students' stress. As mentioned in the introduction, students could have felt challenged and stressed by the multi-language clinical environment. Leong stated that even the students majoring in languages in Macao, e.g. Translation and Interpretation majors, have to cope with three formidable languages and several dialects [23]. It suggests that school should help students build up their language ability by employing more strategies, e.g. adding Portuguese leaning in the curriculum, facilitating mandarin leaning and practicing opportunities.

Among the top ten common stressors ranked by Macao nursing students, most of them were clinical and education related stressors. Particularly, the first and second most common stressors encountered by students were due to stress from the clinical dimension, such as 'Fear of making a mistake in clinical placement' (M = 4.00, SD = 0.93) and 'Having too much clinical responsibility' (M = 3.86, SD = 0.71). These findings are consistent with the previous findings by Wilson and by Mahat [24,25]. The high stress scores could be a result of inadequate preparation and lack of confidence. Students often worry that any mistake they make will affect their grade and even their status. According to the currently implemented clinical placement regulations in the studied school, a student who makes any mistake in invasive procedures, administering oral medications, or procedures causing any injury to clients, would be suspended from his/her clinical placement. The student is then asked back to the school laboratory to practice the skills until judged "satisfactory" by the School Pedagogical Committee, whereupon the student is allowed to resume his/her clinical practice. Besides, the students' fear could have been exaggerated by the preceptors' high

expectations of the students' performance, particularly on the part of clinical preceptors [25,26]. A special training program is needed to equip clinical preceptors' knowledge and skills in precepting students in clinical environment.

The other most common stressors were related to the heavy workload. The findings supported those from the studies in Hong Kong and Taiwan [27,28]. This might be a result of the heavy curriculum with too many clinical placement hours compared to those in western countries. According to the California Board of Registered Nursing, nursing students in the United States are only required to complete about 1000 hours of clinical practice before graduation [29]; the University of Notre Dame in Australia requires 1240 hours of clinical placement [30]. The 4-year Bachelor of Nursing program in Macao was designed with 160 learning credits, among which 46 credits (1840 hours) are clinical placement [31]. In each clinical unit, students are required to submit at least three assignments including a clinical learning plan, clinical reflections and case study reports. In addition, both clinical supervision nurses and academic teachers are required to assess the performance of each student, which might have caused additional stress to students. Considering the present study findings, the researchers suggest that the teaching and learning modalities and the workload of nursing students should be reviewed.

4.2. Factors associated with stress

Among all demographic variables, only 'year of study' was found to have a significant effect on students' stress. Post-hoc analysis demonstrated that the second year students claimed to experience less stress than their peers in the other three class groups both for the overall stress scale and sub-

Table 3 - Comparison between year groups with overall SINS-CN and sub-dimensions.

Scale and sub-dimensions Year 1 (n = 54) Year 2 (n = 53) Year 3 (n = 53) Year 4 (n = 43) F p

Mean score (SD)

Overall scale 3.57 (0.54) 2.98a (0.51) 3.46 (0.37) 3.37 (0.44) 5.63 0.021

Clinical 3.58 (0.62) 2.99a (0.54) 3.57 (0.42) 3.48 (0.43) 9.33 0.000

Confidence 3.39 (0.63) 2.98a (0.62) 3.24 (.46) 3.21 (0.60) 7.74 0.000

Finance and time 3.31 (0.74) 2.97a (0.72) 3.36 (0.62) 3.59 (0.75) 3.27 0.022

Education 3.34 (0.52) 3.02a (0.71) 3.34 (0.52) 3.40 (0.60) 4.80 0.003

Personal problem 3.25 (0.78) 2.78a (0.65) 3.03 (0.56) 3.04 (0.67) 3.14 0.026

a p < 0.05.

dimensions (p < 0.05, Table 3). This result is inconsistent with the findings of the previous studies reported from other countries. A study conducted by Rajesh Kumar in Iran found that the first year students had the highest level of stress compared with other senior year students [32]. She explained that the higher stress level experienced by first year students could be a result of being placed in an unfamiliar environment, separation from the families and the demand of forming new social groups apart from academic pressures and clinical training. Interestingly, a study conducted in Malaysia found that second year students in fact claimed to be more stressed than other year groups [33]. It is therefore appropriate to postulate year of study as an independent factor that may affect the nursing students' experience and perception of stress, though the effect is very much dependent on curricular context. Reviewing the curriculum design and organization of clinical placement in the studied school, the researchers noted that no special feature was found in year two study except more extra-curricular activities than in other years of the program. These activities might have helped students enhance their adaptation to and management of the stress induced in the clinical environment. In view of this uncertain association, we recommend a longitudinal cohort study be conducted to assess the possible changes of stress perception of Macao nursing students and the associated factors. To further understand the student's experience and perception, a qualitative study including, but not limited to the use of in-depth interview and story-telling should be carried out either together with the longitudinal study or on its own.

5. Limitations

This study used cross-sectional design, so the data were collected at a single time point. The pattern, consistency and intensity of stress over time were not assessed. Future study should incorporate a longitudinal cohort design to improve the present research methodology. In addition, as previously mentioned, Macao SAR has two higher nursing education institutions, one charity-funded and another government-funded. This study setting was confined only to the government-funded institution. Therefore, generalization of the results should be cautioned. Dimensions of SINS-CN questionnaire does not address local issues such as multi-culturalism and language issue, a modification and validation of scale study may be needed.

6. Conclusions

Macao nursing students, to some extent, experienced stress in clinical learning environment and the stress level was higher than that of Hong Kong nursing students. The most common stressors were related to clinical and educational dimensions. Except for the variable 'year of study', all other demographic variables did not show any statistically significant effect on students' stress. Comparative results analysis indicated that year two students experienced less stress than other peer groups. To further understand the student's experience of stress in learning, the researchers consider it necessary in the

future to conduct a longitudinal study on a cohort of students, and if possible, complementary work with a qualitative procedure.

Acknowledgment

The authors gratefully acknowledge the valuable contributions of Dr. Joanna Radwanska-Williams in the preparation of this manuscript. The project was sponsored by the Macao Polytechnic Institute Research Fund (Code: RP/ESS-03/2012).

Conflict of interest

The authors declare no conflict of interest regarding this research and paper.

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