STRESS MANAGEMENT OF NURSING STUDENTS OF EASTERN SAMAR STATE UNIVERSITY IN THE CLINICAL AREA: BASIS FOR AN EFFECTIVE QUALITY

NURSING CARE

Chapter I

INTRODUCTION

Background of the study

Throughout its distinguished history, nursing has had a significant effect on peoples lives. As rapid change continues to transform the profession of nursing and health care delivery system with which it is linked, nurses embrace broader opportunities to influence human wellbeing. Today, nurses bring knowledge, leadership, spirit, and vital expertise to expanding roles that afford increase participation, responsibility, and rewards. However, nursing continuous to evolve, underlying all is time-honored; fervent and profound commitment to caring. This profession requires academic and clinical training. The clinical duties that the nursing students have to undergo are an integral part of the course. Related learning Experience (RLE) is required in the nursing curriculum. The RLE training is necessary to all nursing student in order that their clinical exposure becomes an in-depth experience, meaningful and early appreciated when they are in actual hospital situation .Any nursing student who does not undergo sufficient clinical duties maybe consider ill prepared to undergo further hospital training and may fail miserably in the major nursing course.

Every nursing students needs to be given sufficient duties in the different hospital wards or areas as well as in the different types of hospital services in order to broaden his/her learning experience while undergoing his or her RLE program. It is in this respect where the clinical duties place a vital role in the development of proper skills, attitudes, and behavior among nursing students so that when they graduate ,take the board examination and become professional nurses in the future their conducts and works ethics will be greatly influence by what they have experienced during clinical duties. As the nursing profession continuously emerges, there is always a question on how a healthcare provider renders service to humanity. Many things that someone is experiencing can give rise to what kind of nurse he/she could be. As these nursing students undergo clinical duties, they will meet some kinds of stressors that produce discomfort and irritation conducive to stress that if not given proper attention may affect their learning experiences and their future professional practice because stress interferes with learning. It is in this context that the study is focused to help the nursing students identify some stressors during their clinical duties to recommend possible solutions on how to manage stress most importantly. Stress is our bodys response to change in our life. Since life involves constant change ( ranging from changing locations from home to work each morning to adapting to major life changes like marriage, divorce or death of a love one), there is no avoiding stress. This is why our goal isnt to eliminate all stress, but to get rid of unnecessary stress, and effectively manage the rest. Some common cause that many nurses are experiencing are increasing the severity of clients illnesses, adjusting to various work shifts, being expected to assume responsibilities for which one is not prepared, and inadequate support from supervisors and peers.

There are different types of stress that range from Eustress, which is a positive and exciting form of stress, to chronic stress, which has been linked to many serious health issues, and is the type of negative stress, most often mentioned in the news. While we want to manage or eliminate the negative types of stress, we also want to keep positive forms of stress in our lives to help us remain vital and alive. Stress affects us in different ways, not all of which are negative. In fact, the stress of an exciting life can actually serve as a good motivator and keep things interesting. However, when the stress levels get too intense, people will experience its negative effect. Some of it are headaches, irritability and fuzzy thinking. These effects are evident that were under too much stress. However, not everybody who is under stress will experience these specific symptoms. We all feel overwhelmed from time to time; that is normal. It is virtually impossible to eliminate times when events conspire and the bodys stress response is triggered, but there are ways that we can quickly reverse our bodys reaction to stress, like buffering the damage to our health and keeping our thinking clear so we can more deal effectively with whats going on in the moment. It may seem that there is nothing we can do about our stress level. However, we have a lot more control than we might think. In fact, the simple realization that we are in control of our life is the foundation of stress management. Managing stress is all about taking charge of our thoughts, our emotions, our schedule, our environment, and our problems. The ultimate goal is a balance life, with time for work, relationships, relaxation, and fun-plus the resilience to hold on under pressure and to meet challenges head on.

Statement of the Problem The study will be conducted to determine the Stress management of the nursing students of Eastern Samar State University in the Clinical area: Basis for an Effective Quality Nursing Care. Specifically, this study aims to answer the following questions: 1. What is the profile of the nursing students of Eastern Samar State University in terms of the following: 1.1 Age 1.2. Gender 1.3. Year level 2. What are the different stressors that affects delivery of quality nursing care to patients? 3. To what extent are the following stress management utilized by the nursing students in the clinical area? 3.1.Stress management 4. Is there a relationship between the degree of stress encountered with the quality of nursing care given to patients? 5. What qualities for effective quality nursing care may be developed on the findings of the study?

Objectives of the Study

This study attempted to determine the following research objectives: 1. To identify the profile of the nursing students of Eastern Samar State University in terms of the following: 1.1 Age 1.2. Gender 1.3. Year level 2. To determine the different stressors that affects delivery of quality nursing care to patients? 3. To identify extent are the following stress management utilized by the nursing students in the clinical area. 3.1.Stress management 4. To determine the relationship between the degree of stress encountered with the quality of nursing care given to patients. 5. To identify the qualities for effective quality nursing care may be developed on the findings of the study.

Significance of the Study The researchers believe in the merits of the study especially to the following: The researchers. Conducting this kind of study brought a learning experience for them. It handed them the pulse of nursing students when it comes to stress management they performed in the clinical area, which was hardly known without survey. The nursing students. Is defined as the individuals enrolled in a school of nursing or a formal educational program leading to a degree in nursing. As used in the study, this refers to those who may acquire greater insights of the stressors, problems and Challenges they may encounter all throughout their clinical performances which are part of their chosen

career. This knowledge will give them better and wider perspective about their profession and aid them in enhancing their coping abilities and self-confidence. The Clinical Instructors. The findings may provide them understanding why nursing students behave like they do. This study will also provide them hints of what remedial measures they need to institute to lessen the learning difficulties of their students while undergoing clinical exposure. Further, it will eventually help them to build a better relationship with the students, promote educational growth, and improve human and public relations with the identified clinical area of operation. The school administrators and faculty. who may help to work out solutions and course of action that will improve the students performance and to lessen their burden in their clinical duties while on the learning process. It also gives them the chance to improve the quality of nursing education for the benefit of the students and the institution as well. The parents. this study will gives insights to the parents about the stressors encountered

by their siblings and to prepare them or strengthen them by means of giving emotional and moral supports in ways that may help them how to face and manage their stress during their clinical duties. The patients. who are the recipients of the healthcare service given by the nursing students. The future researchers. this study can serve as reference material to those students who will conduct exactly the same correlated studies.

Scope and Limitation

The study will cover Stress management of the Nursing Students of Eastern Samar State University in the Clinical area: Basis for an effective quality nursing care. The primary focus of this study is directed toward the different stress management that the nursing students usually utilized and performed to alleviate their stress and to render effective quality nursing care to their patients. The data however were limited from those third year and fourth year the nursing student from Eastern Samar State University as respondents of the study during school year.

Hypotheses Based on the foregoing problems, the proponent formulated the following null hypotheses: H1 There is no significant relationship between the degree of stress encountered by the nursing students and quality of nursing care given to patients. H 2 There is no significant relationship between the degree of stress encountered by the nursing students and quality of nursing care given to patients.

Definition of Terms

To convey clearly the meaning of the words used in this study, the researchers defined the terms used operationally and conceptually, as follows: Clinical Area. Is defined as either the field of principal professional clinical activity or the primary area of responsibility, depending on the profession. It may be described in terms of the particular discipline, skills or knowledge field of the profession, whether general or specialized; or described in terms of the principal client group; or described by the principal activity of an institution, or section of an institution, where clinical practice takes place. As used in the study, This pertains to the hospital setting wherein the nursing students apply and practice what they have learned in terms of rendering or applying nursing focusing on the holistic being of the patient.

Clinical Duties. These refer to the exposure of the nursingstudents in different hospital w ards/areas as well as indifferent types of hospital services in order to broaden his/her learning experiences while undergoing the Related Learning Experience program. Clinical Instructors. These refer to persons who impart knowledge to the students. As used in the study, Demonstrates and teaches patient care in classroom and clinical units to nursing students and instructs students in principles and application of physical, biological, and psychological subjects related to nursing: Lectures to students, conducts and supervises laboratory work, issues assignments, and directs seminars and panels. Supervises student nurses and demonstrates patient care in clinical units of hospital. Coping. It is a behavioral tool which may be used by individuals to offset or overcome adversity, disadvantage, or disability without correcting or eliminating the underlying condition. Coping skills are also sometimes called work-around. Virtually all living beings routinely utilize coping skills in daily life. These are perhaps most noticeable in response to physical disabilities. (Encarta Encyclopedia). As used in the study, this refers to the adaptation to stressful events encountered by the nursing students. Management. This refers to the act or art of managing the whole system of care and treatment of a sick individual. Nursing Students. These refer to the students enrolled in the College of Nursing in Eastern Samar State University. Related Learning Experience. This is a curricular requirement in a nursing degree. It is intended to develop competencies and skills of nursing students in utilization of the nursing processes in varying health situation. As used in the study, this pertains to the clinical

exposure, which the nursing students have to undergo. It isrequired to all nursing students in order for them to have an in depth and meaningful experience and easily appreciated when they are already in actual hospital situation. Stress. It is defined as a chronically high level of mental arousal and body tension that exceeds a persons capacity to cope, resulting in distress, disease, or an increased capacity to cope. As used in the study, this refers to pressure: mental or physical tension or strain encountered by the nursing students in the clinical area. Stressors. Is a chemical or biological agent, environmental condition, an external stimulus or an event that causes stress to an organism.as used in the study, This pertains to the factors affecting the performances of the nursing students. Stress management. Refers to a wide spectrum of techniques and psychotherapies aimed at controlling a person's levels of stress, especially chronic stress, usually for the purpose of improving everyday functioning.

Theoretical Framework

According to Richard Lazarus and Susan Folkman (1984) stress could be thought of as resultingfrom an imbalance between demands andresources or as occurring when pressure exceeds one's perceivedability to cope. Stress management was developed and premised on the idea that stress is not a direct response to a stressor but rather ones resources and ability to cope mediate the stress response and are amenable to change, thus allowing stress to be controllable.

In order to develop an effective stress management program it is first necessary to identify the factors that are central to a person controlling his/her stress, and to identify the intervention methods which effectively target these factors. Lazarus and Folkmans interpretation of stress focuses on the transaction between people and their external environment (known as the Transactional Model). The model conceptualizes stress as a result of how a stressor is appraised stressor-stress link byproposing that if stressors are perceived as positive orchallenging rather than a threat, and if the stressed person is confident that he/she possesses adequate rather than deficient coping strategies, stress may not necessarily follow the presence of a potential stressor. Another theory as framework of this study is the Type A/Type B personality model developed by Friedman and Roseann (1974). They indicated that personality type influences stress as well as the response to stress. They asserted that Type A people frequently caused themselves stress because they tended to be competitive, self-critical, impatient, quick to anger, and frequently do multiple things at once (multitasking). Type B individuals, on the other hand, were less competitive, patient, easy going, and philosophical. As a result, their stress levels were dramatically lower. Type A behavior has been identified as a risk for coronary disease and hypertension.

The health realization/innate health model of stress is also founded on the idea that stress does not necessarily follow the presence of a potential stressor. Instead of focusing on the individual's appraisal of so-called stressors in relation to his or her own coping skills (as the transactional model does), the health realization model focuses on the nature of thought, stating that it is ultimately a person's thought processes that determine the response to potentially stressful external circumstances. In this model, stress results from appraising oneself and one's

circumstances through a mental filter of insecurity and negativity, whereas a feeling of wellbeing results from approaching the world with a "quiet mind".

This model proposes that helping stressed individuals understand the nature of thought especially providing them with the ability to recognize when they are in the grip of insecure thinking, disengage from it, and access natural positive feelingswill reduce their stress.

Conceptual Framework

Research paradigm in this study is illustrated in Figure 1. This included the input, the process and the output. It shows the steps adopted by the researchers in order to come up with the output of the study. It best describes the idea of the procedural design used by the researchers.

Students Profile 1. Age 2. Gender 3. Year level

Stressors

Stress Management

Effective Quality Nursing Care

Chapter II

REVIEW OF RELATED LITERATURE

Foreign literature Stress is a feeling that is created when we react to particular events. It is the body's way of rising to a challenge and preparing to meet a tough situation with focus, strength, stamina, and heightened alertness. The events that provoke stress are called Stressors and they cover a whole range of situations everything from outright physical danger to making a class presentation or taking a semester's worth of your toughest subject. The human body responds to stressors by activating the nervous system and specific hormones.

The hypothalamus signals the Adrenal glands to produce more of the hormones adrenaline and cortisol and release them into the bloodstream. These hormones speed up heart rate breathing rate, blood pressure, and metabolism. Blood vessels open wider to let more blood flow to large muscle groups, putting our muscles on alert. Pupils dilate to improve vision. The liver releases some of its stored glucose to increase the body's energy. Moreover, sweat is produced to cool the body. All of these physical changes prepare a person to react quickly and effectively to handle the pressure of the moment.

This natural reaction is known as the stress response. Working properly, the body's stress response enhances a person's ability to perform well under pressure. However, the stress

response can also cause problems when it overreacts or fails to turn off and reset itself properly. (Wikipedia, 2008."Stress (biological)" http://en.wikipedia.org/wiki/Stress_(medicine)) Rebecca J. Frey(2009) said that stress in humans results from interactions between persons and their environment that are perceived as straining or exceeding their adaptive capacities and threatening their well-being. The element of perception indicates that humans stress responses reflect differences in personality, as well as differences in physical strength or general health. Risk factors for stress-related illnesses are a mix of personal, interpersonal, and social variables. These factors include lack or loss of control over one's physical environment, and lack or loss of social support networks. People who are dependent on others (e.g., children or the elderly) or who are socially disadvantaged (because of race, gender, educational level, or similar factors) are at greater risk of developing stress-related illnesses. Selye explained that stress is no specific response of the body to pay demand made upon it under ordinary circumstances, the bodys reaction to specific stimulus anticipate because ofits repetitive pattern. Therefore, a person experiences pain.When the body is warm, it perspires and when it is used the body shivers. All human exhibits uniform response to stimulus because of homeostasis. When response is erotic and does not uniform to the usual reaction expected from the application of the stimulus, the body is said to be in stress. ( The Nature of Stress http://www.icnr.com/articles/thenatureofstress.html) Walter Cannon (2009) in the meantime said that the human body reacts either positively or negatively to a stress factor producing two kinds of possible reaction. When the human body tries to flee from stress situation, negative reaction is exhibited. Positive reaction comes about

when the body makes theprinciple of homeostasis apply the body to overcome stressfulsituation which is known as adaptation or coping. He advocatedthat while the concepts of stress is an absolute fact, itspresence and intensity reception are all relative in accordance with the physical and psychological makeup of the individual. All people therefore, experience stress but the way stress is present and is handled by each individual is unique for eachother. A little difficulty is hardly felt by another. By understanding, we can more easily identify stress factors and their effects on who need or seek healthcare. Each individual is experiencing stress, in her own particular manner. How the individualadopt or fails to adopt depend on several factors: personality andconditional make past experiences dealing with stress. It is important to remember that stress syndrome can be both positive and negative. Any change or alteration in the balance of life can create stress. We are all unique

individual, we respond differently to various stressors. Thus, it neither does nor matter. Whether, it is positive or negative light or severe. What matter is how we developed adoptive mechanism to cope with these stressors and can be translated as the ability to withstand stress and create a life experiences that do not work against you. The implication of stress theory is by being able to withstand stress and by coping with it. Diluting it when occurs and eliminating it, you can actually affect your life. You are not programmed for premature aging. The fact is you control your own health. The quote of the journal of American Medical Association says, Nature did not intend to grow old and ill, we were designed to die young in old age but free of disease. Schafer (2000) defined stress as the arousal of mind and body in response on the demand made upon them. The concept of stress is important because it provides a way of

understanding the person as a human being who responds in totality (mind, body and spirit) to a variety of changes that takes place in daily life.

Another is the influence of age and gender to stress, the relation between age and stress is a close one. The term aging refers to organic growth and the process of maturation in human beings. As we grow older, the problems and the worries in life also increase. We tend to take more stress in our old age such as parents worrying for their children, job responsibilities and other issues. However, according to researchers, long term exposure to stress leads to early aging. People who take more stress are liable to feel more tired and sick than people who lead a stress free life.

As people grow old, they take more stress. However, taking stress in progressing years is not good for health. It may lead to certain problems and diseases that have an adverse effect on health. Therefore, it is very important to manage stress and avoid tensions and worries as they serve no purpose except deteriorating health. While still catching-up to men in some spheres of modern life, women appear to be way ahead in at least one undesirable category. "Women are particularly susceptible to developing depression and anxiety disorders in response to stress compared to men," according to Dr. Yehuda. Studies of both animals and humans have shown that sex hormones somehow modulate the stress response, causing females under stress to secrete more of the trigger chemicals like CRF than do males under the same conditions. In several of the studies, when stressed-out female rats had their ovaries removed, their chemical responses became equal to those of the males. Adding to a woman's increased dose of stress chemicals, are her increased "opportunities" for stress. "It's not necessarily that women don't cope as well. It's just that they have so much more to cope with," says Dr. Yehuda. "Their capacity for tolerating

stress may even be greater than men's," she observes, "Its just that they're dealing with so many more things that they become worn out from it more visibly and sooner."

Dr. Yehuda, also chief psychiatrist at New York's Veteran's Administration Hospital, notes another difference between the sexes. "I think that the kinds of things that women are exposed to tend to be in more of a chronic or repeated nature. Men go to war and are exposed to combat stress. Men are exposed to more acts of random physical violence. The kinds of interpersonal violence that women are exposed to tend to be in domestic situations, by, unfortunately, parents or other family members, and they tend not to be one-shot deals. The wear-and-tear that comes from these longer relationships can be quite devastating." Men and women report different reactions to stress, both physically and mentally. They attempt to manage stress in very different ways and also perceive their ability to do so and the things that stand in their way in markedly different ways. Findings suggest that while women are more likely to report physical symptoms associated with stress, they are doing a better job connecting with others in their lives and, at times, these connections are important to their stress management strategies. http://health.howstuffworks.com/wellness/stress-management/women-under-stress.htm

Local Literature According to Maraya de Jesus Chebat stress is here to stay. What people must do is to learn more about its nature, sources and alternatives so that people used the energy positively and work in the best possible way.

`Orlandi stated, Your ability to tolerate stressors depends on the number of stressors in your life. People who can handle stress use their coping mechanism, which is powerful tool to use, to analyze events objectively and observe calmly. Gather information at the state of equilibrium, understanding of what to produce the tension that helps you feel that the stress is alleviated. Miranda specified that the most effective way of managing stress are through relation and exercise which ironically are extremely aesthetical acts which involved dynamics of the mind and body. People who are always stress survivors stay healthy throughout their lives. They consider stressful situation opportunist for growth.

Foreign Studies

There has been a trend toward increased student stress nationwide. Defined as the physical and psychological reaction to issues and event emanation from ones environment, stress can be felt as the result of both positive and negative events. Both physical and mental symptoms can develop slowly over a period of time, sometimes masking the problem.

In support of the general belief that more college students are suffering the effects of stress and need additional coping resources, the studies referenced here provide a long term tracking of the number of students seeking help for stress-related issues what those issues may be, if stress affects performance and how stress is related to a college students life as a whole. As a student you face many challenges and stressors. However, as a nursing student you are likely to experience even more stress than your friends and colleagues enrolled in

other programs. A study comparing the stress levels of various professional students found that nursing students experience higher levels of stress than medical, social work and pharmacy students.(Beck, et al.,1997) Even more poignant, another study showed that one third of nursing students experience stress severe enough to induce mental health problems such as anxiety and depression. (Pryjmachuk, 2004) In addition to contending with exams, grades, long hours of studying, work, family and other personal commitments you are also faced with the challenges of clinical practice. Clinical practice has been identified as one of the most anxiety producing components in nursing programs. Lack of experience, fear of making mistakes, difficult patients, discomfort at being evaluated by faculty members, worrying about giving patients the wrong information or medication and concern about possibly harming a patient are just a few of the stressors for the beginning student nurse. (Sharif & Masoumi, 2005).

Local Studies

Nursing has always been associated with conditions of life and death, illness and suffering, recovery or stabilization; however, the severity of illness and the complexity of care in hospitals have never been as great as it is today. Traditionally, nurses have had little say in determining their working conditions and relatively no recognition for their knowledge and ability to participate in planning patient care. Even their schedules, Salaries and job benefits were determined by management without nursing input. This situation has caused problems over the years but the intensity and demands of practice in todays hospitals motivates nurses to leave positions in which they have no opportunity for participating in decisions affecting their practice.

A project by a team of occupational sociologists studied various work settings and found identifiable job types or positions which were seen as placing above average pressure on the worker. These strains were related to the work environment and/or the job content. Four problem areas were categorized as; quantitative overload: too much to do, excessive time pressure and stress, qualitative under load: too narrow and one-sided job content, lack of stimulus variation, no demands on creativity or problem-solving, or low opportunities for social interaction, lack of control: especially in relation to pace of work and working methods, lack of social support: inadequate social networks at home and with fellow workers.

Another study done specifically with nursing personnel showed similar findings plus other negative conditions in the job and hospital setting. According to these researchers, stress exists as a major issue in nursing. Factors which their subjects identified as imposing job-related pressures were: staff shortages, increased demands by management, the need for greater knowledge and skills (compared with requirements when first employed), patients who were more critically ill, and an unmanageable work load (in terms of maintaining quality of work). Nurses and student suffered from unrealistic self-expectations, a high-intensity work environment and an increasing number and variety of health workers with whom care of patient was coordinated.

Stress is described as the non-specific response of the human organism to a change in its environment. Student nurses are so much stressed on their everyday activities but still pursue to continue coz the profession is an occupation which provides a recognizable number of benefits to the newcomer. The occupational characteristics which have drawn aspirants to nursing still characterize the discipline. A study done in 1999 questioned students regarding their reasons for

choosing to study nursing. Responses included: a chance to help people, variety of job options, opportunities for advancement, job security, working with people rather than things and, being a member of a respected occupation. The category, chance to help people was rated as most important twice as often as any other feature, (Sczekan & Betz, 1973). Neff in the book, Work and Human Behaviour lists characteristics that are particularly significant for career choice. These factors include provision of self-esteem, respect from others and opportunities for creativity.

Chapter III METHODOLOGY This chapter presents the method and procedures that will be used in the study. Research Design The researchers took into consideration the present factors and current conditions of a group of persons, events or a class in finding facts and data to be interpreted. This summary includes research in is the a descriptive method, which was used to accomplish this study. study in which bodies of data are Descriptive collected, cause

recorded and analyzed. It is used to answer questions; satisfy curiosity established a and effect relationship.

Moreover, descriptive researching is the most popular approach in research. It systematically, factually and accurately describes anarea of interest or situation. Descriptions, analysis andinterpretation of conditions that exist are involved. Researchers may also deal with comparison and contrast or the discovery of existing relationship between events or groups. In addition, as this method of research will use in the study it describes systematically the nursing course and stress management of the nursing students of Eastern Samar State University in the clinical area: Basis for an Effective Quality Nursing Care.

The study describes also its symptoms, management or treatment and situations in which stress may arise in order to obtain a factual and accurate result of the research in which student could avail.

Research Locale

This study (Stress Management of Nursing Students of Eastern Samar State University in the Clinical area: Basis for an Effective Quality Nursing Care) was to be conducted in the College of Nursing at ESSU. This study focused on the third year and fourth year level nursing students since they are more exposed to clinical area.

Research Instrument The researchers used the questionnaire for collecting data from nursing students of in Eastern Samar State University. The questionnaire on the stress problems and management are based on their readings from various books, manuals and experiences as nursing students. The questionnaire consisted of three parts. Part I aimed to gather information on the nursing students as to his/her name, age, gender and year level. Part II dealt on the stressors met by the nursing students in the clinical area. Part III gathered data regarding the stress management performed by the nursing students.