Factors associated with stress among second year student nurses during
clinical training in Jamaica

Marleise McBean Graham MSN, RN, Jascinth Lindo PhD, MPH, MSN,
RN, Venise D. Bryan MSN, RN, Steve Weaver PhD, RN

PII: S8755-7223(16)00018-1
DOI: doi: 10.1016/j.profnurs.2016.01.004
Reference: YJPNU 947

To appear in: Journal of Professional Nursing

Please cite this article as: Graham, M.M.B., Lindo, J., Bryan, V.D. & Weaver, S.,
Factors associated with stress among second year student nurses during clinical training
in Jamaica, Journal of Professional Nursing (2016), doi: 10.1016/j.profnurs.2016.01.004

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
 ACCEPTED MANUSCRIPT
1

Factors associated with stress among second year student nurses during clinical training in
Jamaica

P T
RI
Marleise McBean Graham., MSN, RN1
Jascinth Lindo, Lecturer, PhD, MPH, MSN RN1

SC
Venise D. Bryan, MSN, RN2

NU
Steve Weaver, Lecturer, PhD, RN 1

MA
ED
PT

1
The UWI School of Nursing
Faculty of Medical Sciences
University of the West Indies
CE

Mona Campus, Kingston 7, Jamaica

Telephone number: +18769703304
AC

Fax: +18769272472
Email: jascinth.lindo02@uwimona.edu.jm

2
Faculty of Nursing,
The University of Calgary
2500 University Drive
NW, Calgary, AB T2N 1N4, Canada
 ACCEPTED MANUSCRIPT
2

Highlights

T
Students enrolled at two nursing schools in urban Jamaica experienced moderately high

P
levels of stress in the clinical environment.

RI
 Financial concerns and interaction with ward staff were significant sources of stress

SC
among students.

 Students were generally young and may benefit from the inclusion of stress management

NU
classes designed specifically to address the findings of the study.
MA
 Nursing schools must partner with clinical placement sites to ensure optimal clinical

learning experiences.
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT
3

Abstract

Objective: To determine the levels of stress among students in the Jamaican clinical setting and
describe the perceived contributing factors to this stress.

T
Methods: This cross sectional study of 106 second year students enrolled at two schools of

P
nursing in Jamaica used a 30- item self-administered questionnaire to gather data on levels of

RI
stress and contributing factors. Participants were asked to rate the levels of stress experienced
(scale 0-5, where 5 was highest). Data were analyzed using SPSS® v 19 for Windows®.

SC
Results: The response rate was 98% (106/108) and 97.2% were females. The average age of

NU
respondents was 23.16±9.01 years. The majority of participants were single (78.3%) and resident
in Kingston and St. Andrew (61.3%). The level of stress experienced in the clinical setting was
MA
rated 3.48± 1.3/5; financial difficulties (3.17± 1.6/5) and interactions with unit staff (3.15 ±
1.4/5) were rated the greatest contributors to stress. Students experienced fear of harming the
patient (50%) and only 24% expressed consistent confidence. Except for the interactions with
preceptors (p< 0.05), there were no differences in levels of stress between schools.
ED
PT

Conclusion: Students enrolled at two nursing schools experienced moderately high levels of
stress in the clinical environment. Financial concerns and interaction with ward staff were
significant sources of stress. Collaborative strategies to address stress in the clinical areas are
CE

imperative.

Keywords: nursing students, stress, clinical area, Jamaica

AC
 ACCEPTED MANUSCRIPT
4

Factors associated with stress among second year student nurses during clinical training in
Jamaica

Introduction

P T
Clinical practice plays an integral role in nursing education as this is the component of

RI
the program where students learn to apply theory to practice and develop their psychomotor

SC
skills (Shaban, Khater, & Akhu-Zaheya, 2012). Unfortunately, the clinical learning environment

has been described as a major source of stress among nursing students globally (Goff, 2011;

NU
Jimenez et al, 2010; James & Chapman, 2009; Sharif & Masoumi, 2005). Nursing students have
MA
identified financial burden, poor interpersonal relationships with clinical staff and preceptors,

high academic demands and lack of free time to socialize or sleep as sources of stress (Moridi,
ED

Khaledi, & Valiee, 2014, Votta & Benau, 2013; Reeve et al., 2013). Stress though difficult to

define has been described as an individual’s perception that the demands of an environment
PT

exceeds the individual’s ability to cope (Dutta, Pyles, & Miederhoff, 2006). Any situation which
CE

results in negative thoughts and feelings can be described as stressful (Ghai, Dutta, & Garg,

2014).
AC

Stressful situations can impact negatively on a student’s wellbeing, with negative

outcomes on academic, clinical and general performances (Gibbons 2010; Shaban, Khater &

Akhu-Zaheya, 2012; Sharif & Masoumi, 2005; Shipton, 2002). Bremner, Aduddell, and

Amason (2008) found that students who were highly stressed were less engaged in clinical

activities and lacked self-confidence in practice. Similarly, a study of 357 student nurses from all

three years of a Spanish nursing college reported that second year students were the most

affected by ―somatic and psychic anxiety, and common symptoms‖ (Jimenez et al.,

2010).Students also reported feeling pressured, frustrated, rundown, worried, exhausted and
 ACCEPTED MANUSCRIPT
5

upset (Evans and Kelly, 2004). Furthermore, student nurses who reported being stressed had

poorer psychological health and sleeping and eating disorders (Shukla, Kalra, & Pakhare, 2013).

T
Second year students in Spain and Iran reported high levels of stress which was associated with

P
lack of confidence and knowledge to carry out procedures and feelings of helplessness (Goff,

RI
2011; Lopez & Lopez, 2011; Sharif et al., 2005).

SC
Constant shifting of students to different clinical areas in the second year and repeated

clinical appraisals were major factors contributing to the negative appraisal of the clinical

NU
learning environment by student nurses (Goff, 2011; Jimenez et al, 2010; James & Chapman,
MA
2009; Watson et al., 2008). Nursing students have displayed greater levels of stress in their

second year of training since this is generally their first introduction to the clinical environment
ED

(Jimenez et al, 2010; Sharif & Masoumi, 2005). Fears identified by students in the clinical area

included: teachers embarrassing them before their peers, patients or other clinical staff, poor
PT

interpersonal relationships with preceptors and clinical staff, contagious disease transmission,
CE

inability to relate theory to practice, and, inability to identify resources on the unit when needed

(Chan, So, & Fong, 2009; Edwards, Burnard, Bennett & Hebden, 2010; Lawal, Weaver,
AC

Anderson-Johnson, & Lindo, 2011; Taghavi Larijani, RamezaniBadr, Khatoni, & Monjamed,

2007).

Evidence related to the causes and effects of stressful factors of Jamaican baccalaureate

nursing students during their first clinical placement in the second year remains limited. This

paper examines factors associated with stress among second year student nurses in the Jamaican

clinical setting. It was done with the view that a better understanding of stress among Jamaican

nursing students during their initial clinical practice and their coping strategies would contribute

to the views on stress amongst nursing students globally. Evidence from this study would better
 ACCEPTED MANUSCRIPT
6

inform practice in the teaching and learning process and form the basis for further work in the

context of nursing education in a developing country.

P T
Background/Literature Review

RI
Jamaican, baccalaureate nursing programs, like many other countries introduce students

SC
to the clinical area in the second year of training which results in students displaying greater

NU
propensities to stress (Sharif & Masoumi, 2005; Lo, 2002). High levels of stress and anxiety

among nursing students may create discrepancies between clinical staff expectations and student
MA
competencies (Jimenez et al, 2010; Gibbons, 2010). A qualitative study of six second year

students in Australia reported that they felt ―overwhelmed and confronted‖ on their first clinical
ED

placement (James & Chapman, 2009). The students reported feeling alienated from clinical staff,
PT

unsure of their professional role in relating to patients, and also reported fears of being evaluated

by preceptors (James & Chapman 2009). The resultant fear of preceptors, difficult patients and
CE

the rigors of the clinical environment, caused students to feel unable to cope and to pass clinical
AC

evaluations, which resulted in attrition (James & Chapman, 2009; Seyedfatemi, 2007). Second

year nursing students in Iran expressed similar sentiments and researchers coined the term

―initial clinical anxiety‖; after studying a group of 90 students. These students cited factors such

as lack of recognition by clinical staff; and feeling torn between demands of clinical preceptors

and practicing nurses as sources of stress (Sharif & Masoumi, 2005).

Nursing students who have experienced high levels of stress have adapted several coping

mechanisms including self-motivation, seeking out family members, peers, and faculty for

support, religious practices, exercise, avoidance, complaining, problem-solving and drinking

(Evans & Kelly, 2004; Reeve et al., 2013; Edwards et al.,2010; Chan et al., 2009). A study of
 ACCEPTED MANUSCRIPT
7

1450 students from six administrative regions in France reported that stress was also linked to

less healthy practices in both second and third year nursing students including smoking and

T
tobacco use (LaMourt, Estryn-Behahr, Le Moel & Matheiu, 2011). Similarly, 52 nursing

P
students in Ireland reported coping with stress by talking to relatives, friends, and peers, self-

RI
determination, spiritual reliance, and ―staying out of trouble‖ (Evans & Kelly, 2004).

SC
Currently, there is a thrust towards raising the standards in professional nursing practice

in the Caribbean and effective 2017 the Regional Nursing Body has elevated the minimum

NU
educational requirement for registered nurses to training at the baccalaureate level. Therefore,
MA
nursing education in Jamaica has shifted from an apprenticeship type model in the hospital

setting to academic, degree granting, universities and colleges (Hill, 2006; The UWI School of
ED

Nursing, 2004 - 15). Evidence presented at a local research conference reported final year

students at one Jamaican school of nursing reported high levels of stress (Llewellyn-Johnson,
PT

Lopez, Lindo, & Duff, 2011) and felt the clinical area was a significant source of stress (Lawal et
CE

al., 2011). Furthermore, the type of interpersonal relationship with clinical staff and preceptors

was identified as a factor which influenced the learning experiences of students during clinical
AC

training. This is important because high levels of stress can have a negative impact on students’

wellbeing and may directly affect their fitness to practice safe patient care (Reeve, Shumaker,

Yearwood, Corwell & Riley, 2013).

 ACCEPTED MANUSCRIPT
8

Theoretical Framework-The Neuman’s System Model

The nursing theory of Betty Neuman is a wide ranging and pertinent framework to

T
describe student nurses and the stress they encounter (Reghuram & Mathias 2014). It highlights

P
the response of the ―client system‖ to the tangible or prospective factors that can cause stress in

RI
the immediate surroundings (Neuman, 2011). The ―human being is a total person with five

SC
variables these include physiological, psychological, socio-cultural, spiritual and developmental‖

NU
(Neuman, 2011). According to Neuman (2011), stress factors can be categorized as

extrapersonal, intrapersonal or interpersonal. In applying Neuman’s theoretical frame work

MA
among student nurses in the clinical learning environment: extrapersonal factors include factors

outside of the individual (e.g. financial concerns) and intrapersonal factors occur within the
ED

individual, example thoughts and feelings. In addition, interpersonal factors occur between
PT

individuals and may include negative interactions with involving staff and patients (Moscaritolo,

2009; Reghuram & Mathias 2014).While the evidence suggests that nursing students are exposed
CE

to significant stress; educators must conduct assessment to ascertain the magnitude of the stress
AC

experienced in the clinical learning environment (Moscaritolo, 2009).

This paper examines factors associated with stress among second year student nurses in

the Jamaican clinical setting. A better understanding of stress among Jamaican nursing students

during their initial year of clinical practice and their coping strategies may inform the

development of strategies to best mitigate this perceived stress.

 ACCEPTED MANUSCRIPT
9

Research Questions:

The study was guided by the following questions:

T
1. What were the levels of stress experienced by study participants in the clinical learning

P
environment?

RI
2. What factors in the clinical learning environment were perceived to be stressful among

SC
second year nursing students?

3. What are the differences that exist between perceived levels of stress experienced in the

NU
clinical area at the level of school and health institution among study participants?
MA
4. How does second year nursing students cope with stress experienced in the clinical

setting?
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT
10

Methods

Ethical approval was granted from the institutions' review boards and permission to

T
conduct the study by the nursing schools' administrators. A cross-sectional survey was

P
conducted of undergraduate nursing students enrolled in 3-year baccalaureate programs at two

RI
urban nursing schools in Jamaica. Several nursing programs from across Jamaica used the

SC
clinical learning environment as part of the licensure requirement of the Nursing Council of

Jamaica.

NU
Sample MA
A total of 132 (74 at school A and 58 at school B) second year student nurses were

enrolled at both schools of nursing. Both schools were located in Kingston, Jamaica and used the
ED

same curriculum, and clinical practice sites, including public hospitals, one quasi-government

teaching hospital, health centers and schools in the Kingston Metropolitan Area. The duration of
PT

clinical rotations ranged from two to eight weeks on units such as medical surgical, obstetrics
CE

and gynecology, pediatrics and community health. The study's sample size of 108 was

determined using Raosoft (2004) with a confidence level of 90%, response distribution of 50%,
AC

and non-response rate of 10%. A convenience sampling method was utilized.

Data Collection and Instrumentation

Data collection was done once using a 30 item self- administered questionnaire. The

questionnaire was designed by the researchers following a review of the literature. Items were

mainly Likert type scaled responses (never [0] to always [5]); participants were also asked to rate

the level of stress experienced in the clinical area using a scale of zero to five with five being the

highest level of stress, a single open ended question. There were five questions about
 ACCEPTED MANUSCRIPT
11

demographic data (Votta and Benau, 2013), three about the experiences in relating to patients

(Edwards et al., 2010; Shaban et al., 2012; Sheu et al., 2002), six on interpersonal relationships

T
with the clinical unit team and preceptors (Shaban et al., 2012; Moridi et al., 2014), nine about

P
experiences in the clinical area (Chan et al., 2009; Gibbons, 2010; Moridi et al., 2014), four

RI
about personal and health issues (Edwards et al., 2010; Shukla et al., 2013), one on coping

SC
mechanisms (Chan et al., 2009; Reeve et al., 2013) and one with sections on levels of stress

(Hamaideh & Ammouri, 2011).

NU
A moderate Cronbach alpha score of 0.64 was yielded when the instrument was pretested
MA
for reliability among 10 third year students at one of the study sites. Third year students typically

had similar clinical experiences with similar placements and clinical preceptors. Hence, they
ED

possess a frame of reference which makes them an appropriate group for pretesting of the

instrument. Pretest participants were asked for feed-back regarding the instrument and three
PT

clinical and educational specialists were invited to review the instrument. This led to minor
CE

changes in a few of the items. A Cronbach alpha score of 0 .799 was achieved by the instrument

in the study population (N=106)

AC

The study was conducted between May and June 2012. Faculty members at both schools

were contacted and arrangements made to allow the researchers to address the targeted

populations at the end of classes. The study was explained explicitly to those who consented to

participate, and all were reminded to refrain from submitting any names or other identifiers on

the questionnaires. The researchers were not actively involved in teaching the students at the

time the study was conducted. Participants were informed that participation in the study was

voluntary, and they could withdraw from the study at any stage without fear of penalty or

discrimination. Written informed consent was obtained before the questionnaire was
 ACCEPTED MANUSCRIPT
12

administered. All information was treated confidentially, and completed questionnaires were

stored as per the World Medical Association Council Guidelines (World Medical Association,

T
2011). No favors, grants, or sponsorship were associated with this study.

P
RI
Data Analysis

SC
Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software

for Windows® version 19. Measures of central tendencies, univariate and bivariate descriptive

NU
statistics were used to analyze and summarize data. The significance level was set at p<0.05.
MA
Independent sample t-test was used to determine differences between perceived levels of stress

experienced in the clinical area at the level of school and health institution. Variables geared at
ED

describing the level of stress experienced by students were subjected to exploratory factor

analysis to examine the structure or relationship between variables and ensure congruence with
PT

the theoretical model of choice. Data were presented using tables and graphs. Analysis of the
CE

single open-ended question was done by categorizing responses as being negative or positive.

Each response was then coded and themes identified.

AC
 ACCEPTED MANUSCRIPT
13

Results

A total of 106/108 participants responded (98% response rate), with 50 respondents from

T
School A and 56 respondents from School B. The mean age of the participants in the research

P
was 23.16± 9.0 years (range 19-50yrs); the majority of whom were females (97.2%). Most of

RI
the participants were single (80%) and 20% were married or in a common-law relationship.

SC
More than half of the participants (61.3%) lived in the urban municipality where the schools of

nursing were located. A quarter (26.4%) of the participants had children, but only 22.4%

NU
reported their children living with them. MA
The factors student nurses perceived to be stressful in the clinical learning environment were

categorized to include environmental, staff and personal related.

ED

Reported levels of stress in the clinical environment

PT

Interpersonal factors (staff)

CE

Relating with staff in the clinical area was moderately stressful (25.5%), to maximally

stressful (42.0%) for some participants. More than half of the participants (52.8%) found the
AC

staff friendly at times and 49.1% felt that preceptors treated them with respect most of the time.

However, students reported staff rarely: assisted with procedures (22.6%), treated students with

respect (25.5 %) orientated students to ward (23.6%), friendly to students (30.2%). More than a

third of the students studied (36.9%) stated they rarely felt they were an integral part of the team.

Of the 14 possible sources of stress explored, stress experienced during interactions with

preceptors was the sole factor which was different between the schools studied. This was

significantly higher among students at nursing School A, the larger school of nursing (mean

scores 3.0±1.3/5 versus 2.3±1.4; p<0.002).

 ACCEPTED MANUSCRIPT
14

Interactions with patients

Interaction with patient at the sites visited was rated low (29.2 %) to moderate (18%)

T
sources of stress and almost all (97.2%) of the students studied were able to safely manage their

P
assigned allocation of 1-3 patients during clinical learning experiences. Most (69.8%) students

RI
were comfortable relating to patients most or all of the time; similarly a third were competent in

SC
dealing with ill and dying patients and 34% of students experienced fears of harming the patients

most of the time. Majority of participants (63%) had fears that they would contract a disease

NU
from patients at some point. MA
Extra-personal factors
ED

Less than 15% of participants rated the schools, health centers and public hospitals

visited as most stressful. However, the lone quasi-government teaching hospital was rated as
PT

most stressful by 62.3% of the participants. Classroom lectures during clinical rotations were
CE

rated moderate and highly stressful by 37.7% and 26.4 % of participants, respectively. Surgical

and Obstetric areas were deemed moderately stressful by 29.2% and 19.8% of participants,
AC

respectively. Clinics, health centres and schools were all considered low stress areas.
 ACCEPTED MANUSCRIPT
15

Intrapersonal factors

Financial difficulties were rated as maximum stress for 47.2% of participants. More than

T
half of the participants (67.9%) felt confident doing procedures some of the time, and only

P
(4.7%) of them were always able to relate theory to practice during ward procedures. The larger

RI
number of participants (38.7%) felt confident when supervised by a nurse or preceptor. Stress

SC
from students’ immediate family members was moderate for 22.6% of the participants. Emotions

experienced by the participants while in the clinical learning environment were fear (67%),

NU
feeling overwhelmed (66%), feeling inferior (57.5%) hopelessness (40.6%) and anger (31.1%).
MA
Neuman’s model of stress suggest that stress can be explained by extrapersonal, intrapersonal or

interpersonal factors; as such fourteen stress variables were included in the instrument. These
ED

were subjected to exploratory factor analysis to determine how well the instrument was aligned
PT

to the constructs of the theory and the percentage of variance explained by the extrapersonal,

intrapersonal or interpersonal factors. An Eigen value of greater than 1.0 was accepted. The
CE

model explained 70% of the variance and clinical characteristics appeared to be most influential
AC

in explaining the stress among the students studied (Table 1). Five factors emerged from the

factor analysis and were characterized as relating to: clinical setting, interactions, school,

financial difficulties and family support (Table 2.) To demonstrate congruence with the

theoretical framework the loading patterns in the rotated component matrix explaining students’

stress in the Jamaican clinical environment are included in the results (Table 2). The responses to

the question ―During clinical rotations rate the level of stress you experience in/ with [items 1-

14]‖ are reported in Table 2. The table excludes values less than 0.5.
 ACCEPTED MANUSCRIPT
16

Table 1. Total Variance explained by stress factors based on Neuman’s Model of stress

Initial Eigenvalues

P T
Emergent components based on factor analysis Total % of Variance Cumulative %

RI
Stress related to the clinical setting 5.005 35.751 35.751

SC
Stress related to interactions 1.461 10.434 46.185

Stress related to the school 1.249 8.924 55.109

NU
Stress related to finance and commuting 1.196 8.546 63.655

Stress related to Family MA 1.012 7.225 70.880

ED
PT
CE
AC
 ACCEPTED MANUSCRIPT
17

Table 2. Rotated component matrix explaining stress in the clinical area based on
exploratory factor analysis

During clinical rotations rate the Factor 1 Factor 4 Factor 5

T
Factor 2 Factor 3

P
level of stress you experience in/ Clinical Financial Family
Interactions School
with: setting difficulties support

RI
1. Clinical setting overall .852

SC
2. Medical areas .839
3. Surgical areas .787

NU
4. Obstetrics .557
5. Clinics and health centers .802
6. Interaction with patients .703
MA
7. Interaction with lecturers .630
8. Interactions with Preceptors .630
9. Interaction with staff .496
ED

10. Classroom lectures .863

11. Skills lab demonstration .702
PT

12. Financial difficulties .783

13. Commuting to school .705
CE

14. Family members .941

AC
 ACCEPTED MANUSCRIPT
18

Coping in the clinical learning environment

The participants used a number of coping methods which were grouped into major

T
themes (Figure 1). Almost half of the participants (50.9%) said they rarely had time to socialize

P
RI
and to sleep. Only 17.9% of the participants used negative coping strategies which involved

avoiding people, crying, blaming others, skipping school, and eating unhealthy diets. Only 1.9%

SC
of participants smoked and 8.5% of participants drank alcohol sometimes.

NU
Relaxation techniques that students (55.7%) used to cope included reading, sleeping,

deep breathing, taking long baths, eating and eating chocolate. Recreational activities included
MA
going out, watching television, surfing the internet (using social media websites), dancing,

singing, exercising and having sex and were used by 50.9% of the participants to relieve stress.
ED

Emotional support from faculty was sought by 34% of the participants. Religious coping
PT

mechanisms included praying and reading the bible, were used by approximately a third of the

participants (32.1%). Participants described socialization with friends and family including
CE

telephone conversations as helpful. Self-motivation was the least used by 8.5% of participants
AC

and included positive thinking, and a determination to complete the program of study.
 ACCEPTED MANUSCRIPT
19

Reported coping mechanisms utilized by second

year nursing students (%)

T
Self motivation 8.5

P
Negative coping 17.9

RI
Socialization 18.9

Religion 32.1

SC
Faculty support 34

Recreation 50.9
55.7

NU
Relaxation techniques

0 10 20 30 40 50 60
MA
Figure 1. Coping mechanisms used by 2nd year students at two schools of nursing during clinical
practice
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT
20

Discussion

The findings of the study appear to suggest that clinical characteristics or environmental

P T
influences may be the greatest sources of stress in the clinical area given its capacity to explain

RI
the greatest percentage of the variance among the stress variables subjected to exploratory factor

SC
analysis.

NU
Stress experienced in clinical placement areas such as surgical and obstetric units was reportedly

greater than reported in the clinics and health centers. Clinical setting characteristics can make a
MA
difference in students learning experience (Blomberg, Bisholt, Kullén Engström, Ohlsson,

Sundler Johansson, & Gustafsson, 2014). Hamaideh and Ammouri (2011) reported that among
ED

Jordanian nurses, units were viewed as being more stressful based on perceived job stressors of
PT

the specific unit. Furthermore, the stress was exacerbated in the presence of inadequate

preparation and training. Gibbons (2010), concluded in the presence of high stressed clinical
CE

environments, the type of support given to nursing students determined the quality of the
AC

learning experience and whether it is rated positively or negatively.

Specialty units such as the obstetrics and surgery can be unpredictable and may present

additional challenges when compared to the daily routine activities of clinics and health centers.

Study participants from both schools, described the semi-private teaching hospital as particularly

stressful. Though there were no probing questions related to this finding, it is fair to

acknowledge variations across healthcare institutions (Blomberg et al., 2014). For example, there

are dissimilarities in patient staff ratio, unit capacity and available resources across Jamaican

hospitals. Furthermore, nurses at the teaching hospital are compensated for assisting with guiding
 ACCEPTED MANUSCRIPT
21

students in the clinical area and may provide greater oversight of the students’ progress and

require higher standard of care. This hypothesis should be tested through additional research.

T
Exploration of the factors associated with stress among second year students in their

P
clinical nursing training revealed that financial difficulties was a source of maximum stress.

RI
Financial difficulties were also ranked as the second largest source of stress among nursing

SC
students across Jamaica (Llewelyn et al., 2011). Financial difficulties have also been mentioned

in the literature as a significant contribution to nursing students’ stress levels in first world

NU
settings (Jimenez et al, 2010). These constraints emerged as a source of stress among diploma
MA
nursing students in Dublin, Ireland, as in the past, hospital based students received a salary

(Timmins and Kaliszer, 2002). Nursing education programmes, have also evolved from the
ED

hospital based apprenticeship program of study, with the Students’ Loan Bureau, (2005-2011)

claiming that most students attending tertiary institutions are utilizing student loans in a cash
PT

strapped society. Creative and collaborative private / public partnerships to identify additional
CE

financial resources and the implementation of a wellness program for students must be an

integral part of faculty advocacy for students (Misra & McKean, 2000; University Students’
AC

Council of the University of Western Ontario, 2015).

The students’ perceptions of the clinical environment brought about negative emotions

such as fear, feeling overwhelmed or inferior, hopelessness, anger, apprehension and loneliness.

These findings have also been reported among second year students in Australia where students

studied felt ―overwhelmed and confronted‖ on their first clinical placement and these emotions

can lead to discontinuation of training (Lopez & Lopez, 2011; James & Chapman, 2009; Jimenez

et al; 2010). Newman’s Systems Model describes the invasion of the normal line of defense by

the stress factors and the resultant anxiety among students who are unable to cope. When this
 ACCEPTED MANUSCRIPT
22

happens students need supportive measures in order to reduce their anxiety, which will enable

them to confront the ―stressors and strengthen the students flexible line of defense‖ (Moscaritolo,

T
2009).

P
The clinical area and interactions between students and staff in this space were major

RI
sources of stress for the students as they perceived the staff as unhelpful and disrespectful. The

SC
students also reported not being adequately orientated to the unit and its routines or procedures

and they felt alienated from the team. This resulted in students reporting moderately high stress

NU
attributed to interactions with staff in the clinical area. Studies conducted among nursing students
MA
in Jordan and Hong Kong have also highlighted lack of familiarity with the unit, medical

techniques and terminology as major sources of stress for students (Shaban et al., 2012; Sheu,
ED

Lin & Hwang, 2002). These conditions were exacerbated by negative attitudes including

disrespect towards students, confusion and depersonalization (Moridi et al., 2013; Gibbons,
PT

2010). Gibbons (2010) highlighted the converse by stating that those students who found clinical
CE

experiences uplifting and enjoyable felt more engaged and part of the team. Clinical preceptors

should help students to enjoy their clinical placement experience, and engage students by
AC

requiring them to set weekly or bi-weekly personal goals to be achieved in the clinical area

(Blanchard & McBride, 2008). This presents an opportunity for positive reinforcement as the

achievement of each goal can be celebrated, and will ultimately motivate students (Billings &

Halstead, 2013).

Fear of contracting a disease from the patients and harming the patient were sources of

stress among the students studied. It is unclear whether a lack of knowledge or inability to relate

theory to practice contributed to this fear. Fortunately, the preceptor’s presence reportedly abated

or lessened this source of stress among the group. Similar findings have been reported where
 ACCEPTED MANUSCRIPT
23

students reported fears of getting contagious diseases, harming patients and difficulties bridging

the knowledge practice gap as major sources of stress (Edwards et al., 2010; Yazdankhah Fard et

T
al., 2009; Evans & Kelly, 2004). Likewise, Hong Kong baccalaureate nursing students studied

P
worried about their ability to provide nursing care and to make appropriate decisions that would

RI
not harm the patient (Chan et al. 2009). Collaborating with the unit’s educator and staff with

SC
expertise can be great resources to the nurse preceptor and students. Pre and post clinical

conferences present opportunities where preceptors can remind students about safe practice and

NU
ways to protect themselves and patients from disease transmission (Carolan-Olah & Kruger,
MA
2013; Hsu, 2007).

Despite the negative views of the clinical area, students reported no difficulty relating to
ED

and caring for patients; even those who were very ill and dying. Students reported this as a

source of low to moderate stress. This was contrary to other studies that reported these two
PT

factors as sources of stress for students during clinical practice especially those on their initial
CE

clinical placement (Edwards et al., 2010; Evans & Kelly, 2004). In addition, students were

comfortable with their patient assignment and workload. Chan et al. (2009) reported opposite
AC

findings where patient assignments and workload were major sources of stress among nursing

students in Hong Kong.

Nursing students in the past have placed high value on the preceptor support provided

(Moridi et al., 2013; Edwards et al., 2010). This could be attributed to the confidence the

students had in the preceptor’s expertise and as such the possibility of making a mistake or

harming the patient would be greatly reduced under the preceptors watch (Chan et al., 2009).

Nurse preceptors are integral to students learning how to provide optimal patient care in clinical

settings; they must use ―strong communication skills and demonstrate effective techniques and
 ACCEPTED MANUSCRIPT
24

procedures to strengthen students skills‖ (Day, 2012). Nursing students in the Jamaican setting

have also reported feeling increased confidence to carry out nursing procedures when preceptors

T
were present (Lawal et al., 2011). These findings were important since the level of stress

P
experienced during interactions with preceptors was significantly higher among some students.

RI
SC
Students may respond to stress in the clinical area through the use of negative coping

such as drinking, abusing drugs and avoidance especially on initial clinical placement and

NU
without enough support (Reeve et al., 2013; Shaban et al., 2012; Gibbons, 2010). Coping
MA
mechanisms utilized by the students were both positive and negative. Furthermore, the students

reported lack of time to sleep or socialize. This is congruent with previous studies where students
ED

reported the nursing program was so intense, there was rarely anytime to socialize or sleep

(Edwards et al., 2010; Reeve et al., 2013). In spite of this a third of the students used relaxation
PT

and recreational coping methods. More than half of the students used religious practices and
CE

support from faculty to cope with the stress they were experiencing. Religious practices reported

in a study of 1,276 nursing students in China were deemed an important predictive factor for
AC

clinical stress. It was reported that spirituality assisted students to manage clinical practice stress,

altered moods and promote health behaviors such as engaging in exercise, eating healthy, and

improvement in relating to others (Hsiao, Chien, Wu, Chiang, & Huang, 2010). Faculty members

are being encouraged to avail themselves to students (Bryan et al., 2013) and to be quick in

identifying stressful behaviors in students while helping students to cope positively (Billings &

Halstead, 2013; Reghuram & Mathias, 2014).

Implications for practice

 ACCEPTED MANUSCRIPT
25

This study provides important assessment data regarding the students stress levels and could

inform the development of collaborative problem solving strategies to address issues such as

T
financial difficulties and interactions with unit staff which were described as the greatest

P
contributors to stress (Reghuram & Mathias, 2014).

RI
The analysis supports the use of Betty Neuman’s model of stress in the current study population

SC
demonstrating contagiousness, consistency and accuracy (Meleis, 2011). Primary and secondary

NU
prevention interventions aimed at reducing undergraduate student nurses anxiety in the clinical

learning environment are indicated among nursing students in Kingston, Jamaica (Neuman,
MA
2011). Primary prevention strategies are appropriate on identification of potential stressors in the

absence of symptoms while secondary prevention, geared at achieving client system stability
ED

should be activated when the stressor invades the line of defense or primary prevention has failed
PT

(Moscaritolo, 2009).
CE

More than half of the students experienced fear, feeling overwhelmed and hopelessness

while in the clinical learning environment and one-fifth practiced negative coping.
AC

Understanding the magnitude of the effects of stress in the clinical learning environment enables

faculty to implement strategies to mitigate the negative consequences of stress (Reghuram &

Mathias, 2014). For example providing educational content on stress, counselling services and

accessible academic advisement are essential for any comprehensive stress reduction strategy

(Massey, 1999; Nipissing University, 2015; University of Victoria, 2014). Support from faculty

through positive interpersonal relationships has been reported to be helpful in the Jamaican

academic and clinical settings as well (Lawal et al., 2011; Bryan et al., 2013).
 ACCEPTED MANUSCRIPT
26

Limitations of the study

The study was limited to second year students at two schools of nursing, and therefore the

T
findings cannot be generalized to all student nurses in Jamaica. Additionally, data were gathered

P
by means of a self-report newly developed questionnaire and used convenience sampling. For

RI
future studies a mixed method approach may prove beneficial so that greater insight could be

SC
garnered about stress, its effect on learning and the coping mechanism employed by students.

NU
Conclusion MA
Students enrolled at two nursing schools in urban Jamaica experienced moderately high

levels of stress in the clinical environment. Financial concerns and interaction with unit staff
ED

were significant sources of stress. This gives credence to the studies done internationally and

locally that student nurses face high levels of stress in the clinical learning environment. Students
PT

were generally young and may benefit from the inclusion of stress management classes designed
CE

specifically to address the findings of the study. Betty Neuman’s theory of stress appears to be

appropriate for understanding the students stress experience in the clinical setting. Emphasis
AC

should be placed on improving preceptorship programs within the schools of nursing, as faculty

support was one of the resources the students depended on to cope. Finally, there is a clear need

for greater collaboration between the schools of nursing and the administrators in the clinical

sites given the importance of clinical learning experiences.

.
 ACCEPTED MANUSCRIPT
27

References

Al-Sowygh, Z. (2013). Academic distress, perceived stress and coping strategies among dental

T
students in Saudi Arabia. The Saudi Dental Journal, 25(3), 97-105.

P
Beck, DL., Srivastava, R., (1991). Perceived level and sources of stress in baccalaureate nursing

RI
students. Journal of Nursing Education, 30(3), 127-33.

SC
Billings, D. M., & Halstead, J. A. (2013). Teaching in nursing: A guide for faculty. Elsevier

Health Sciences.

NU
Blanchard, K., & McBride, M. (2008). The 4th secret of the one minute manager: A powerful
MA
way to make things better. New York: William Morrow.

Blomberg, K., Bisholt, B., Kullén Engström, A., Ohlsson, U., Sundler Johansson, A., &
ED

Gustafsson, M. (2014). Swedish nursing students' experience of stress during clinical

practice in relation to clinical setting characteristics and the organisation of the clinical
PT

education. Journal of Clinical Nursing, 23(15-16), 2264-2271.

CE

Bremner, M., Aduddell, K., Amason, J. (2008). Evidence-based practices related to the human

patient simulator and first year baccalaureate nursing students’ anxiety. Online Journal of
AC

Nursing Informatics,12,10.

Brown, B. (2009). Men in nursing: Re-evaluating masculinities, re-evaluating gender.

Contemporary Nurse, 33(2), 120-129.

Bryan, V., Weaver, S., Anderson-Johnson, P., & Lindo, J. (2013). The effect of

interpersonal relationships between nursing students and lecturers on learning outcomes

at a Jamaican nursing school. Caribbean Journal of Nursing, 1(1), 41-48.

Bryan, V., Lindo, J., Anderson-Johnson, P., & Weaver, S. (2014). Using Carl Rogers' Person-
 ACCEPTED MANUSCRIPT
28

Centered Model to Explain Interpersonal Relationships at a School of Nursing. Journal

of Professional Nursing, 31(2), 141-48.

T
Carolan-Olah, M., & Kruger, G. (2013). Final year students' learning experiences of the

P
of midwifery course. Midwifery, doi: 10.1016/j.midw.2013.07.010

RI
Chan, C., So, W., & Fong, D. (2009). Hong Kong Baccalaureate Nursing Students' Stress and

SC
Their Coping Strategies in Clinical Practice. Journal of Professional Nursing, 25(5), 307-

313.

NU
Day, R. (2012). How to be a better RN preceptor. Retrieved from:
MA
http://www.ehow.com/how_6822477_better-rn-preceptor.html

Dutta, A. P., Pyles, M. A., & Miederhoff, P. (2006). Measuring and understanding stress in
ED

pharmacy students. In M.V. Landow (Ed.), Stress and mental health of college
students, (pp.1-29). New York, NY: Nova Publishers
PT

Edwards, D., Burnard, P., Bennett, K., & Hebden, U. (2010). A longitudinal study of stress and
CE

self-esteem in student nurses. Nurse Education Today, 30(1), 78-84.

Evans, W., & Kelly, B. (2004). Pre-registration diploma student nurse stress and coping
AC

measures. Nurse Education Today, 24(6), 473-482.

Ghai, S., Dutta, M., & Garg, A. (2014). Perceived level of stress, stressors and coping behaviours

in nursing students. Indian Journal of Positive Psychology, 5(1), 60.

Gibbons, C. (2010). Stress, coping and burnout in nursing students. International Journal of

Nursing Studies 47 (10) 1299-1309.

Goff, A. (2011). Stressors, academic performance & learned resourcefulness in baccalaureate

nursing students. International Journal of Nursing Education Scholarship 8 (1) 1-13.

Hamaideh, S., & Ammouri, A. (2011). Comparing Jordanian nurses' job stressors in stressful and
 ACCEPTED MANUSCRIPT
29

non stressful clinical areas. Contemporary Nurse, 37(2), 173-187.

Hill, K. (2006). Shot in arm for nursing - Lee Chin donates $155m to Northern Caribbean

T
University (NCU). Retrieved from, http://jamaica-

P
gleaner.com/gleaner/20060908/lead/lead1.html.

RI
Houser, M., & Frymier, A., 2009. The role of student characteristics and teacher behaviors in

SC
students' learner empowerment. Communication Education, 58(1), 35-53.

doi:10.1080/03634520802237383

NU
Howard, D., (2001). Student nurses’ experiences of Project 2000. Nursing Standard, 15(48), 33-
MA
8.

Hsiao, Y., Chien, L., Wu, L., Chiang, C., & Huang, S. (2010). Spiritual health, clinical practice
ED

stress, depressive tendency and health promoting behaviors among nursing students.

Journal of Advanced Nursing 66 (7) 1612-1622.

PT

Hsu, l. l. (2007). Conducting clinical post-conferences in clinical teaching: a qualitative study.

CE

Journal of Clinical Nursing, 16(8), 1525-1533.

James, A., Chapman, Y. (2009) Preceptors and patients—the power of two student experiences
AC

on their first acute clinical placement. Contemporary Nurse, 34 (1) 34-47.

Jimenez, C., Pilar, M; Navia-Osorio, P., & Diaz, C. (2010). Stress and health in novice and

experienced student nurses. Journal of Advanced Nursing, 66 (2) 442-455.

LaMourt, F., Estryn-Behahr, M., Le Moel, R., Chrétien, T., & Matheiu, B. (2011). Survey on the

satisfaction regarding their studies and the health habits of nursing students in France.

Recherche en Soins Infirmiers, Jun (105) 44-59.

Lawal, J., Weaver, S., Anderson-Johnson, P., & Lindo, J. (2011). Factors influencing learning
 ACCEPTED MANUSCRIPT
30

experience of nursing students in the clinical area. West Indian Medical Journal

Suppl.60 (4) 1-54.

T
Llewellyn-Johnson, S., Lopez, S., Lindo, J., & Duff, E.M. (2011). Stress and burnout

P
experienced by BscN final year nursing students in Jamaica. West Indian Medical

RI
Journal, 60 (4) 1-54.

SC
Lo, R. (2002). A longitudinal study of perceived level of stress, coping and self-esteem of

undergraduate nursing students: An Australian case study. Journal of Advanced Nursing,

NU
39 (2) 119-126. MA
Lopez, F.V. & Lopez, M. J. (2011). Situations that generate stress in nursing students in clinical

practice. Cienc. Enfermeria, 17 (2) 47-54

ED

Massey, M. (1999). Promoting Stress Management: The Role of Comprehensive School Health

Programs. ERIC Digest. Retrieved from http://www.ericdigests.org/1999-1/stress.html

PT

Meleis, A. I. (2011). Theoretical nursing: Development and progress. Lippincott Williams &
Wilkins.
CE

Misra, R., & McKean, M. (2000). College students' academic stress and its relation to their
AC

anxiety, time management, and leisure satisfaction. American Journal of Health Studies,
16(1). Retrieved from http://www.biomedsearch.com/article/College-students-academic-
stress-its/65640245.html

Moscaritolo, L. (2009). Interventional strategies to decrease nursing student anxiety in the

clinical learning environment. Journal of Nursing Education 48(1) 17-23.

Moridi, G., Khaledi, S., & Valiee, S. (2014). Clinical training stress-inducing factors from the

students' viewpoint: A questionnaire-based study. Nurse Education in Practice, 14(2),

160-163.

Nolan, G., Ryan, D. (2008). Experience of stress in psychiatric nursing students in Ireland.
 ACCEPTED MANUSCRIPT
31

Nursing Standard 22 (43) 35-43.

Neuman, B. (2011). Retrieved from: http://currentnursing.com/nursing _theory/neumanhtml.

Nipissing University. (2015). Stress. Retrieved from, http://www.nipissingu.ca/departments/student-

P T
development-and-services/personal-counselling/resources/Pages/Stress.aspx

RI
Raosoft sample size calculator. (2004). Retrieved from

SC
http://www.raosoft.com/samplesize.html

Reeve, K., Shumaker, C., Yearwood, E., Crowell, N., & Riley, J. (2013). Perceived stress and

NU
social support in undergraduate nursing students' educational experiences. Nurse

Education Today, 33(4), 419-424.

MA
Reghuram, R., & Mathias, J. (2014). A study on occurrence of social anxiety among nursing
ED

students and its correlation with professional adjustment in selected nursing institutions at

Mangalor E. Nitte University. Journal of Health Science,4(2), 64.

PT

Seyedfatemi, N., Tafreshi, M., & Hagani, H. (2007). Experienced stressors and coping strategies
CE

among Iranian nursing students. BMC Nursing, 6(11), 11– 20.

Shaban, I., Khater, W., & Akhu-Zaheya, L. (2012). Undergraduate nursing students’ stress
AC

sources and coping behaviours during their initial period of clinical training: A Jordanian

perspective. Nurse Education in Practice, 12(4), 204-209.

Sharif, F., Masoumi, S. (2005). A qualitative study of nursing students experience of clinical

practice. Biomed Central Nursing 4 (6) 1186/1472-6955.

Sheu, S., Lin, H., & Hwang, S. (2002). Perceived stress and physio-psycho-social status of

nursing students during their initial period of clinical practice: The effect of coping

behaviors. International Journal of Nursing Studies, 39(2), 165-175.

Shipton, S.P., (2002). The process of seeking stress-care: coping as experienced by senior
 ACCEPTED MANUSCRIPT
32

baccalaureate nursing students in response to appraised clinical stress. Journal of Nursing

Education, 41 (6), 243–256.

T
Shukla, A., Kalra, G., & Pakhare, A. (2013). Understanding stress and coping mechanisms in

P
Indian student nurses. Sri Lanka Journal of Psychiatry, 4(2), 29-33.

RI
Students' Loan Bureau. (2005 - 2011). Financing Higher Education in Jamaica. Retrieved March

SC
31, 2015, from https://www.slbja.com/about.us.aspx

Student nurse dropout rate high (2008, April 9) BBC News, pp. A1. Retrieved from

NU
http://.news.bbc.co.u/1/hi. MA
Taghavi Larijani, T., RamezaniBadr, F., Khatoni, A., Monjamed, Z., (2007). Comparison of the

sources of stress among the senior Nursing and Midwifery Students of Tehran Medical
ED

Sciences Universities. Hayat, 13 (2), 61–70.

The UWI School of Nursing. (2004 - 2015). The UWI School of Nursing (UWISON)
PT

History. Retrieved from, http://myspot.mona.uwi.edu/nursing/about/history.

CE

Timmins, F., Kaliszer, M., (2002). Aspects of nurse education programmes that frequently cause

stress to nursing students – fact-finding sample survey. Nurse Education Today, 22(3),
AC

203-211.

University Students’ Council of the University of Western Ontario. (2015). Health & wellness

support service. Retrieved from http://westernusc.ca/wp-content/uploads/2015/02/Health-

and-Wellness-Support-Service-Coordinator.pdf

University of Victoria. (2014). Student mental health strategy. Retrieved from

www.uvic.ca/mentalhealth/assets/docs/StudentMentalHealthStrategy.pdf

Votta, R., & Benau, E. (2013). Predictors of stress in doctor of pharmacy students: Results from

a nationwide survey. Currents in Pharmacy Teaching and Learning, 5(5), 365-372.

 ACCEPTED MANUSCRIPT
33

Whyley, H., (1996). Finance, travel and lack of preceptorship put heavy burden on Welsh

students. Nursing Standard, 10 (35), 10.

T
World Medical Association. (2011). WMA declaration of Helsinki - ethical principles for

P
medical research involving human subjects. Retrieved from,

RI
http://www.wma.net/en/30publications/10policies/b3/index.html

SC
Yazdankhah Fard, M., Pouladi, S., Kamali, Zahmatkeshan, F., Mirzaei, K., Akaberian S., (2009).

The stressing factors in clinical education: the viewpoints of students. Iranian Journal of

NU
Medical Education, 8 (2), 341–350MA
Yonge, O., Myrick, F., & Haase, M. (2002). Student nurse stress in the preceptorship experience.

Nurse Educator, 27(2), 84-88.

ED
PT
CE
AC