Research Briefs

Changes in Stress and Nurse Self-Concept among Baccalaureate Nursing Students

Desiree Hensel, PhD, RN, CNE; and Wendy Stoelting-Gettelfinger, PhD, JD, APN, NP-C

ABSTRACT
This pilot studys purpose was to investigate the relationship between stress and nurse self-concept. Specifically, it examined whether enrollment in a wellness course affected stress levels and self-concept acquisition among sophomore baccalaureate nursing students (N = 52). The findings showed that early in the curriculum these students had a fairly well developed sense of professional self-concept but made gains in facets of leadership and communication over the course of the semester. Students demonstrated high levels of stress that remained unchanged over the semester, regardless of self-concept acquisition. This study concluded that enrollment in a wellness course was insufficient to prepare nursing students to manage stress as they transition to professional roles, and it was possible that undergraduate education perpetuated the internalization of stress as part of a nurses professional identity. Future studies are needed to determine effective ways to teach stress management and best design nursing curricula to reduce stressors.

he purpose of undergraduate nursing education is to help students acquire the unique knowledge, skills, and attitudes of the profession (Cronenwett et al., 2007). During the process, students form perceptions of their adequacy in their professional role. These perceptions are known as a professional or nurse self-concept. Developing a healthy professional self-concept is important because it empowers nurses to positively affect patient care and may moderate the effects of a stressful work environment, leading to improved retention (Arthur & Randle, 2007; Cowin, Johnson, Craven, & Marsh, 2008). However, for many nurses, perceptions of extreme stress actually begins well before entering the workforce in prelicensure education (Pryjmachuk & Richards, 2007; Rella, Winwood, & Lushington, 2008). Perceptions and manifestations of stress may lead to a perpetuating cycle where physical, emotional, cognitive, and behavioral symptoms increase the individuals stress (Benson & Stuart, 1992). As stress inhibits the ability to think clearly, stress and the stress cycle have the potential to negatively affect a students professional growth. Some nurse educators advocate that courses in stress management are needed to promote student success (Billingsley, Collins, & Miller, 2007; Kand, Choi, & Ryu, 2009), but little is known about how such courses affect the acquisition of a strong nurse self-concept. This pilot study investigated how stress and professional self-concept changed over the course of a semester among sophomore baccalaureate nursing students enrolled in a required wellness course and explored whether stress was adversely related to the students acquisition of a strong selfconcept.

Received: January 18, 2010 Accepted: August 31, 2010 Posted: January 31, 2011 Dr. Hensel is Assistant Professor, and Dr. Stoelting-Gettelfinger is Assistant Clinical Professor, Indiana University School of Nursing, Bloomington, Indiana. The authors thank Dr. Leanne Cowin for sharing the Nurse Self-Concept Questionnaire. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to Desiree Hensel, PhD, RN, CNE, Assistant Professor, Indiana University School of Nursing, Sycamore Hall 444, 1033 East 3rd Street, Bloomington, IN 47405-7005; e-mail: dehensel@indiana.edu. doi:10.3928/01484834-20110131-09

Literature Review
The term self-concept is used to describe ones perceptions of self-adequacy and is thought to be multidimensional (Shavelson, Hubner, & Stanton, 1976). For nurses, a dimension of their total self-concept is their professional or nurse self-concept (Arthur & Randle, 2007). What exactly constitutes a nurse self-concept is subject to debate. Arising from recommendations from the Institute of Medicine, nursing education leaders proposed that nurses perceptions of professional adequacy should be based on their ability to provide patient-centered and safe care, utilize evidence-based practice and informatics, work collaboratively as team members, and use quality improvement strategies (Cronenwett at al., 2007). However, to date there is little evidence that nurses self-concepts are actually based on those recommendaCopyright SLACK Incorporated

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tions. Evolving from the theory of Shavelson et al., research exists supporting Cowins (2001) model of nurse self-concept. Cowin used a pilot group and two large samples that consisted of nursing students near graduation (N = 506) and experienced nurses (N = 528) to create a model of self-concept with six subscales. Cowins model includes facets of caring, communication, knowledge, leadership, staff relations, and a nurse general self-concept or self-esteem. This model provides an effective framework to examine the relationship between stress and professional self-concept acquisition. A strong nurse self-concept is thought to mediate the effects of a high stress workplace and empower nurses in their work (Arthur et al., 1999; Siebens et al., 2006). Cowin and Hengstberger-Sims (2006) found that graduate nurses with higher self-concepts were more likely to be retained for at least 1 year in their first job. Job satisfaction has long been thought to be a major factor in retention, but one study found that nurse self-concept was a stronger predictor of retention than job satisfaction (Cowin et al., 2008). The process by which an undergraduate student develops a nurse self-concept has been described as a social phenomenon where students build on a foundation of knowledge by taking it all in (Ware, 2008, p.10). However, stress can cause trouble thinking clearly, impair memory, and suppress creativity (Benson & Stuart, 1992) and thus impair real learning. In a longitudinal study, Edwards, Burnard, Bennett, and Hebden (2009) found that stress and self-esteem changed over the course of nursing education and that increased stress was related to decreased self-esteem in nursing students at three of five measurement points. Sources of stress arising from prelicensure education included examinations, deadlines, fear of making an error in patient care, demands of studying after work, and watching suffering. In one study, Randle (2003) also found that nursing education threatened students self-esteem, with 95% of the students having classified themselves as anxious, unhappy, or depressed by graduation. In another study, Pryjmachuk and Richards (2007) found that approximately one third of the nursing students could be classified as stressed (N = 937). Although stress may be endemic in nursing education, failure to teach students adequate stress management may disadvantage students as they enter the workforce. Seriously stressed new graduates may have had little time to recover from the nursing school experience and this unresolved stress may put them at risk for early burnout (Rella et al., 2008). There is little evidence to suggest that protective self-care practices improve after graduation because stress management and physical activity have been reported to be nurses least practiced aspects of a healthy lifestyle (Hensel, 2008; McElligott, Siemers, Thomas, & Kohn, 2009). Courses in stress management and self-care have been suggested as ways to reduce stress among students (Billingsley et al., 2007; Stark, Manning-Walsh, & Vliem, 2005). In fact, nursing students have identified the need for such courses (Gardner, Deloney, & Grando, 2007), but the most effective way to provide such education is still in question. Short-term reductions in stress and anxiety were found after an 8-week mindfulness meditation course among one group of nursing students, but how long the benefits lasted is unknown (Kand et al., 2009).
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One 2-week online stress management course was found to improve physical activity and stress management behaviors for 6 months among a group of college students, but the study included students from a variety of majors (Chiauzzi, Brevard, Thurn, Decembrele, & Lord, 2008). Benefits from a nursing elective course that included self-care were found to persist up to 7 years (Downey, 2007), but more studies are needed to identify the long term effects of such courses and how stress affects nurse self-concept development. Using Cowins (2001) model as a frame work, the research questions for this pilot study were: l How does nurse self-concept change during the fourth semester of nursing school? l How does a wellness course that includes stress management affect students stress? l How are stress and nurse self-concept formation related?

Method
After receiving institutional review board approval, all 54 BSN students enrolled in a required wellness course were invited to participate in this voluntary pilot study; 52 students completed both the pretest and posttest and were included in the study. Although described as fourth semester students, these students spent their first year taking prerequisites and were actually enrolled in their second semester of nursing courses. The students were concurrently enrolled in nursing fundamentals and a communication course. Early content in the wellness course included health behavior theory, nutrition, and pharmacology for across the lifespan. In the second half of the class, content on exercise, stress management, and complementary and alternative medicine was presented. At the beginning of the course, students were required to select one personal health area that they would like to improve and to devise a plan to meet their goals. The students were then asked to submit progress journals at the middle and end of the semester. The journals provided the instructor with an opportunity to provide student feedback, but they were not used data analysis. At the beginning and end of the semester, students were asked to assess how they thought and felt about themselves as a nurse and to assess the manifestations of stress that they were experiencing. Measures were repeated at the end of the course. The anonymous data were kept in sealed packet identifiable only by a symbol the students drew. Students claimed the packets at the end of the semester to complete the posttest. Data were collected using the Nurse Self-Concept Questionnaire (NSCQ) and the Stress Warning Signals (SWS) checklist. The NSCQ is a 36-item, 8-point ordinal scale that measures the six facets of nurse self-concept identified by Cowin (2001). The NSCQ and has evidence of theoretical and construct validity. In this study, the NSCQ showed good internal consistency. Cronbachs alpha scores for all scales were adequate, with total scales scores of 0.87 at baseline and 0.91 at exit. Designed as a self-assessment tool, the SWS checklist identifies 12 physical, 8 behavioral, 9 emotional, 8 cognitive, 10 spiritual, and 13 relational signs of stress (Benson-Henry Institute for Mind Body Medicine, 2010; Casey & Benson, 2004). When used as a summative scale, checking five or fewer symptoms indicates the user is most likely coping well.
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Checking more symptoms indicates that stress may be negatively affecting quality of life.

Findings
Data were analyzed using PAWS Statistics for Windows version 17 software. Fifty-two students completed both the pretest and posttest. All participants were female and primarily traditional students, with a mean age of 21.3 years. The groups ethnicity was 96% Caucasian. The students could be considered very high achievers, with a mean grade point average of 3.75 on entry into the program. Baseline mean scores for the NSCQ were 226.7 (standard deviation [SD] = 26.91, range = 135-284). Paired t tests showed nurse self-concept increased significantly over the course of the semester (mean = 231.91, SD = 27.46, range = 166 to 283, p = 0.019). At baseline, the highest self-concept scores occurred for self-esteem (mean = 42.1, SD = 4.68, range = 33 to 48). The lowest scores were seen for leadership (mean = 31.7, SD = 7.35, range = 11 to 48). Over the course of the semester, the facets of self-concept that increased significantly were communication (p = 0.001) and leadership (p = 0.003). Dimensions of knowledge, self-esteem, and staff relations decreased but not significantly. In addition, caring scores increased, but the increases were not statistically significant. At baseline, students reported mean SWS checklist scores of 16.4 (SD = 8.17, range = 3 to 36). This score did not change significantly over the semester (mean = 16.7, SD = 8.88, range = 4 to 42). In this study, only 4 students at baseline and 6 students at the end of the semester reported experiencing 5 or fewer symptoms on the SWS checklist, indicating that stress was most likely adversely affecting the vast majority of students (BensonHenry Institute for Mind Body Medicine, 2010). However, this study did not find any significant relationships between stress and nurse self-concept or self-concept acquisition.

Discussion
Ware (2008) posited that students enter nursing school with the foundations of a nurse self-concept that has arisen from life experiences, personal philosophies, role models, and religious beliefs. This study lends support to this theory, as the participants, in only their second semester of their nursing courses, had mean NSCQ scores of 222.7 of a possible 288. Relatively speaking, Hensel (2008) found a mean NSCQ score of 245.3 (SD = 26.39) in a sample of experienced nurses in which 84% of the participants reported having 10 years or more of nursing experience. How professional self-concept increased over the course of the semester among the students was surprising. The students were concurrently taking a nursing fundamentals course and a communication course. It was anticipated that they would have significant gains in knowledge and communication, but the knowledge and self-esteem scores trended downward. One explanation might be that students were becoming more reflective and gaining an appreciation of how much they still had to learn. Still, the end-of-semester self-esteem scores (mean = 41.7, SD = 4.9) were higher than what Cowin (2001) found in students near graduation (mean = 38.59, SD = 6.9). Following this group longitudinally to graduation would have helped cre292

ate a clearer picture if self-esteem truly began to suffer early in the nursing curriculum. In this study, stress was not related to nurse self-concept development, but the instrumentation may not have been sensitive enough to measure differences in stress in this group of students. Perhaps the most troubling finding of this study was the consistently high stress levels experienced by these nursing students. At the beginning of the semester, 92% of the students reported enough warning signals to indicate that stress was most likely affecting their lives. At the end of the semester, the percentage of students experiencing high stress decreased only slightly to 88%. Still, posttest data were collected 1 week before the end of the semester, which makes it difficult to interpret whether the stress levels represented a steady trend or were reflective of a temporary increase in stress associated with impending finals. This study did not attempt to identify the sources of the students stress. Although clinical education and demanding course work have been identified as sources of stress in nursing school, other factors that predict stress include self-reports of feeling pressure, having children, having personal problems, and using emotional coping styles (Pryjmachuk & Richards, 2007). Rella et al. (2008) found that the need to work predicted stress and fatigue. Given the cost of nursing education and current economic climate, there is no reason to believe that the number of students having to work will decrease, making it even more important to understand how to reduce student stress. When evaluating the effectiveness of the wellness course format on reducing student stress, one problem may have been that too much time was spent on lecturing on stress management theory and too little time was allotted for practicing techniques. In addition, the content may have been presented too late in the course. The students may have benefited from having stress management principles introduced earlier in the course instead of being introduced mid-semester. At the same time, a single course may not have been sufficient to help students learn to manage stress if the overall nursing curriculum was designed in a way that students perceived as being overly stressful or was in conflict with their external responsibilities. The finding of such high stress levels in students leaves in question whether these students felt being stressed was just a natural part of a nurses identity. Pryjmachuk and Richards (2007) thought that worklife balances must be central to nursing curricula, but the role faculty play in perpetuating or mitigating student stress is difficult to assess. In the face of a nursing shortage, partially due to a faculty shortage, faculty with high workloads may manifest signs of stress and not role model successful management strategies to students. Further, Pryjmachuk and Richards (2007) thought that faculty may also not be aware of the true stress levels of their students. Although accustomed to intervene when academic failure is seen, faculty may be unaware that self-reports of pressure and personal concerns, not academic problems, predict stress. Students have reported feeling inadequately prepared to cope with the strain of professional nursing (Rella et al., 2008). The implication of this study for nursing education is that because nursing can be a stressful profession and stress contributes to burnout and attrition, nurse educators have a responsibility to prepare graduates to successfully manage stress just as they preCopyright SLACK Incorporated

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pare their graduates to provide high quality, safe patient care. Educators should not assume students are incorporating stress management practices into their lives simply because they receive information on the topic. More studies are needed to determine the best way to teach students to manage their stress and best design nursing curricula to reduce unnecessary stressors.

References
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