Running head: MANIFESTATIONS OF STRESS

Manifestations of Stress in Occupational Therapy Students

Samantha Burneo, Edith Feld, Danielle Palmer, and Michelle Versten
Touro University Nevada

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Introduction

Stress can sometimes be an unavoidable part of life that occurs when there is a change
from an individual's everyday norm. Demands and pressures of school and work may lead to an
increased level of stress. High levels of stress can lead to panic and tension that affect
individuals in a variety of ways. Long-term stress can lead to lifelong manifestations of stress
such as obesity, hypertension, heart attack, stroke, and substance abuse (Chipas & McKenna,
2011). In todays society, graduate students experience high degrees of stress that manifest
differently among each of them. High-intensity curriculum programs require commitment and
hard work from the students, and this stress may negatively impact the students (Gupchup,
Borrego, & Konduri, 2004). In a learning environment, positive stress contributes to the positive
motivation of a student, but if it exceeds a healthy level it can affect them negatively in many
aspects of their lives.
Stress is seen as an individual experience since each person has unique responses and
manifestations of stress. According to Chipas, Cordrey, Floyd, Grubbs, Miller, & Tyre (2012),
some of the most common manifestations of stress found in students include forgetfulness,
preoccupation, depression, headaches, fatigue, diarrhea, decreasing levels of self-esteem,
depressive thoughts, and thoughts of suicide. A study conducted on pharmacy students showed
evidence to indicate that stress does affect academic performance among graduate students and
medical students (Gupchup et al., 2004, p. 297). Additionally, the study suggested that there
was a negative relationship between perceived student-life stress levels and the mental
component of their quality of life (Gupchup et al., 2004). Further, a study that focused on the
perceived level of stress in occupational therapy students at a Texas university found that the
students in their entry-level graduate program experienced more than average stress, but the

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authors emphasized that there still needs to be a lot more research conducted to discover types of
stress and specifically how stress manifests differently in graduate students (Pfeifer, Kranz, &
Scoggin, 2008). Based upon the knowledge gathered from this literature review, the study
presented in this paper asked the following research question: How does stress manifest in
graduate students at Touro University Nevada in the Masters of Occupational Therapy program?
Methodology: Design of the Study
The purpose of this qualitative study was to understand the manifestations of stress for
occupational therapy (OT) students in the 2016 cohort at Touro University Nevada (TUN). This
would allow the participants to be aware of the consequences of their stress and take the
necessary actions to reduce it. Narrative research was the qualitative strategy used in this study
because the researchers asked the participants to explain how they experienced stress. The
researchers randomly selected eight names from the 32 other students (excluding the four
researchers from the 36 total) in the 2016 OT cohort at TUN. All eight selected participants
accepted the request. The interviews were individual, semi-structured interviews consisting of
open-ended questions. All four researchers participated in the interviews. There were two
researchers per interviewee, where one researcher asked the questions and the other researcher
recorded the answers. Once all the interviews were conducted, the researchers coded the
answers together to understand how stress manifested in the participants. Open coding and axial
coding were the strategies used to analyze the participants answers to find themes. To validate
the findings, the researchers used triangulation methods.
Results
Participants and Data Collection

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After a random selection of eight participants from the 32 cohort members, the
researchers sent out an e-mail on January 7th, 2015 to request participation. All eight selected
individuals confirmed participation via e-mail on that same day. The researchers then sent a
follow-up e-mail to determine times and dates that worked for the participants to be
interviewed. The researchers waited one week to begin interviews because many other studies
were being conducted during that same week. This allowed the researchers to easily conduct all
interviews within two days. Seven interviews were conducted on January 14th, and one
interview was conducted on January 16th. The interviews each lasted between 10 and 20
minutes. The population for the participants consisted of seven female OT students and one
male OT student from the 2016 cohort at Touro University Nevada.
Thematic Analysis
Through the interviews, the researchers asked six questions that focused on determining
the different aspects of the manifestations of stress. The researchers also asked five additional
questions related to sources and occurrences of stress (see Appendix for interview
questions). Each interview was conducted by two of the four researchers. One researcher asked
the questions while the other transcribed the interviewees responses on a laptop. Also, all
interviews were recorded using a cell phone after consent was obtained from each participant.
Once all interviews were conducted, all four researchers came together to interpret
responses and code themes. Through the process of triangulation, the researchers together
agreed upon the interpretations of the responses. Once interpretations were agreed upon,
responses were coded by category into common themes. The four overarching categories of the
manifestations of stress included physical, psychological, emotional, and social. The categories
were further broken down into themes based on the different responses of the participants. Any

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response that was given at least three times between all interviews was considered a
theme. Table 1 outlines the common themes of each category and the total number of responses
that fell into each theme.
Responses coded under the physical category included anything related to internal and/or
external body responses. The themes that emerged included nervous system, gastrointestinal
system, cardiopulmonary system, and muscular system. The nervous system theme included
responses such as headaches and fatigue, as well as appetite and body temperature changes. For
example, when asked about physical manifestations of stress, Participant #4 stated, Fatigue...my
appetite decreases a little bit. The gastrointestinal theme included responses such as bloating,
increased frequency of bowel movements, diarrhea, and constipation. Participant #2 stated,
When I am really stressed, I will have frequent bowel movements. The cardiopulmonary
theme included responses such as increased heart rate and shortness of breath. Participant #3
said, In times of great stress, my heart will pound. The muscular system theme included
responses such as body aches and tense muscles. Participant #3 explained, I feel tightness in
my shoulders a lot. I feel it right around my trapezius muscles, and it just feels really tight. I
will sit there and constantly rub it. Some of the less common responses under the physical
category included sweaty hands and acne, which would relate to the integumentary system.
While the psychological and emotional categories were similar, responses coded under
the psychological category included manifestations related to thoughts and feelings, whereas
responses coded under the emotional category included manifestations related to the expression
of or reaction to those thoughts and feelings. Due to the similarity of these categories,
participants were prompted to help differentiate between the two definitions. The themes for the
psychological category included self-esteem, thought-related, and psychological distress. The

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self-esteem theme included responses such as self-doubt, lack of confidence, and generalized
insecurities. For example, Participant #4 stated, self-doubt and thinking...can I actually do
this? The thought-related theme included responses such as cloudy or scattered thoughts, lack
of focus, and inflammatory thinking. Participant #1 explained, I think my focus isnt as sharp
when Im stressed just because I feel like Im a little all over the place or scattered. The
psychological distress theme included responses such as anxiety, fear, and depression. For
example, Participant #8 stated, I get really bad anxiety when Im stressed. Each response
regarding the psychological manifestations of stress was mentioned at least three times between
all the interviews, so each response fell into one of the themes.
The themes for the emotional category included crying and irritability. The crying theme
included responses such as getting teary-eyed or crying. For example, Participant #1 explained,
Ive even teared up because Im so stressed that I just cant handle it. All responses coded
under the irritability theme were simply being irritable. For example, Participant #3 stated, I get
very irritable. I make big things out of small things. Some of the less common responses under
the emotional category included anger and sadness.
Responses coded under the social category included the effects of stress on relationships
with others. The themes that emerged included isolation/withdrawal, short temper, and
decreased interaction. The isolation/withdrawal theme included responses related to isolating
oneself from others or withdrawing from social situations. For example, Participant #5
explained, When I am stressed, it is hard to socialize or be around other people because I have
so much to do and a lot on my mind. The short temper theme included responses such as being
snippy and taking ones stress out on others. Participant #3 stated, I become very snippy and
short tempered. The decreased interaction theme included responses such as being less

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talkative or interactive when in social situations. For example, Participant #6 said, It [stress]
makes me not want to talk to them [my friends]. Some of the less common responses under the
social category included suffering friendships and the use of foul language.
When asked if they experienced any other symptoms related to stress, none of the
participants mentioned any. The other interview questions provided us more in-depth
information about the sources and occurrences of stress. For example, all eight participants
listed school as a primary source of stress. Similarly, six participants expressed that they were
most stressed before exams, and five participants expressed that they were most stressed before
big assignments were due. Five participants indicated that they were most stressed early in the
week, whereas seven participants indicated they were least stressed on the weekends. There
were no significant trends indicating a specific event or situation in which participants felt the
least amount of stress. Additionally, when participants were asked to compare manifestations of
stress related to school versus stress related to other life events, majority of participants (six out
of eight) responded that school stress was a bigger deal than other stressors. However, with this
the researchers must keep in mind that all participants were students in an accelerated graduate
school program, so this type of response would be expected.
Discussion and Implications for Practice
The significance for this study includes the fact that there was a wide range of symptoms
in every category, but the physical category had the widest range. The idea that so many
different physical symptoms manifest in people as a result of stress shows the importance of
reducing stress to improve physical health. In the social category, a common theme was that
when stressed, participants tended to act out on others and withdraw from social situations. As
the occupational therapy community is well aware, social participation is a crucial aspect of a

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balanced life. Therefore, another reason it is important for people, especially those who
withdraw from social situations during times of stress, to reduce their stress is to increase social
participation for a more balanced life. Additionally, the fact that school was the main source of
stress is significant because it shows that students must take the necessary steps to reduce their
stress levels in order to prevent such physical, psychological, emotional, and social
manifestations of stress that were found in this study.
A major limitation of this study was that the participants were only selected from the
class of 2016 OT students at Touro University Nevada. All of the participants were students in
an accelerated program, and most were from out of state. These individuals had the stresses of
school as well as the stress of being away from family and friends, so their manifestations of
stress could have been compounded by the additional stressors. Another limitation was that out
of the eight participants, only one of them was a male. All of the researchers in this study were
females, which could have skewed the participants answers. Additionally, the interview
questions were categorized based on physical, psychological, emotional, and social symptoms
beforehand, which made it difficult to create themes and subthemes when coding. It is unknown
what themes would have naturally emerged had the researchers not prompted the specific
categories within the interview questions. Another limitation was that participants had a hard
time discriminating between emotional and psychological symptoms. The categories could have
been combined before the interviews for simplicity and to minimize confusion. A final
limitation was that the researchers did not conduct member checking, which would have assured
that the meaning of the participants answers were accurately portrayed.
Recommendations for further research include conducting interviews with a larger and
more diverse population. In this study, only eight people were interviewed, and they were all

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part of the same graduate program at the same school. More people need to be interviewed about
their manifestations of stress to increase the generalizability of the results. Also, only one male
was interviewed in this study. Having more input from males would also be beneficial for a
more evenly distributed set of responses from both males and females. Many of the studies in
the current literature are primarily focused on what causes stress rather than the manifestations or
symptoms of stress that can ultimately cause a decrease in school performance. Therefore, it is
recommended that future research explores such manifestations.
The intensity of a graduate school program can produce a variety of symptoms of stress
in students. Through this study, the researchers learned that stress varies between students and
impacts their lives differently. The common theme found throughout this study was that
students main source of stress was school. However, each student experienced this stress in
different ways, and many students had additional stressors, such as money and
relationships. Overall, this topic still needs to be researched and expanded upon with larger and
more diverse populations to gain a better understanding of the manifestations of stress.

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References

Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012). Stress: Perceptions,
Manifestations, and Coping Mechanisms of Student Registered Nurse Anesthetists.
AANA Journal, 80(4 Suppl), S49-55.
Chipas, A., & McKenna, D. (2011). Stress and Burnout in Nurse Anesthesia. AANA Journal,
79(2), 122-128.
Gupchup, G. V., Borrego, M. E., & Konduri, N. (2004). The Impact of Student Life Stress on
Health Related Quality of Life Among Doctor of Pharmacy Students. College Student
Journal, 38(2), 292.
Pfeifer, T. A., Kranz, P. L., & Scoggin, A. E. (2008). Perceived stress in occupational therapy
students. Occupational Therapy International, 15(4), 221-231.

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Appendix

1. What are your biggest sources of stress?

2. When do you feel the most stressed?
a. During which types of situations or events do you feel most stressed?
b. Are there certain times of day or times during the week when you feel most stressed?
3. When do you feel the least stressed?
a. During which types of situations or events do you feel the least stressed?
b. Are there certain times of day or times during the week when you feel least stressed?
4. What physical symptoms do you experience when you are stressed?
5. What emotional symptoms do you experience when you are stressed?
6. What psychological symptoms do you experience when you are stressed?
7. How does your stress impact you socially?
8. What, if any, other symptoms do you experience due to stress?
9. Do you notice different types of symptoms due to school-related stress versus other life
stressors?

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Table 1

CATEGORY

THEME

# RESPONSES

Physical

nervous system

gastrointestinal

cardiopulmonary

Muscular

Irritability

Crying

psychological distress

thought-related

self-esteem

isolation/withdrawal

short temper

decreased interaction

Emotional

Psychological

Social