BUKIDNON STATE UNIVERSITY

Malaybalay City, Bukidnon 8700

Tel (088) 813-5661 to 5663; TeleFax (088) 813-2717, www.buksu.edu.ph

Proponent: 

Abalde, John Paul

Bolotaolo, Nicole Shane

Caamiño, Aireen Anykka

Dabon, Christian Dave

Guil-an, Godriel Zayne

Pizaña, Phoebe Joy

Tentative Research Title:

The Relationship of Stressors and Stress Management among Nursing Students

During Clinical Duties: A Correlational Study

___________________________________________________________________

Introduction

Stress is any environmental change that causes the body to respond physically

or mentally. Environmental changes may cause either beneficial or unpleasant types

of stress (Bhandari, 2021). Academic stress affects nursing students, particularly the

3rd year students who need to do many return demonstrations and clinical duties.

However, as a result of the pandemic, education is now obtained through online

platforms under the new normal, which makes some duties more challenging.

According to Sala, one-third of nursing students face stress that is severe enough to

cause mental health issues, including anxiety and depression. Furthermore, they had
to deal with exams, long hours of studying, work, family, and personal obligations;

they also faced the challenges of clinical practice. And clinical practice has been

recognized as one of the most stressful aspects of nursing education.

              Stress management refers to the methods, tactics, or procedures that help to

alleviate stress and the negative effects it has on your mental or physical well-being.

Stress can be managed using a variety of approaches, including mental, emotional,

and behavioral techniques. It may improve the well-being by using stress management

on a daily basis and in reaction to stressful life situations. Stress may be both acute

and chronic. Work, income, relationships, and several other factors can all cause

stress, but stress can also emerge from inside the body as a result of diseases or

inflammation.  (Davis, 2015). 

To emphasize an idea, stress has far-reaching implications for nursing

students' academic performance. Saving people's lives is a lot of pressure, this gives

student nurses anxiety and fear on how to deal with it in the future in their chosen

field. The chanmanagement among the nursing students regarding on their clinical

duties.

Stressors are stressful circumstances or incidents. Life stressors include life

change events, major life crises and traumas, and chronic stressors. Life stressors are

associated with psychological stress reactions that involve depression and anxiety.

Stressor exposure also initiates a characteristic biological response that is associated

with the onset or exacerbation of a wide spectrum of physical illnesses. (C.J. Holahan

& R.H. Moose, 2017)

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 Statement of the Problem

This study aims to discuss the stress level among nursing students during their clinical

duties.

This study sought to answer the following questions:

1. What is the level of Stressors among Nursing Students during Clinical Duties?

2. What is the level of Stress Management among Nursing Students during

Clinical Duties??

3. Is there a relationship between Stressors and Stress Management among

Nursing Students during Clinical Duties?

Hypothesis Statement:

There is no relationship between stressors and stress management.

Framework of the Study

This chapter presents with the following sections: theoretical framework, review of

related literature and studies, conceptual framework, and paradigm.

The theoretical framework for this study is based upon the Transactional

Model of Stress and Coping by Lazarus and Folkman (1984) and The Roy Adaptation

Model by Sister Callista Roy (1976).

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 The Transactional Model of Stress and Coping is a framework for evaluating

the processes of coping with stressful events. The Model is useful for health

education, health promotion and disease prevention according to Glanz et al. (2008).

Nurses are usually faced with enormous responsibility and demand for care, intense

emotional pressure surrounding death and dying, prolonged and exhausting working

hours. (Sexton et al. 2009) and as such, studying how they are affected by stress

should take into consideration both their physical as well as psychological responses.

Emphasis should be laid on how stress affects their behavior and output as it relates to

the quality of care they are capable of rendering. The current study is applied to the

nursing practicum wherein nursing students undertaking and interacting in clinical

placements are unable to recognize the presence of stressors in the clinical

environment that could jeopardize their resources and well-being through primary

appraisal. Nursing students who are stressed reduce or eliminate stressors by making

efforts to change the stressful conditions so that they are not perceived as stressors.

The Roy Adaptation Model states that a person's health is an essential aspect

of their existence and is represented by a continuum of health and sickness. A state

and process of becoming integrated and entire is another way to define health (Roy,

1976). This model describes the environment as comprising stimuli from external and

internal sources that act as stressors. These stimuli serve as input to the person,

provoking a response.

In summary, the theory seeks to answer questions bothering on sources of

work stress for nurses working in the hospitals, the nature of the stress they are

exposed to, their individual reactions and the management and coping strategies

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available as well as possible implication for the different form of stress nurses are

exposed to. The nursing care plan should be modified throughout the nursing process

based on the patient's progress toward health by the nurse and other medical

professionals.

Review of Related Study

Stress is a type of psychological pain. Small amounts of stress may be

beneficial, as it can improve athletic performance, motivation and reaction to the

environment. Excessive amounts of stress, however, can increase the risk of strokes,

heart attacks, ulcers, and mental illnesses such as depression (Sapolsky RM, 2012)

and also aggravation of a pre-existing condition. Stress can be external and related to

the environment (Jones, Bright, & Clow, 2014) but may also be caused by internal

perceptions that cause an individual to experience anxiety or other negative emotions

surrounding a situation, such as pressure, and discomfort.

Stress is a common feeling we get when we feel under pressure, overwhelmed

or unable to cope. Small amounts of stress can be good for us and motivate us to

achieve goals like taking an exam or giving a speech. But too much of it, especially

when it feels out of control, can negatively impact our mood, physical and mental

well-being and relationships.

Stress management is a wide spectrum of techniques and psychotherapies

aimed at controlling a person’s level of stress, especially chronic stress, usually for

the purpose and for the motive of improving everyday functioning. Stress produces

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numerous physical and mental symptoms which vary according to each individual’s

situational factors. These can include a decline in physical health, such as headaches,

chest pain, fatigue, and sleep problems as well as depression. The process of stress

management is named as one of the keys to a happy and successful life in modern

society. Life often delivers numerous demands that can be difficult to handle, but

stress management provides a number of ways to manage anxiety and maintain

overall well-being.

Stress can be effectively managed in many different ways. The best stress

management plans usually include a mix of stress relievers that address stress

physically and psychologically and help to develop resilience and coping skills. Quick

stress relievers like breathing exercises, for example, may not build your resilience to

future stress or minimize the stressors that you face. But they can help calm the

body’s physiology once the stress response is triggered. Long-term healthy habits,

like exercise or regular meditation, can help to promote resilience towards stressors if

you make them a regular part of your life. Communication skills and other lifestyle

skills can be helpful in managing stressors and changing how we feel from

overwhelmed to challenged or even stimulated (Scott, 2019).

Coping usually involves adjusting or tolerating negative events or realities

while you try to keep your positive self-image and emotional equilibrium. Coping

occurs in the context of life changes that are perceived to be stressful. Psychological

stress is usually associated with negative life changes, such as losing a job or loved

one. However, all changes require some sort of adaptation. Even positive changes

such as getting married or having a child can be stressful (Albert, Falcone, and

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Cardona, 2016). Coping strategies to manage stress through social care can positively

reduce stress levels and promote health (Lo 2022; Payne 2001)

According to the Transactional Model of stress and Coping Theory by Lazarus

and Folkman (1984), stressors are demand made by both internal and external

environments, thus affecting both physical and psychological well-being and

requiring action to restore balance. The theory aims to provide answers to issues

regarding the reasons for work-related stress.

There are many known and traditional means of managing everyday stress.

These could be in the of physical exercise, emotional and psychological therapies,

change in work approach, medications among others. The choice of management

procedure adopted is usually subjective to the source and nature of the stress and the

resources available to the individual under stress (Cohen 1984). To cope according to

the Online dictionary is to face and deal with responsibilities, problems, or

difficulties, especially successfully or in a calm or adequate manner.

Conceptual Framework

Nursing students employ a variety of coping strategies such as talking to

friends, sports, crying, ignoring stress, feelings of sadness/misery and the use of

alcohol, which may be adaptive or maladaptive. According to Emad Shdaifat, Aysar

Jammal & Mohammed Al-Amer (2018) they pointed to problem solving as the most

utilized strategy in nursing students. Others refer to emotion-focused coping methods,

while some believe that transference, optimism and problem solving are the most used

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strategies among nursing students, For nurses working in hospitals, the types of stress

they experience, how they react personally, the management and coping mechanisms

that are accessible, as well as any potential repercussions for many types of stress

nurses experience. Lockley et al. (2007), there is a need to establish a safe hour work

limit for nurses in order to prevent the high rate of fatigue related medical errors and

injuries. In other words, there is a need for management action on limiting the amount

of hours done by nurses. The kind of shifts and the duration of shifts can be controlled

by a combined effort of the nurse managers and the nurses working in the hospitals.

Stressors are demands made by both internal and external environments that

upset the balance of an individual, thus affecting both physical and psychological

well-being and requiring action to restore balance (Lazarus & Cohen, 1977).

Clinical stress in nursing students include the fear of unknown events, working

with equipment, staff and faculty incivility, theory and practice gap, the fear of

making a mistake and communication with staff, peers and patients. Nursing students

face not only academic stress but stress at work during their training period. One

focus of interest in research on stress at work is the sources of stress or stressors,

which interact and contribute to the onset of stress in organizational settings

(Spielberger & Reheiser, 2005). Some of the common stressors are time pressures,

workload, making decisions, continuous changes and economic mistakes.

Stress on nursing students can impact not only on academic performance but

could also trigger several disorders such as depression or anxiety, as well as sleep

disorders, alcohol, and headaches, which may affect the patient’s care. Among the

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negative effects of stress on the individual are physical, psychological and

behavioural disorders (Shirom, 2003). Stress is associated with organizational level

issues, such as increased absenteeism, decreased quality of work and decreased

productivity (Elkin & Rosch, 1990).

The theory aims to provide answers to questions regarding the sources of

stress experienced by hospital nurses, the types of stress to which they are exposed,

how each nurse responds personally, the management and coping mechanisms that are

available, as well as potential implications for the various types of stress nurses

experience.

STRESSORS STRESS MANAGEMENT

Paradigm

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Figure 1. The Relationship of Stressors and Stress Management among Nursing

Students During Clinical Duties: A Correlational Study

Methodology

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 This chapter presents the methodology of the study. It includes the research

design, locale of the study, participants of the study, and research instrumentation.

Research Design

Correlational research design will be used in this study to determine the coping and

stress management strategies on the nursing students enrolled in one of the University

in Malaybalay City in the year 2022-2023. A correlational research design

investigates relationships between variables without manipulating any of them.

Correlational research design describes statistics such as mean and standard deviation

to compute the level of stress and stress management of The Relationship of Stressors

and Stress Management among Nursing Students During Clinical Duties.

Locale of the Study

This study will be conducted in one of the schools in Bukidnon. This

Institution offers the Bachelor of Science in Nursing to conduct a feasibility study.

This Institute is a State University school under the Commission of Higher Education

(CHED) and a high standard of education in the City of Malaybalay.

Participants of the Study

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 The participants of the study are the students studying in one of the

universities in Bukidnon specifically in the third year of nursing students. As

surveyed, there are a total of 86 students, 43 students in each section of the 3 rd year

nursing students.

Research Procedure

The researchers will be sending a letter asking permission to conduct this study.

This study will be participated by the selected 3rd year college of nursing enrolled in

one of the schools in Malaybalay City in the year 2022-2023.

A designated questionnaire will be followed to determine the relationship of

stressors and stress management among nursing students.

. The researchers will be conducting the study from September 2022 to

November 2022.

The participants are studying in one of the schools in Malaybalay City and are

officially enrolled in the higher year nursing students in the school year 2022-2023.

This group was exposed to blended learning which includes face to face and online

class to enhance learning throughout the conduct of the study.

Research Instrumentation

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The questionnaire is adapted from Mark Anthony S. Castillo

The survey questionnaire is divided into two parts:

The first part is a 20-items assessment survey on nursing students stress level

manage their stress. Reverse scoring procedure is done for negative statement 5 –

Always 4 – Often 3 – Sometimes 2 – Seldom 1 – Never. 

The score procedure is as follows:

Rating Scale Descriptive Rating Interpretation

5 4.51-5.00 Always Highly Positive

4 3.51-4.50 Often Positive

3 2.52-3.50 Sometimes Fair

2 1.51-2.50 Seldom Negative

1 1.00-1.50 Never Highly Negative

The second part is a 20-items assessment survey on Stressors. Reverse scoring

procedure is done for negative statement 5 – Always 4 – Often 3 – Sometimes 2 –

Seldom 1 – Never. 

The score procedure is as follows:

Rating Scale Descriptive Rating Interpretation

5 4.51-5.00 Always Highly Positive

4 3.51-4.50 Often Positive

3 2.52-3.50 Sometimes Fair

2 1.51-2.50 Seldom Negative

1 1.00-1.50 Never Highly Negative

Results

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 This section presents the interpretation of data gathered from the nursing

students survey questionnaire. The researchers developed a survey questionnaire

which is divided into two parts with 20 questions each category: stressors and stress

management. The researchers found out that the type of stressors perceived by the

participants was 3 and the level of stress management has an overall mean of 3.47.

Table 1. The Factors that explained the Stressors of nursing students during
clinical duties after 2 years of suspension

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 Stressors Mean Standard Interpretation
Deviation
Conflict with the healthcare team with 2.1 1.0615 N
handling the patients during clinical duties 1
The death of a patient. 2.2 1.3940 N
1
Not enough time to complete all your 3.7 0.9755 P
nursing tasks. 3
Lack of an opportunity to talk openly with 2.7 1.1963 F
staff about problems on a clinical 7
placement.
Watching a patient suffer. 3.4 1.1915 F
8
Feeling inadequately prepared to help with 3.4 1.1963 F
the emotional needs of patient. 8
Fear of making a mistake in caring for a 4.5 0.8351 P
patient. 2
Not knowing what a patient or patient’s 3.1 1.1744 F
family ought to be told about the patient’s 9
medical condition and treatment.
Uncertainty regarding the operation and 3.1 1.1584 F
functioning of specialized equipment. 4
Difficulty in working with a particular 2.3 1.2761 N
nurse or nurses on a clinical placement. 8
Listening or talking to a patient about 2.5 1.4513 F
his/her approaching death. 9
Disagreement concerning the treatment of a 2.1 1.2981 N
patient. 5
Feeling inadequately prepared to help with 2.9 1.1663 F
the emotional needs of a patient’s family. 7
Too many patients to handle. 2.2 1.2363 N
6
Criticism by a healthcare team while doing 2.6 1.3339 F
checkups on patients. 7
Patient with serious cases. 3.8 1.1222 F
2
Mixed cases of patients due to lack of 3 1.2360 F
rooms
Wrong procedure performed to the patient. 2.5 1.7081 F
5
Unfamiliar healthcare setting in the 3.0 1.1663 F
hospitals 3
Finishing charting on time. 3.8 1.0497 P
5
Overall 3 1.2114 Fair

Legend:

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 Rating Scale Descriptive Rating Interpretation

5 4.51-5.00 Always Highly Positive

4 3.51-4.50 Often Positive

3 2.52-3.50 Sometimes Fair

2 1.51-2.50 Seldom Negative

1 1.00-1.50 Never Highly Negative

Table 1 shows the result of the given survey questionnaires to identify the type of

stressors Nursing students deal during their clinical duties. As for the top result, this

shows that the “fear of making a mistake in caring for a patient” is the main source of

stress that are affecting the Nursing students with a total mean of (4.52) which is

interpreted as highly positive. Secondly, “Finishing Charting on time” is the source of

stress on nursing students encounter often with a mean of (3.85) which is explained to

be positive. And lastly, “Not enough time to complete all your nursing tasks “is one of

the high result of why nursing students encounter stress due to patients with serious

cases with a mean of (3.73), The lowest mean of this table are "Conflict with the

healthcare team with handling the patients during clinical duties" with a mean of

(2.11), "Disagreement concerning the treatment of a patient" with a mean of (2.15),

and "The death of a patient" with a mean of (2.21). The overall mean score of the

Stressors of nursing students during clinical duties after 2 years of suspension is 3

which Is Interpreted as Fair. This implies that nursing students deals with these

stressors during their clinical duties. the pressure of the task given would cause an

influx of occurring problems during clinical duties due to the requirement of high

demand work that has been given to the students. The given subject clarified that

nursing students encounter these kinds of stress often which can be translated into

positive. This can be supported by the study of K. Kleehammer, RN, BSN, A Louise

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Hart, RN, DNS, and J. Fogel Keck, RN, DNS (2013), stated that Aspects of nursing

students’ clinical experiences are anxiety provoking. High anxiety may contribute to

decreased learning. The results also supported by the findings of Latif and Zarawi

(2019) that Clinical assignment was the

main stressor among nursing students; therefore, successful activities should be

promoted to help them in managing clinical assignment and developing effective

interventions to reduce the stress they encounter. However, according to Crary (2013),

the involvement of nursing students in both didactic and clinical settings concurrently

does not occur in their health professions which negate the results of the study.

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 Table 2. Stress Management of nursing students use to cope up with the
Stressors
Stress Management Mean Standard Interpretation
Deviation
I try to do or think of some things that will 3.97 1.2344 P
make myself relax during clinical duties.

Reassuring patients that everything will be fine 3.85 1.2472 P

while having a conversation with them.
I talk with classmates or friends or disclose to 3.45 1.0432 F
my workmates in clinic.
I let myself calm down first and think of how 4.34 0.9196 P
to reprogram my mind to achieve peace of
mind.
I tried to look on the bright side of things. 4.44 0.9464 P
I consider the stress regarding clinical duties to 4.25 0.9612 P
be a type of self-challenge
I do usual things such as watching TV, reading 4.08 0.9749 P
books, listening to music, sleeping, eating or
going out to temporarily forget these
frustrating things.
I tell myself to persevere and to keep an 4.59 0.9473 HP
optimistic and positive attitude in dealing with
patients.
To have confidence in overcoming difficulties 4.26 0.9653 P
during clinical duties.
I create a strategy for how I'll approach 4.1 0.9816 P
whatever issues the event brings up step-by-
step.
I ask people who had similar experiences for 3.9 0.9944 P
their advice.
Withdrawal from social life to focus on clinical 3.4 1 P
duties
I concentrate on any potential clinical 3.92 0.991 P
responsibilities that may result from the
situation.
I tell myself to never surrender. 4.42 0.9511 P
I tried to make myself feel better by working, 3.79 0.9831 P
studying, etc.
I discuss issues with family, co-workers or 3.41 1 F
friends and classmates and ask for their
opinions.
When I encounter conflicts in my clinical 3.88 0.9574 P
duties and activities, I will first arrange and
plan.
I leave aside the problem first to assist my 4.34 0.5773 P
patients and works.

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I am used to leaving aside the problem and not 3.48 0.7071 F
handling it for the time being.
I take some time off and get away from my 3.67 0.9811 P
working life.
Overall 3.47 0.96818 Fair

Legend:

Rating Scale Descriptive Rating Interpretation

5 4.51-5.00 Always Highly Positive

4 3.51-4.50 Often Positive

3 2.52-3.50 Sometimes Fair

2 1.51-2.50 Seldom Negative

1 1.00-1.50 Never Highly Negative

Based on the data gathered on the table 2, it shows that the different stress

management nursing students use to cope up with stressors. “I tell myself to never

surrender” got the highest mean of (4.59), Next statement is “I tried to look on the

bright side of things” with a mean of (4.49), And lastly, the statement I tell myself to

never surrender with a mean of (4.42). As lowest mean the “I leave aside the problem

first to assist my patients and works” with a mean of (4.34), “I ask people who had

similar experiences for their advice” with a mean of (3.9), and lastly in the

“Withdrawal from social life to focus on clinical duties” with a mean of (3.4). The

overall mean score of the Stress Management of Nursing students used to cope up

with the Stressors is 3.47 which is interpreted as Fair. The result implies that Nursing

students experience high levels of stress. Stress management such as utilization of

social support are effective in managing the effects of stress and promoting individual

well-being. Promoting the usage of sensible management of stress by nursing students

will improve the standard of care they provide for their patients. This can be

supported in the study of Cruz (2018), Nurses are often exposed to challenging

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situations in the clinical area, which may have negative impact on the quality of life

on nursing students. However, Tumwijit et al. (2009) stated that most nursing students

experienced high stress and saw the clinical nursing practicum as a threat which

negates the results of the study.

Table 3. Test of Relationship between Stressors and Stress Management among

Nursing Students during Clinical Duties
N x̄ R P-value
Stressors 73 2.98
0.97 0.691
Stress Management 73 3.98

Table 3 shows the significant relationship of Stressors and Stress Management

among Nursing Students during Clinical Duties. The result shows that there is a

correlation between stressors and stress management with a P-value of 0.691.

According to Johnson (2013), stress management strategies of emotion control and

active coping had a more positive effect on emotional exhaustion. This states that

nursing students had experienced a moderate level of stress of academic works and

clinical duties but still managed to overcome the challenges and stressors in their

chosen field. Nursing students often experience moderate levels of stress during

training that may result in psychological or emotional impairment during their

professional life ultimately affecting the quality of patient care they provide. Clinical

instructors provide the needed support and guidance for students to relieve stress and

promote a positive clinical experience. The results of this study showed that, nursing

students were employing a range of coping strategies to manage job-related stress in

the clinical environment. However, Participants employed techniques to improve their

professional competency, correct their mistakes, deal with difficult situations, and

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reflect on stressful matters in order to actively manage the stress of the clinical

setting.

Conclusion

Based on the findings of the study, conclusions were drawn. The level of stressors

among nursing students during clinical duties is fair. The nursing students’

performance level in the stressor survey indicates that they can deal with the stress

during clinical duties. Usually, students are initially intimidated by clinical practice

environments, and this was visible in this study from the stress of clinical duties.

Furthermore, the level of stress management among nursing students during clinical

duties was indicated as fair. Nursing students also experienced stress related to

assignments and work capacity during clinical duties, particularly with regard to the

quality of work they were expected to achieve and the guidelines they were required

to follow, considering they were not fully familiar with hospital protocols. Lastly,

there is a relationship between stressors and stress management among nursing

students during clinical duties. Nursing students, during their clinical duties, deal with

stressors and use stress management to relieve stress. In clinical settings, stress levels

among nursing students are considerable. Any type of planning in this subject requires

a thorough understanding of those participating in nursing education, including their

coping mechanisms for dealing with stress.

Recommendations

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 The research study's findings can be applied to enhance clinical teaching

activities for clinical practical in nursing schools. In order to lower stress levels and

enhance the clinical practicum experience, nursing instructors should think about

developing a clinical teaching program that emphasizes social support, improving

knowledge and skills that are immediately applicable to clinical practice, and

providing appropriate learning facilities. Further study should look into the

relationship between stress level and stress coping strategy, as well as stress and

coping mechanisms in all other clinical nursing practice areas. Also, the clinical

practice preparation program might be created as an experimental research study to

assist students in lowering their stress levels and thereby enhancing their clinical

performance.

In nursing, occupational stress such as workload and organizational factors,

including leadership, are the major factors causing stress among nurses. As a result, it

is suggested that the facility improve the workforce quality of nurses. Effective stress

management and coping strategies are essential steps to produce nurses’ work

achievement and to reduce or control the level of stress among nurses.

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 Ethical Statement

         This study will involve nursing students. The researchers will develop criteria to

identify who will be included and excluded as respondents. Precautions are made to

ensure the safety and security of participants. Before commencing, the researchers

will obtain approval from school authorities. Furthermore, the researchers will seek

the participant’s voluntary decision to participate in the study based on sufficient

information given by the latter on the purpose, methods, demands, risks and potential

benefits of the research and adequate understanding of both the proposed research and

the implications of participation in it.

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