Stress and Coping Strategies among nursing students in Western Uttar Pradesh India: A Descriptive Study

Surat Ram Kudi¹, Balamani S Bose¹, Taniya³,Neha¹, Amisha Saini¹, Kusum Lata²*

¹College of Nursing LLRM Medical College SVBP Hospital, Meerut U.P, India.

²Ch. Kehar Singh Educational Trust Baraut, Baghpat U.P, India.

*Corresponding Author E-mail: Kusum.bhardwaj.133@gmail.com

ABSTRACT:

Background: 70% nursing students suffering from high level distress due to the demanding nature of their education and training. This further affects their academic performance, learning outcome of the students, physical and mental health, quality of life, resilience and even leads to suicidal behavior. Aim of this study was to explore stressors and coping strategies among nursing students. Material and methods: A descriptive survey was conducted on 100 nursing students of medical college. Structured standardized measuring tool perceived stress scale and coping behavior inventory were used to assess stressors and coping behaviors of the nursing students. Pearson corelation (r) was used to find the correlation between stressors and coping behavior. Multivariate analysis was used to find association between stress level, coping behaviour and demographic variables. Result: Mean age of the participants was 20.53±2.1. 93% participants were female and 7% were male. 67% were doing BSc Nursing course and 33% were doing GNM. Overall mean stress score was 47.85±13.16. Stress from taking care of patients, stress from the clinical environment and stress from teachers and nursing staff were highest source of stress. Overall mean score of coping mechanism was 38.08±8.14. Problem solving was the commonest coping mechanism used by participants against stressor. Conclusion: Students had higher stress from taking care of patient or environmental stress, so students should be prepared in simulation lab till they become skilled and confident to work on patient and clinical environment.

KEYWORDS: Coping Behavior, Perceived Stress, Students, Nursing.

INTRODUCTION:

Human being experience stress daily which further causes number of diseases.¹ According to Selye, Stress is caused by environmental stimuli.² When one body places demands on another, such placing one object on top of another, stress or anxiety is created in the physical environment that can lead to the collapse of the second object if it is unable to sustain the pressure from the first object.³ Similar to this, excessive or unmanaged stress can cause physical and mental breakdown in biological systems, including the human body, which can eventually have a negative impact on health.

Nursing students often experience high levels of stress due to the demanding nature of their education and training.⁴ Though nursing students are not responsible for care of the patient as registered nurse used to be. Nursing academics and clinical practices both are stressor for nursing students, Stressors for nursing students are academic workload heavy assignments and examination, engaging in various clinical activities, patient care, lacking nursing subjects knowledge and skills, fear of failure, interpersonal relationships with faculty and nursing staff, and fear of unknown.⁵ Compared to other educational program nursing students have higher level of stress.⁶ Stress level among nursing students increasing.⁷

Stress in mild level can be motivating to students and it may further encourage the students to learn and can improve their academic performance and clinical skills. Studies have shown 70% nursing students suffering from high level distress.⁸ Evidences have shown that High level of stress affects emotional, cognitive and physiological domains.⁹ Distress further affect their academic performance, learning outcome of the students, physical and mental health, quality of life, resilience and even leads to suicidal behavior.¹⁰

Students use various adaptive and maladaptive strategies. It includes adaptive coping strategies such as problem solving and actively facing the problems, ventilating emotions and asking for help, doing exercise or yoga, and positive thinking and maladaptive both.^11,12 Some students also use maladaptive coping strategies such as consuming alcohol or drugs, avoidance of problem.⁴

Stress is an individual response. Stressor can vary person to person. It depends on the individual at which extent they will response to the stressor. Utilization of the adaptive coping strategies can help the students to cope with the stress.¹³ It is required to work on emotional and behavioural adaptation with changing and challenging internal and external situations. Stress and coping skills of nursing students is essential for supporting their mental health, academic success, and professional development. It helps to ensure that nursing students are well-prepared to enter the healthcare workforce as competent and resilient professionals. A stress is constant issue but response to stress and coping strategies can vary with generations. Researcher were interested to know about the stressors which affect nursing students of western U.P. India and coping strategies used by them to deal with those stressors. Aim of this study was to explore stressors and coping strategies among nursing students.

MATERIALS AND METHODS:

A descriptive survey was done to conduct this study. Based on the finding from meta-analysis, prevalence rate of stress among nursing students was 0.35% and considering 95% confidence interval and 5% precision, sample size was calculated.¹⁴ Calculated sample size was 6. Total 100 students were chosen using simple random sampling technique. Researcher had taken data from nursing students studying in college of nursing LLRM Medical college Meerut. Participants who were willing to participate, between the age 17-40 years and available during the period of data collection were selected. Participants who do not understand English language, suffering from physical and mental illness were excluded.

Measuring Tools:

Tool A: Self developed structured Socio- demographic Tool. This part consists of 13 items. Modified Kupa swami scale guidelines were followed for the development of the tool for socio demographic characteristics.¹⁵

Tool B: Structured Perceived stress scale (PSS). It is a five-point Likert scale (0=never, 1=almost never, 2= sometimes, 3=fairly often, 4= very often) which has total 29 items and subdivided in six subscales i.e., Stress from taking care of patients, Stress from teachers and nursing staff, Stress from assignments and workload, Stress from peers and daily life, Stress from lack of professional knowledge and skills, Stress from the environment. The content validity index is 0.94.¹⁶

Tool C: Structured Coping behaviour inventory (CBI). It is a five-point Likert scale (0=never, 1 =Infrequently, 2= sometimes, 3=frequently, 4= always) which has total 19 items and subdivided in four subscales Avoidance, Problem Solving, Stay Optimistic, Transference. The Cronbach alpha for CBI was 0.76.¹⁶

DATA COLLECTION PROCEDURE:

The institutional review board approved the study. Participants were recruited using Simple Random sampling from BSc and GNM courses. The purpose of the study was explained to the participants and they were asked to withdraw from study anytime without having the fear of their academic grades being affected. Written informed consent was taken from the participants and unique identifier has been given to each participant. Participants were instructed that there is nothing right and wrongs responses, they have to choose the answers which is related to them. Researcher self-administered measuring tool one on one basis. Demographic data has been taken on the socio-demographic sheet. After administration of the socio-demographic sheet, participants were asked about their responses against Perceived stress scale and coping Behaviour inventory. It took 20 minutes to administer the measuring tools. At the end of data collection, participants queries have been cleared.

DATA ANALYSIS:

Data were analysed using SPSS version 20. Appropriate descriptive and inferential statistics was used for data analysis. For statistical significance p-value of <0.05. Mean score of the Perceived stress scale and coping behaviour inventory has been calculated. Frequency percentage of participants response against each item of Perceived stress scale and coping behaviour inventory has been calculated. Correlation between Perceived Stress Scale and Coping Behaviour Inventory has been calculated using Pearson’s correlation. Multivariate analysis has done to find association between demographic variable and Perceived Stress Scale and Coping Behaviour Inventory.

RESULTS:

Table 1: Sociodemographic characteristics of the participants N=100

Demographic Characteristics of patients		Mean± SD
Age in years		20.53± 2.1
		Percentage
Gender	Male	7
Gender	Female	93
Class	GNM	33
Class	BSCN	67
Native Place	Rural	27
	Urban	46
	Semi urban	27
Religion	Hindu	90
	Muslim	7
	Other	3
Educational Status of father	Illiterate	3
	Primary School Certificate	7
	Middle School Certificate	8
	High School Certificate	17
	Intermediate/ Post high school diploma	19
	Graduate or post graduate, Professional or honours	46
Occupation	Unemployed	10
	Elementary occupation	29
	Plant & machine operators and assemblers, Craft and related trade workers, Skilled Agricultural and Fishery Workers, Skilled Workers and Shop & Market Sales Workers	40
	Clerks	2
	Technician and associate professionals, Professionals	17
	Legislators, Senior officials, and managers	2
Socio Economic Status	Upper	4
	Upper Middle	47
	Upper Lower	29
	Lower Middle	18
	Lower	2
Accompanied with	Alone	22
	Dorn or roommate	41
	With spouse	2
	With parents	35
Average hours spend on studying per day	Hour or less	13
	3-4 hours	55
	5-6 hours	21
	7 or more	11
Hours spent in didactic lectures per week	<20 hours	32
	21-25 hours	30
	26-30 hours	20
	31-35 hours	18
Sleeping hours per day	<6 hours	23
	7-8 hours	61
	9-10 hours	10
	11 or more	6

Table 3 Percentage distribution of the Perceived stress among nursing students on Perceived Stress Scale N=100

Stress items	0 Never	1 Almost never	2 Sometimes	3 Fairly often	4 Very often
Stress from taking care of patients
Lack of experience and ability in providing nursing care and in making judgments	27	20	31	9	13
Do not know how to help patients with physio-psycho-social problems	12	33	27	15	13
Unable to reach one’s expectations	20	27	30	14	9
Unable to provide appropriate response to teacher’s and patient’s questions	11	36	28	9	16
Worried about not being trusted or accepted by patients or patient’s families.	23	30	20	11	16
Unable to provide patients with good nursing care	25	31	17	9	18
Do not know how to communicate with patients	22	21	27	18	12
Experience difficulties in changing from the role of a student to that of a nurse.	24	19	31	13	13
STRESS FROM ASSIGNMENT AND WORKLOAD
Worry about bad grades.	16	24	16	23	21
Experience pressure from the nature and quality of clinical practice.	15	20	16	27	22
Feel that one’s performance does not meet teacher’s expectations.	7	27	28	18	20
Feel that clinical practice requirement exceeds one’s physical and emotional endurance.	19	19	25	21	16
Feel that dull and inflexible clinical practice affects one’s family and social life.	12	28	17	26	17
STRESS FROM LACK OF PROFESIONAL KNOWLEDGE AND SKILLS
Unfamiliar with the medical history and terms.	28	12	25	12	13
Unfamiliar with professional nursing skills.	30	26	22	10	12
Unfamiliar with patient’s diagnosis and treatments.	18	23	21	30	8
STRESS FROM AREA OF PRACTICE
Feel stressed in the hospital environment where clinical practice takes place.	19	31	24	13	13
Unfamiliar with the ward facilities	13	16	38	16	17
Feel stressed from rapid changes in patient’s conditions.	17	22	29	15	17
Stress from peers and daily life
Experience competition from peers in school and clinical practice.	15	27	24	17	17
Feel pressure from teachers who evaluate students’ performance by comparison.	19	22	25	25	9
Feel that clinical practice affect involvement in extracurricular activities.	13	29	22	25	11
Cannot get along with peers.	25	25	22	21	7
STRESS FROM TEACHERS AND NURSING STAFF
Experience discrepancy between theory and practice.	14	37	24	14	10
Do not know how to discuss patient’s illness with teachers or nursing personnel.	23	26	20	13	18
Feel stressed because teacher’s instructions differ from one’s expectations.	15	33	25	12	15
Doctors lack empathy and are un-willing to help.	20	26	18	30	6
Feel that teachers do not evaluate students fairly.	18	29	32	15	6
Lack of care and guidance from teacher.	18	22	33	12	15

Table 5 Percentage distribution of the coping behavior among nursing students on Coping Behavior Inventory N=100

Coping Strategies	0 Never	1 Infrequently	2 Sometimes	3 Frequently	4 Always
Avoidance
To avoid difficulties during clinical practice	22	17	28	13	20
To avoid teachers	23	23	20	19	15
To quarrel with others and lose temper	32	27	18	14	9
To expect miracles so one does not have to face difficulties	28	17	16	18	21
To expect others to solve the problem	19	20	28	13	20
To attribute to fate	17	21	29	14	9
Problem solving
To adopt different strategies to solve problems	15	23	22	19	21
To set up objectives to solve problems	18	22	18	14	28
To make plans, list priorities, and solve stressful events	30	15	16	18	21
To find the meaning of stressful incidents	17	28	16	26	13
To employ past experience to solve problems	18	9	22	26	25
To have confidence in performing as well as senior schoolmates	19	21	17	20	23
Stay optimistic
To keep an optimistic and positive attitude in dealing with everything in life	21	21	17	18	23
To see things objectively	11	22	19	23	25
To have confidence in overcoming difficulties	19	22	25	18	16
To cry, to feel moody, sad, and helpless	14	19	17	23	27
Transference
To feast and take a long sleep	14	11	31	20	24
To save time for sleep and maintain good health to face stress	18	26	17	23	16
To relax via TV, movies, a shower, or physical exercises	16	24	21	17	22

Table 6 showing corelation among type of Stressors and Coping behaviours. Pearson corelation (r) test was used to find the correlation. Statistically significance was considered at p<0.05. A positive weak corelation (r=0.31) was found between avoidance and Stress from teachers and nursing staff, problem solving and stress from assignments and workload (r=0.35) and stress from the environment (r=0.33). Multivariate analysis was used to find association between stress Level, coping Behaviour and Demographic Variables. A statistically significant difference was found between stress from taking care of patients and socio economic stress R² 0.32, F=1.83, at p=0.03, Stress R²= 0.33 F=1.83, p=0.02, stress from assignments and workload and socio economic status R² 0.17= F= 1.94, p=0.04, stress from peers and daily life and socio economic status R² 0.27= F= 2.709, p=<0.01, stress from lack of professional knowledge and skills and socio economic status R²0.33 F=3.347, p<0.001), Education of father R²0.27 F=2.159, p<0.001). A statistically significant difference was found between overall stress and socio- economic stress R²0.54 F=1.731, p=0.02, hours spent in didactic lectures per week R²0.51 F= 1.578 p=0.04.

A statistically significant association was found between avoidance and gender R²0.26 F = 1.892 p= 0.03, socio-economic status R²0.27 F =1.917 p= 0.03, average hours spend on studying per day R² 0.41 F =3.736 p= <0.001. A statistically significant association was found between problem solving and average hours spend on studying per day R²0.33 F=2.223 p=< 0.01. A statistically significant association was found between stay optimistic and religion of participants R²0.24 F =1.940 p= 0.03, average hours spend on studying per day R² 0.22 F = 1.803 p= 0.04.

DISCUSSION:

Understanding stress and the coping strategies employed by nursing students is crucial for developing interventions to support their well-being and academic success. In our study we found overall mean score of Perceived stress on Perceived stress scale was 47.85±13.16. Toqan et.al. found PSS overall mean score 41.2(SD = 19.5).¹⁷ In this study we found most common source of stress for nursing student was stress from taking care of patient was (M=13.73±4.91) followed by environmental stress (M=10.76±4.96), stress from teachers and nursing staff was (M=10.51±4.12), stress from lack of professional knowledge and skills was (M=7.29±3.43), stress from peers and daily life was (M=5.71±2.48) and stress from assignments and workload (M=4.95±2.90). One study found common source perceived was stress from “taking care of the patients” (M = 11.4±0.85), followed by “stress from teachers and nursing staff” (M = 8.32±5.3) and “stress from assignments and workload” (M = 7.5±4.6).¹⁷

Ahmed et.al. found mean of stress related to patient care was 1.56±0.45, stress related to assignments and capacity was 1.60±043, stress related to deficiency of professional knowledge and competences was 1.24±0.45, stress related to the environment of practice was 1.47±0.49, stress related to peers and daily life events was 1.89±0.67, and stress related to instructors and nursing staff was 1.45±079.¹⁸ Hamaideh et.al found highest source of stress teachers and nursing staff and assignment and workload.¹⁹ Chaabne et.al found clinical stressors as patient care, workload, assignments while academic stressors were lack of breaks course load and low grades.²⁰

Overall mean score of coping behavior was 38.08±8.14. Toqan et.al. found overall mean score of coping behavior was M = 29.0±15.2.¹⁷In our study coping strategy used by nursing students was problem Solving (M=12.36±4.00), followed by avoidance (M=10.95±3.82), stay optimistic (M=8.50±3.43) and transference was (M=6.27±2.48). This study findings are consistent with Toquan et al. found common coping strategy used by participants was problem-solving (M = 9.48±5.63), followed by avoidance (M = 8.84±5.74) and being optimistic (M = 6.35±3.96), while transference was the least commonly used (M = 4.36±3.02).¹⁷ While Ahmed et.al. found problem solving (M=1.84±0.67), stay optimistic (M=1.56±0.76), transference(M=1.34±1.20), avoidance (M=1.23±0.56).¹⁸ Chaabne et.al found nursing students use problem solving, regulation of emotions, ventilation of emotions as coping behavior.²⁰ A positive weak corelation (r=0.31) was found between avoidance and Stress from teachers and nursing staff, problem solving and stress from assignments and workload (r=0.35) and stress from the environment (r=0.33). Ahmed et.al. also found corelation between avoidance and stress related to teachers and nursing staff, problem solving and stress related to assignments and workload and Stress from the environment.¹⁸

LIMITATION:

In this study we get the information about the nursing student stressor and coping behaviour at a single point of time as we used cross-sectional research approach. Secondly data has been collected from one nursing college which affects generalizability of study. Although we used randomization to choose participants but homogeneity was not there. We did not explored individual stressor and coping behavior other than standardized tool.

RECOMMENDATION AND IMPLICATIONS:

Longitudinal research can be used to assess students stress and coping behaviour. Qualitative study or mixed research approach can also be used to understand stressors and coping behaviour in depth. Students had higher stress from taking care of patient or environmental stress, so students should be prepared in simulation lab till they become skilled and confident to work on patient and environment. Teachers should deal with students one on one basis and their all doubts should be cleared.

CONCLUSION:

Most common source of stress for nursing student was stress from taking care of patient was followed by environmental stress from teachers and nursing staff was stress from lack of professional knowledge and skills was, stress from peers and daily life was and stress from assignments and workload. Coping behaviour used to deal with stress was problem Solving followed by avoidance, staying optimistic and transference.

CONFLICTS OF INTEREST:

There are no conflicts of interest.

ACKNOWLEDGEMENT:

We are thankful to the participants for sparing their valuable time.

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Received on 23.07.2024 Revised on 08.11.2024

Accepted on 16.01.2025 Published on 28.02.2025

Available online from March 26, 2025

A and V Pub Int. J. of Nursing and Med. Res. 2025; 4(1):13-19.

DOI: 10.52711/ijnmr.2025.03

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Stress items	Item Ranking	Mean	SD
Overall PSS		47.85	13.16
Stress from taking care of patients	1	13.73	4.91
Stress from teachers and nursing staff	3	10.51	4.12
Stress from assignments and workload	6	4.95	2.90
Stress from peers and daily life	5	5.71	2.48
Stress from lack of professional knowledge and skills	4	7.29	3.43
Stress from the clinical environment	2	10.76	4.96

Coping mechanism	Item Ranking	Mean	SD
Overall		38.08	8.14
Avoidance	2	10.95	3.82
Problem Solving	1	12.36	4.00
Stay Optimistic	3	8.50	3.43
Transference	4	6.27	2.48

Stress items	Avoidance	Problem Solving	Stay optimistic	Transference
Stress from taking care of patients	-0.06	-0.07	0.02	0.02
Stress from teachers and nursing staff	0.31*	-0.16	0.03	0.03
Stress from assignments and workload	-0.10	0.35*	-0.01	-0.01
Stress from peers and daily life	-0.11	0.02	0.03	0.03
Stress from lack of professional knowledge and skills	-0.14	0.13	0.10	0.10
Stress from the environment	-0.10	0.33*	-0.06	-0.06