With the advancement of medicine and changes in the structure of diseases, there is an increase in demand for improved health and medical services. Therefore, nurses are expected to improve their practical nursing skills and the quality of care. Nursing practicums provide nursing students with valuable learning opportunities and help them acquire practical nursing skills. Meanwhile, during a practicum, students experience an environment that is different from what they are familiar with. Nowadays, students interact with fewer people during their childhood. Therefore, a nursing practicum can be a source of significant stress for them (Nakajima, 1990). Students can experience reduced motivation and self-efficacy if they chronically face difficulties in alleviating stress. In such a situation, they are unable to effectively address it (Munakata, 2000). Especially in Japan, the problem of turnover due to burnout of new nurses has become apparent, and it is required to improve the stress coping ability of nursing students.
Individuals, including nurses, can experience stress in life. It is important for them to accurately understand and manage it (Kageyama & Kobayashi, 2017). Stress-coping skills include a sense of coherence (SOC). Antonovsky (1987, 2008) defined the SOC as a stress-coping skill to effectively address stressful events and situations, and maintain health. He stated that the SOC can be enhanced by coping with stress. In other words, nursing students are enhancing their SOC while experiencing various types of stress during a nursing practicum which is a preparation period for them to acquire a new role as a professional. Whether a student has successfully addressed stress or not during a nursing practicum affects their subsequent attitude toward studying nursing (Hasegawa et al., 2010). It is a pressing issue to provide students with educational support to enhance their SOC and stress-coping behaviors.
Hence, in this study we reviewed papers that are focused on stress caused by a practicum in nursing students. From the study, we obtained suggestions for educational support for enhancing the SOC and stress-coping behaviors of students by elucidating their stress factors, the SOC, stress-coping behaviors, and stress reaction.
In this study, we aimed to shed light on stress factors, the SOC, stress-coping behaviors, and stress reaction in students participating in a nursing practicum. We conducted a literature search and obtained suggestions for educational support to enhance the SOC and stress-coping behaviors of students.
3. Study Methods
3.1. Literature Search
A literature search was conducted using Ichushi-Web version 5 (Igaku Chuo Zasshi), and EBSCO (MEDLINE, CINAHL). The search period was from 2009 to April 2020. During this period, the Japanese government issued “A Report on the Discussion Meeting on the Improvement of Basic Nursing Education” (Ministry of Health, Labour and Welfare, 2007), and the current curriculum was implemented.
Ichushi-Web version 5 was used to search for papers published in Japan. The following keywords were used during the search: “nursing students,” “stress,” and “nursing practicum.” The search was limited to original papers. The researchers reviewed the abstracts of 56 extracted papers, and selected 16 which were aligned with the aim of this study. To search for papers published outside Japan, EBSCO (MEDLINE, CINAHL) was used with the following keywords: “nursing students,” “stress,” and “nursing practice.” The search was limited to research articles. The researchers reviewed the abstracts of 51 extracted papers and selected four that aligned with the aim of this study. Through the above-mentioned process, a total of 20 papers from Japan and overseas were identified for examination.
3.2. Analysis Methods
For the analysis of the papers, the researchers focused on descriptions that mention the trend in studies on stress in nursing practicums, stress factors, the SOC, stress-coping behaviors, and stress reaction. Then, the relevant parts were extracted. This analysis is performed among researchers throughout the analysis process.
The validity of the discussion analysis has been improved.
3.3. Ethical Considerations
The researchers respected the copyrights of the papers examined, and ensured that citations were accurate.
The 20 papers extracted are listed in Table 1. It is followed by a discussion on the trend in studies on stress, stress factors, the SOC, stress-coping behaviors, and stress reaction.
4.1. The Trend in Studies on Stress in Nursing Practicums
A review of papers on stress in nursing practicums by area found that two papers were categorized as “Basic Nursing Practicum I,” and three as “Basic Nursing Practicum II.” These two types of practicums were considered as Specialty I. For Specialty II, two papers were categorized as adult nursing practicum, one as a geriatric nursing practicum, two as maternal health nursing practicum, and two as psychiatric nursing practicum. No papers were categorized as pediatric nursing practicum. For integrated areas, two papers were categorized as home nursing practicum, and one as nursing integration and practical practicum. Five papers did not belong to any area or discipline.
4.2. Stress Factors in Nursing Practicums
A review of stress factors in nursing practicums found that they were related to Basic Nursing Practicum I including “relationship with teachers and instructors” and “relationship with patients, families, and healthcare staff” (Kaneko & Momino, 2015a). Stress factors specific to Basic Nursing Practicum II were “progress in the course of nursing” and “regular practicum plans” (Kaneko & Momino, 2015b).
Table 1. Stress factors, the sense of coherence, stress-coping behaviors, and stress reactions in examined papers.
In adult nursing practicums, approximately 80% of students found recording stressful (Kikuchi et al., 2018). In maternal health nursing practicum, participants were feeling stressed due to “frustration, anxiety, and nervousness along with a lack of practical nursing skills” (Nakajima & Hayakawa, 2014). For nursing integration and practical practicums, participants found the following aspects stressful: “understanding roles within the hospital organization,” and “the course of nursing in which students are assigned to multiple patients” (Yoshioka et al., 2019).
Moreover, a paper that was not categorized as any area or discipline reported that students were feeling stress from the possibility of harming a patient and multiple care-related assignments (Suarez et al., 2018).
4.3. The Sense of Coherence of Nursing Students
The sense of coherence of nursing students was predominantly measured by a SOC scale. A review of relevant papers found that SOC scores of students for Basic Nursing Practicum I were 49.6 ± 9.3 (Hongo et al., 2011) and 51.5 (Kaneko & Momino, 2015a). The scores for Basic Nursing Practicum II were 55.5 ± 8.1 (Kaneko & Momino, 2015b; Momino & Kaneko, 2016), adult nursing practicums were 54.6 ± 9.5 (Yamanaka et al., 2018), and nursing integration and practical practicums were 51.3 ± 4.6 (Yoshioka et al., 2019).
An analysis of SOC scores for each nursing practicum found that, in Basic Nursing Practicum II, students with a high SOC score had high sense of comprehensibility, manageability, and meaningfulness than those with a low SOC score (Usui et al., 2014). For nursing integration and practical practicums, there was a negative relationship between the SOC item, “sense of meaningfulness” and the following stress factors: “practicing nursing as a member of a nursing team” and “adjusting autonomous nursing practice with teachers and instructors” (Yoshioka et al., 2019).
4.4. Stress-Coping Behaviors of Nursing Students
Stress-coping behaviors of nursing students were predominantly measured by the Brief Scales for Coping Profile (BSCP). A review of relevant papers found that there was a significant negative correlation between SOC scores and avoidance and suppression such as coping with issues by postponement. For Basic Nursing Practicum II and home nursing practicums, participants with a low SOC score were likely to engage in avoidance and suppression (Usui et al., 2014; Inoue & Totsuka, 2010). For psychiatric nursing practicums, there was also a significant negative correlation between the SOC item, “sense of meaningfulness” and coping with issues by postponement (Takahashi et al., 2011). For maternal health nursing practicums, a large number of participants were the “problem-focused” type, such as those who acquired knowledge through self-learning before the practicum (Nakajima & Hyakawa 2014). For nursing integration and practical practicums, there was a negative relationship between “adjusting autonomous nursing practice with teachers and instructors” and the BSCP item “active solution.” It was reported that students were positively coping with stress after receiving instructions from teachers in resolving issues as well as building a relationship with others; in other words, students were proactively working toward self-improvement despite stress (Yoshioka et al., 2019). Meanwhile, a study on adult nursing practicums found that students with a high level of stress failed to cope with stress in a problem-focused manner. The study stated that educational support is needed for such students, including clarifying issues and illustrating specific behaviors (Kikuchi et al., 2018).
4.5. Stress Reaction of Nursing Students
The stress reactions of nursing students were predominantly measured by the Japanese version of the General Health Questionnaire (GHQ)-12. A review of relevant papers found that students had poor mental health with a low mental health score after the completion of a practicum in adult nursing (Kikuchi et al., 2018; Yamanaka et al., 2018). It was also reported that the condition of students who took part in a practicum in geriatric nursing was characterized by severe anxiety and depression, reduced motivation, and chronic fatigue (Tsutsumi et al., 2019). Meanwhile, another study reported that, for home nursing practicums, depression and anxiety of students were alleviated after the practicum (Inoue & Totsuka, 2011).
5.1. The Trend in Studies on Stress in Nursing Practicums
This study reviewed papers on stress in nursing practicums. It was found that 14 out of 20 papers studied only one institution. The findings from these studies reflect that: first, the practicum environment varies because the specific methods and details are at the discretion of each university (Ministry of Education, Culture, Sports, Science and Technology, 2020); and second, the reviewed studies aimed to examine how teachers understand the stress of the students they supervise in a practicum, and design specific support. However, most of them extracted and examined question items on stress factors for nursing practicums based on earlier studies. Only three papers examined the reliability and validity of stress factors and created a scale (Kaneko & Momino, 2015a; Yoshioka et al., 2019). For future studies, it is important to develop a scale to objectively measure the stress factors of students in different types of nursing practicums and to improve stress research.
Meanwhile, a review by area found that, among the 20 papers, 15 focused on stress in the following areas: Specialty I, Specialty II, and the integrated area. However, no reports on pediatric nursing practicums were found. The Ministry of Education, Culture, Sports, Science and Technology (2020) states that a clinical practicum is an opportunity for students to build a relationship with those they care for, and develop problem-solving skills by providing support to people from diverse backgrounds. Students understand the development of pediatric patients and engage with them in a pediatric nursing practicum. They are expected to have a high level of interpersonal and problem-solving skills required to help pediatric patients use their capabilities to the maximum when providing support (Ojiro & Naragino, 2010). However, students can no longer work with each pediatric patient for a long period as hospitals have been reducing the number of days of hospitalization for pediatric patients. It is assumed that students are experiencing various types of stress because they are required to make progress in the course of nursing within a limited time frame, and understand each pediatric patient while engaging in nursing practice. To elucidate stress factors in pediatric nursing practicums, and understand the SOC and stress-coping behaviors of students, it is necessary to accumulate relevant studies in the future.
5.2. Stress Factors in Nursing Practicums
Stress factors in nursing practicums that were common for all university years were: nursing course and recording tasks. Making progress in a nursing course is a required skill. Students need it to provide quality nursing care to different patients. However, students were found to be experiencing severe stress as they had to spend a considerable amount of time recording their practicum activities while working on learning modules and completing assignments for their patients (Masamura et al., 2003; Otani et al., 2015; Kikuchi et al., 2018). Through these findings, it was considered that teachers need to identify specifically which recording task poses stress on students, and refine the support system through different ways such as examining educational methods.
Furthermore, stress factors in nursing practicums were found to reflect the objectives of practicums. In Basic Nursing Practicum II, students experienced stress related to the nursing course because the practicum was the first opportunity for them to engage in it (Kaneko & Momino, 2015b). Students who took part in a geriatric nursing practicum (Tsutsumi et al., 2019), a psychiatric nursing practicum (Kosaka & Moon, 2010), and a maternal health nursing practicum (Nakajima & Hayakawa, 2014) felt stress from providing nursing care according to the needs of each patient as these areas require extensive knowledge and skills to address the patient’s development stage, physical condition, and other aspects. Moreover, students enrolled in a home nursing practicum (Inoue & Totsuka, 2010) were feeling stress along with depression and anxiety before the practicum because they visited a patient’s home to learn how to care for a patient living at home, and worked in a small team with a visiting nurse or individually during the practicum (Inoue & Totsuka, 2010). Considering these findings, it is necessary for teachers to provide cross-sectional support to students in different disciplines by utilizing tools such as a portfolio, so that they can continue to learn. In doing so, teachers need to, for example, recognize the stress that students have experienced in each nursing practicum, predict the types of stress that students are likely to experience in the relevant practicum, and examine measures to address it.
5.3. The Sense of Coherence of Nursing Students
There was a tendency for SOC scores in nursing students to be higher than those in other university departments. Mean SOC scores in first- and second-year university students were 52.54 ± 9.82 (male students) and 50.07 ± 9.62 (female students) (Endo et al., 2013) and in health care colleges were 53.4 ± 1.30 (male students) and 48.6 ± 0.97 (female students) (Ochiai et al., 2011). As shown in the results section, there was a tendency for SOC scores in first- and second-year students in nursing departments to be higher. Students pursuing nursing tend to have a higher SOC score compared to those in other university departments because nursing students establish their identity at an early stage, and set clear career goals. Therefore, they are capable of overcoming difficulties that they may face while working toward achieving their goals.
Also, the total SOC score of novice nurses at the time of employment in FY 2010 was 54.5 points (960 nurses in 111 hospitals) (Nakajima, 2017). There was no significant difference between this score and the total SOC score for nursing integration and practical practicums (Yoshioka et al., 2019), which is reported in the results section. The objectives of nursing integration and practical practicums are: to help students integrate their knowledge and skills so that they can work in situations similar to real-world settings during the practicum; and to help students adapt to clinical settings without issues after graduation (Ministry of Health, Labour and Welfare, 2007). Hence, educational support for students to cope with stress following employment may play a significant role. Considering these findings, it is necessary for teachers to provide students with opportunities that allow them to think about their situation through nursing practice and collaboration with healthcare professionals, so that students can improve their capabilities related to the following subordinate SOC concepts: a sense of comprehensibility, manageability, and meaningfulness. It is also necessary for teachers to help students accumulate their experiences of successfully addressing stress by understanding their situation and utilizing their strengths and weaknesses.
5.4. Stress-Coping Behaviors of Nursing Students
Students’ stress-coping behaviors that were frequently observed were as follows: avoidance and suppression in Basic Nursing Practicum II (Usui et al., 2014); and active solution in nursing integration and practical practicums (Yoshioka et al., 2019). There was a tendency for students in Basic Nursing Practicum II to select avoidance and suppression, such as giving up on resolving issues, because they had difficulties in communicating with patients and instructors as well as recording their practicum work due to a lack of experience. Those in nursing integration and practical practicums were likely to select “active solution” rather than emotional reaction. It was considered that this is because the students understood what kind of stress-coping behaviors they are likely to use as they had successfully addressed various types of stress through the experience of the nursing practicum.
Meanwhile, it was pointed out that a certain number of students had a low score for “active solution” (Inoue & Totsuka, 2010). Students who are likely to select avoidance and suppression may experience failure in addressing stress after they start their career as a nurse. Due to this, they may end up committing nursing malpractice or near misses. Therefore, teachers should help students learn from experience by objectively evaluating themselves through self-reflection, so that they understand how they are likely to cope with stress, and take actions accordingly.
5.5. Stress Reaction of Nursing Students
An analysis of the stress reaction of students in nursing practicums found that their General Health Questionnaire (GHQ)-12 scores were high during the practicum (Yamanaka et al., 2018; Kikuchi et al., 2018). Reduced thinking ability and concentration persisted even after the nursing practicum (Ogura & Taniguchi, 2013). Certain students continued to have poor mental health even after they started their fourth year of study (Kawashima et al., 2018). Students interact with patients and their families as well as health professionals during a nursing practicum. They also experience events that they have never experienced before during a practicum, and are emotionally stimulated by such experience. Therefore, they may need help from others in coping with stress. Hence, teachers should encourage students to actively seek help. With this, teachers can proactively provide students with opportunities such as collaborative learning sessions and briefings, in which students can learn through interaction with others.
Also, students can suffer from poor physical and mental health if they accumulate experiences of failure in coping with stress. Therefore, the kinds of support that would be key in helping students manage their stress not only during but also after the practicum are: support from various other professionals such as student counselors, continuous engagement with students, and opportunities for reducing stress.
This study proposed three suggestions for educational support by shedding light on the stress factors, SOC, stress-coping behaviors, and stress reaction of students regarding nursing practicums. First, cross-sectional support should be provided across different nursing practicums, so that students can recognize their stress, predict the types of stress that they are likely to experience during the practicum, and consider measures to address it. In doing so, a portfolio can be utilized. Second, opportunities for proactive thinking should be provided to students so that they understand their current situation, and have experiences of successfully coping with stress by utilizing their strengths and weaknesses. Third, students should be encouraged to practice self-reflection so that they can objectively evaluate how they are likely to address their stress, and learn to cope with stress from experience.
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