Nurse Education in Practice 15 (2015) 192e195

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Learning and teaching in clinical practice

Assessment of nursing students' stress levels and coping strategies in

operating room practice
Ummu Yildiz Findik a, 1, Ayfer Ozbas b, 2, Ikbal Cavdar b, 2, Sacide Yildizeli Topcu a, *,
Ebru Onler c, 3
a
Trakya University Faculty of Health Sciences, Nursing Department, Edirne, Turkey
b _
Istanbul University Florence Nightingale Nursing Faculty, Istanbul, Turkey
c
Namık Kemal University, School of Health, Tekirdag, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this study was to evaluate the stress levels and stress coping strategies of nursing students in
Accepted 10 November 2014 their first operating room experience. This descriptive study was done with 126 nursing students who
were having an experience in an operating room for the first time. Data were collected by using Personal
Keywords: Information Form, Clinical Stress Questionnaire, and Styles of Coping Inventory. The nursing students
Clinical stress mostly had low clinical stress levels (M ¼ 27.56, SD ¼ 10.76) and adopted a self-confident approach in
Coping with stress
coping with stress (M ¼ 14.3, SD ¼ 3.58). The nursing students generally employed a helpless/self-
Nursing student
accusatory approach among passive patterns as their clinical stress levels increased, used a self-
Operating room practice
confident and optimistic approach among active patterns as their average age increased, and those
who had never been to an operating room previously used a submissive approach among passive pat-
terns. The results showed that low levels of stress caused the nursing students to use active patterns in
coping with stress, whereas increasing levels of stress resulted in employing passive patterns in stress
coping. The nursing students should be ensured to maintain low levels of stress and use active patterns
in stress coping.
© 2014 Elsevier Ltd. All rights reserved.

Introduction
The clinical practice in the nursing education is essential to the
acquisition of nursing competence (Blomberg et al.). However,
several studies suggest that clinical practices, which constitute an
important part of nursing training, are very stressful for nursing
students (Gorostidi et al., 2007; Pryjmachuk and Richards, 2007;
Sharif and Masoumi, 2005; Sendir and Acaroglu, 2008; Sheu
et al., 2002). In the literature, it is stated that the practical parts
of nursing training programs were more stressful than the aca-
demic parts (Blomberg et al., 2014; Taşdelen and Zaybak, 2013), and
Blomberg et al. (2014) determined that 57% of nursing students
* Corresponding author. Tel.: þ90 284 213 30 42; fax: þ90 284 212 61 07.
E-mail addresses: uyildizfindik@mynet.com (U. Yildiz Findik), ayferozbas@
hotmail.com (A. Ozbas), ikbal@istanbul.edu.tr (I. Cavdar), sacideyildizeli@yahoo.
com (S. Yildizeli Topcu), eonler@nku.edu.tr (E. Onler).
1 Kipping, 2000; Pryjmachuk and Richards, 2007). In their study,
Tel.: þ90 284 213 30 42; fax: þ90 284 212 61 07.
2
Tel.: þ90 212 440 00 00; fax: þ90 212 224 49 90.
3
Tel.: þ90 282 293 23 82; fax: þ90 282 293 35 18.
experienced stress in the clinical field. Reasons for stress in clinical
practices vary among nursing students. Chan et al. (2009) deter-
mined the most common reason for stress is lack of knowledge and
skills. The first clinical experience, fear of making mistakes, emer-
gency situations, expectations, irregularity of clinical training, pa-
tients, communication problems between the health professionals
and clinical trainers, academic assessments on the clinical field,
practicing on humans, and equipment and operation of the clinical
areas are significant causes of stress (Gorostidi et al., 2007;
Pryjmachuk and Richards, 2007; Sharif and Masoumi, 2005; Sendir
and Acaroglu, 2008; Timmins and Kaliszer, 2002). Another cause
for nursing students' increased clinical stress is practicing in special
units. Children's services, intensive care units, emergency services,
and operation rooms where the nursing students are required to
practice in their second and third years are more stressful clinical
practice areas due to the heavy workload and the assignment of too
much responsibility to the students (Evans and Kelly, 2004;
Sharif and Masoumi (2005) found that nursing students experi-
enced much more stress during their second, third, and fourth years

http://dx.doi.org/10.1016/j.nepr.2014.11.008
1471-5953/© 2014 Elsevier Ltd. All rights reserved.
 U. Yildiz Findik et al. / Nurse Education in Practice 15 (2015) 192e195
in nursing training. Stress is viewed as a complex and dynamic
transaction between individuals and their environments (Evans
and Kelly, 2004). The presence and level of stress has positive and
negative effects on learning and thinking where high levels of
stress impedes learning; low levels motivate students while
learning (Burnard et al., 2007; Gammon and Morgan-Samuel,
2005; Sendir and Acaroglu, 2008; Tully, 2004). The effects of
stress on individuals depend on the sufficiency of their coping
behaviors. Lazarus and Folkman (1984) define it as “continuous
effort by an individual to overcome the imbalance between the
internal and external conditions” (Gammon and Morgan-Samuel,
2005; Sawatzky, 1998; Sheu et al., 2002). When coping efforts are
successful, the stressful situation can be resolved and balance is
retained by reducing the negative effects of stress (Sheu et al.,
2002). In the scale developed for university students, Lazarus and
Folkman (1984) defined the problem-oriented/active and
emotion-oriented/passive patterns as coping patterns for different
stressful situations. The problem-oriented/active coping patterns
aim to change or manage the situation causing the stress, whereas
the aim of emotion-oriented/passive coping patterns is organizing
the emotional responses to stressors (Burnard et al., 2007; Evans
and Kelly, 2004; Sawatzky, 1998; Temel et al., 2007). Gammon
and Morgan-Samuel (2005) determined in their study that the
nursing students with high stress levels had low coping levels.
Presence and level of stress affect the academic performance and
coping efforts of students in clinical practices (Gammon and
Morgan-Samuel, 2005; Sendir and Acaroglu, 2008; Sheu et al.,
2002). One of the practice areas for the surgical diseases nursing
course provided Turkey's second-year nursing training is the
operating room. In operating room practice, nursing students gain
knowledge and skills in caring for patients undergoing surgery. The
operating rooms are distressing for students because of their spe-
cific structure, operational rules, experience on patients, and the
first-time experience of the students with regard to an operation on
a patient. Despite of the fact that studies in the clinical area about
stress among nursing students increased from day by day, there is
no study evaluating the stress levels and stress coping behaviors of
the nursing students in an operating room. Determination of the
stress levels and stress coping behaviors of the nursing students
will provide guidance to the nursing instructors in reducing the
negative effects of stress and providing an effective clinical training
in operating room practice (Kaya et al., 2007; Sheu et al., 2002).
The aim of this study is to determine the stress levels and stress
coping patterns of nursing students in their first operating room
practice.
Study questions
 What is the stress level of nursing students in their first oper-
ating room experience?
 What are the stress coping patterns of nursing students in their
first operating room experience?
 What is the relationship between the stress level and stress
coping patterns of nursing students in their first operating room
experience?
Materials and methods
This study was conducted as a descriptive study at Trakya Uni-
versity and two Healthcare Schools in the region between February 1,
2008, and May 15, 2009. Data collection forms were given to 160
nursing students who experienced their first operating room practice;
126 of them (78.75%), who completed the forms fully, were included in
the study. The survey forms were distributed to the students at the end
of their first operating room practice and the students were asked to
193
return the forms to the researchers after 20 min. Before distributing
the survey forms, the researchers explained that the students were not
required to participate in the study or identify themselves, that the
data were to be used for a scientific research, and that the students
might ask any questions about the study. The students were left on
their own while completing the survey forms. A Personal Information
Form, Clinical Stress Questionnaire, and Stress Coping Patterns Scale
were used as data collection materials.
Personal Information Form
Collects data about age, sex, school of the students, and infor-
mation such as whether the students have seen an operating room
and their preference of school.
Clinical Stress Questionnaire (CSQ)
A Likert-type self-assessment scale developed by Pagana in
1989 to determine the initiation value of the stress levels of the
nursing students or requiring them to struggle in their first clinical
practice experience. The Clinical Stress Questionnaire can be used
in all internal and surgical clinics at the end of the day the student
experiences his/her first clinical practice. The items of the ques-
tionnaire consists of four scales including threat (I was sad, I was
nervous, I was bored, I was affected, I was cowered, I was scared),
struggle (I was stimulated, I was cheerful, I was hopeful, I liked it, I
was aspired, I was excited, I was happy), harm (I was furious, I was
grieved, I felt guilty, I was disgusted, I was disappointed), and
benefit (I was relieved, I was in confidence). Each item is assessed in
5 levels; the students are asked to choose one of the following: “0-
none”, “1- a little”, “2- medium”, “3- pretty much”, “4- very much.”
On the basis of points for each item, the minimum score of the
questionnaire is “0” and maximum is “80”. Low scores indicate low
stress levels, whereas high scores indicate high stress levels. The
reliability and validity of the Turkish form was demonstrated by
Sendir and Acaroglu (2008).
Stress-coping patterns scale (SCPS)
A scale for university students in relation with coping mecha-
nismsdin particular, depression, solidarity, and psychosomatic
problemsdand valid for short, different distressing situations,
prepared on the basis of the stress-coping Ways Inventory (devel-
oped by Lazarus and Folkman (1984)). The reliability and validity of
the Turkish form consisting of 30 items was demonstrated by Sahin
and Durak (1995). It is a four Likert-type scale to measure two
major stress-coping patterns, including problem-oriented/active
patterns and emotion-oriented/passive patterns. Active patterns
include sub-scales of “seeking social support (SSS), optimistic
approach (OA) and self-confident approach (SCA)”, and passive
patterns include sub-scales of “helpless approach (HA)” and “sub-
missive approach (SA)”. The Cronbach alpha consistency co-
efficients of the scales are determined to be 0.63 for SSS, 0.68 for
OA, 0.61 for SCA, 0.70 for HA, and 0.51 for SA. Items 8, 10, 14, 16, 20,
23, and 26 of the scale are related to SCA; 2, 4, 6, 12, and 18 are
related to OA; 3, 7, 13, 15, 21, and 24 are related to HA; 5, 7, 13, 15, 21,
and 24 are related to SA; and 1, 9, 29, and 30 are related to SSS. The
scale has been developed to determine what individuals do to cope
with troubles in life and stress (Kaya et al., 2007; Temel et al., 2007).
Statistical analysis
The data were assessed on computer by using percentage,
average, t-test, and Pearson correlation test. The value of P < 0.05
was accepted as the statistical significance limit.
194 U. Yildiz Findik et al. / Nurse Education in Practice 15 (2015) 192e195

Findings

¡2.155**
0.034**
0.087
0.167
0.058
0.261
0.928
0.365

0.858
0.393
Submissive approach

r/p

t/p
The average age of the nursing students participating in their

b
a
first operating room experience was 20.48 (min ¼ 18, max ¼ 23),

10.76
88% were female, 39% were attending Edirne Health College, 76%

2.71

2.71
1.14
2.75
2.29

2.18
2.83
2.76
2.56
had never seen an operating room before, and 68% chose the pro-

±
±
±
±
±
±

±
±
±
±
X ± SS
fession willingly (Table 1).

5.42
27.56
5.42
20.48
5.46
4.86

4.66
5.66
5.53
5.10
The average clinical stress score of the nursing students in their
first operating room practice was determined to be M ¼ 27.56,
SD ¼ 10.76 (min ¼ 7, max ¼ 66) (Table 1).

Emotion-oriented/passive patterns

Helpless/self-accusatory approach
When the nursing students' stress-coping patterns examined, it

0.136

0.620
0.149**
0.047**

0.064
1.048
0.307

0.537
0.056
0.956
was found that self-confident approach subscale score was

r/p

t/p
14.3 ± 3.58, optimistic approach score was 8.95 ± 2.89 (min ¼ 1,

b
a
max ¼ 15), seeking social support score was 7.38 ± 2.44 (min ¼ 1,
max ¼ 12), helpless/self-accusatory approach score was 9.68 ± 4.24
(min ¼ 0, max ¼ 19) and submissive approach score was 5.42 ± 2.71

10.76
4.24

4.24
1.14
4.26
3.53

4.09
4.24
4.15
4.35
(min ¼ 0, max ¼ 16) (Table 1).

±
±
±
±
±
±

±
±
±
±
The nursing students used helpless/self-accusatory approach of

X ± SS

9.68
27.56
9.68
20.48
9.77
8.73

9.28
9.79
9.67
9.62
the passive patterns (r ¼ 0.149, P ¼ 0.047) as their clinical stress
levels increased, and self-confident and optimistic approaches of
the active patterns (r ¼ 0.199, P ¼ 0.013, r ¼ 0.205, P ¼ 0.011,

0.046
0.303
0.031
0.366
0.768
0.452

1.736
0.087
0.404
0.688
Seeking social support

r/p

t/p
respectively) as their average age increased, and those who had

b
a
never seen an operating room before used submissive approach of
the passive patterns (t ¼ 2.155, P ¼ 0.034) (Table 2).

10.76
2.44

2.44
1.14
2.48
2.17

2.29
2.47
2.35
2.67
±
±
±
±
±
±

±
±
±
±
Discussion

X ± SS

7.38
27.56
7.38
20.48
7.46
7.00

8.00
7.20
7.47
7.27
The nursing students were found to have low stress levels in

1.198 0.242
operating room practice and to use the self-confident approach
among active patterns. There is no study evaluating the stress levels

0.205**
0.011**
0.007
0.470

1.629
0.107
1.451
0.151
and stress coping patterns of the nursing students in their first r/p

t/p
Optimistic approach

b
a

operating room experience. However, there are studies that have a

similar assessment as our study in terms of low stress levels in first 10.76
2.89

2.89
1.14
2.99
1.64

2.22
3.07
2.80
3.02
clinical practices. In the delivery room practice, which we thought
±
±
±
±
±
±

±
±
±
±
to be similar to operating room practice, Sirin et al. (2003) found no
X ± SS

8.95
27.56
8.95
20.48
8.93
9.60

9.60
8.80
9.26
8.45
Problem-oriented/active patterns

difference in anxiety levels of the students before, during, and after

the practice. Similarly, Sheu et al. (2002) found the stress levels of
the students during their first clinical practice as mid-range, and
0.633
0.199**
0.013**
Self-confident approach

0.109
0.111

0.533

1.156
0.251
1.431
0.156
Chan et al. (2009) determined the stress levels of the nursing stu-
r/p

b
t/p
a

dents, again, as mid-range during clinical practices. In our study, we

think that low stress levels of the nursing students were due to the
10.76
3.58

3.58
1.14
3.74
2.63

3.09

3.72
3.36

fact that the first day in the operating room was used as adaptation
379

day to the operating room environment and personnel, the stu-

±
±
±
±
±
±

±
±
±
±
X ± SS
Correlation between individual characteristics and stress and stress coping.

14.3
27.56
14.3
20.48
14.25
14.73

14.86
14.10
14.59
13.65

dents were not assigned important responsibilities, and the data

were collected at the end of that day.
0.103

Table 1
0.126
0.073
0.942

0.495
0.623
1.141
0.257
r/p

t/p

Individual variables.
e

b
a

Variables (n ¼ 126)
27.56 ± 10.76

10.76

10.92

11.28
10.55
11.32
1.14

9.27

9.17

Age (X ± SD. min., max.) 20.48 ± 1.14 (min ¼ 13, max ¼ 23)
±
±
±
±

±
±
±
±
X ± SS

Gender (n/%) Female 111 88.1

27.56
20.48
27.45
27.26

28.23
27.14
28.09
25.95

Male 15 11.9
School attended (n/%) Edirne HCa 49 38.9
Kırklareli HC 41 32.5
Unwillingly

Tekirdag HC 36 28.6
Willingly
Not seen
Female

Having seen operating room previously Seen 30 23.8

Male

Seen

Not seen 96 76.2

School preference (n/%) Willingly 86 68.3
Unwillingly 40 31.7
Having seen operating

Pearson correlation.

Clinical stress level 27.56 ± 10.76 (min ¼ 7, max ¼ 66)

room previously

Stress-coping patterns (X ± SD. min., max.)

School preference

Self-confident approach 14.3 ± 3.58 (min ¼ 6, max ¼ 21)

Optimistic approach 8.95 ± 2.89 (min ¼ 1, max ¼ 15)
Seeking social support 7.38 ± 2.44 (min ¼ 1, max ¼ 12)
Variables

*p < 0.05.

t test.

Helpless/self-accusatory approach 9.68 ± 4.24 (min ¼ 0, max ¼ 19)

Stress

Stress
Table 2

Submissive approach 5.42 ± 2.71 (min ¼ 0, max ¼ 16)

Age

Sex

a
b

a
Health college.
 U. Yildiz Findik et al. / Nurse Education in Practice 15 (2015) 192e195
The study demonstrated that the nursing students mostly
employed self-confident approach among active patterns. Temel
et al. (2007) demonstrated that the nursing students mostly
adopted self-confident approach among the active patterns. Tully
(2004) determined that employment of the self-confident
approach among the active patterns in coping with stress was
related to low stress levels and an indication of adaptation to the
situation. Chan et al. (2009) found in their study that the students
with low stress levels used problem-solving (active patterns) in
coping with stress. Gammon and Morgan-Samuel (2005) deter-
mined that education guidance decreased stress in students and
increased their coping skills. The low stress levels and high use of
the self-confident approach support each other in the study.
Moreover, employment of active coping patterns by the students
demonstrated that they could effectively cope with stress.
It was determined that the nursing students used helpless/self-
accusatory approach of the passive patterns much more as their
clinical stress levels increased. Kaya et al. (2007) found that the
health care school students mostly used passive patterns (helpless/
self-accusatory) in their study where the nursing students were
also included. Evans and Kelly (2004) showed that the nursing
students used passive patterns much more in coping with stress,
when they experience stress, and Chan et al. (2009) found that
nursing students with high stress levels adopted “avoidance”
strategy to a greater extent. Tully (2004) found in the study con-
ducted with psychiatry nursing students that the students with
high stress levels preferred to think different things, relieve pres-
sure by eating, smoking, or consuming alcohol, take drugs, and try
to forget about the situation (passive patterns) in coping with stress
rather than problem-solving (active patterns). According to the
results of our and other studies, high levels of stress lead to
employment of ineffective stress coping patterns.
The nursing students used self-confident and optimistic ap-
proaches among active patterns to a greater extent as their average
age increased. In line with the study findings, Evans and Kelly
(2004) found that the younger students had a greater emotional
reaction (passive patterns) to stress than the older students.
Gorostidi et al. (2007) found that the nursing students tended to
perceive the stressful situations as less stressful as the nursing
education proceeded (as well as their average age increased). In
parallel with age, the students have increased knowledge, experi-
ence, and self-confidence, which reduce their stress.
The students who had not seen the operating room before for
any reason (e.g., illness), used a submissive approach among the
passive patterns in coping with stress. An unknown environment
causes stress in students. High levels of stress cause the nursing
students to use ineffective patterns in stress coping (Tully, 2004).
Conclusion
The stress levels of the nursing students were low in the first day
of operating room practice. The students were found to use self-
confident approach among active patterns in coping with stress.
The nursing students generally employed helpless/self-accusatory
approach among passive patterns as their clinical stress levels
increased, they used self-confident and optimistic approach among
active patterns as their average age increased, and those who had
never been to an operating room previously used submissive
approach among passive patterns. The first operating room practice
showed that low levels of stress caused the nursing students to use
active patterns in coping with stress while increasing levels of
195
stress resulted in employment of passive patterns in stress coping.
In line with these results the following are recommended.
 Clinical teachers should be aware that students are at risk of
stress and may have increased need of support during the
clinical practice.
 The nursing instructors should take into consideration the stress
levels of the nursing students who are to experience operating
room practice, the stress-coping patterns, and affecting factors
(age, having seen operating room before) to attain effective
clinical training in the operating room environment.
 By teaching the stress management strategies in the educational
process, the nursing students should be ensured to maintain low
levels of stress and use active patterns in stress coping in
operating room practices.
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