ISSN 2320 -5083 Journal of Internationalcould cause a lot of physical, mental and psychological...

Journal of International Academic Research for Multidisciplinary

ISSN 2320 -5083

A Scholarly, Peer Reviewed, Monthly, Open Access, Online Research Journal

Impact Factor – 1.393

VOLUME 1 ISSUE 10 NOVEMBER 2013

A GLOBAL SOCIETY FOR MULTIDISCIPLINARY RESEARCH

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A GREEN PUBLISHING HOUSE

Editorial Board

Dr. Kari Jabbour, Ph.D Curriculum Developer, American College of Technology, Missouri, USA.

Er.Chandramohan, M.S System Specialist - OGP ABB Australia Pvt. Ltd., Australia.

Dr. S.K. Singh Chief Scientist Advanced Materials Technology Department Institute of Minerals & Materials Technology Bhubaneswar, India

Dr. Jake M. Laguador Director, Research and Statistics Center, Lyceum of the Philippines University, Philippines.

Prof. Dr. Sharath Babu, LLM Ph.D Dean. Faculty of Law, Karnatak University Dharwad, Karnataka, India

Dr.S.M Kadri, MBBS, MPH/ICHD, FFP Fellow, Public Health Foundation of India Epidemiologist Division of Epidemiology and Public Health, Kashmir, India

Dr.Bhumika Talwar, BDS Research Officer State Institute of Health & Family Welfare Jaipur, India

Dr. Tej Pratap Mall Ph.D Head, Postgraduate Department of Botany, Kisan P.G. College, Bahraich, India.

Dr. Arup Kanti Konar, Ph.D Associate Professor of Economics Achhruram, Memorial College, SKB University, Jhalda,Purulia, West Bengal. India

Dr. S.Raja Ph.D Research Associate, Madras Research Center of CMFR , Indian Council of Agricultural Research, Chennai, India

Dr. Vijay Pithadia, Ph.D, Director - Sri Aurobindo Institute of Management Rajkot, India.

Er. R. Bhuvanewari Devi M. Tech, MCIHT Highway Engineer, Infrastructure, Ramboll, Abu Dhabi, UAE Sanda Maican, Ph.D. Senior Researcher, Department of Ecology, Taxonomy and Nature Conservation Institute of Biology of the Romanian Academy, Bucharest, Romania Dr. Reynalda B. Garcia Professor, Graduate School & College of Education, Arts and Sciences Lyceum of the Philippines University Philippines Dr.Damarla Bala Venkata Ramana Senior Scientist Central Research Institute for Dryland Agriculture (CRIDA) Hyderabad, A.P, India PROF. Dr.S.V.Kshirsagar, M.B.B.S,M.S Head - Department of Anatomy, Bidar Institute of Medical Sciences, Karnataka, India. Dr Asifa Nazir, M.B.B.S, MD, Assistant Professor, Dept of Microbiology Government Medical College, Srinagar, India. Dr.AmitaPuri, Ph.D Officiating Principal Army Inst. Of Education New Delhi, India Dr. Shobana Nelasco Ph.D Associate Professor, Fellow of Indian Council of Social Science Research (On Deputation}, Department of Economics, Bharathidasan University, Trichirappalli. India M. Suresh Kumar, PHD Assistant Manager, Godrej Security Solution, India. Dr.T.Chandrasekarayya,Ph.D Assistant Professor, Dept Of Population Studies & Social Work, S.V.University, Tirupati, India.

JOURNAL OF INTERNATIONAL ACADEMIC RESEARCH FOR MULTIDISCIPLINARY Impact Factor 1.393, ISSN: 2320-5083, Volume 1, Issue 10, November 2013

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THE RELATION BETWEEN STRESSORS OF CLINICAL ENVIRONMENT WITH ANXIETY AND DEPRESSION IN NURSING STUDENTS

NAJAFI DOULATABAD SH*

MOHEBBI ZINAT** DR. MOHAMADHOSSAINI F***

DR. HOSSAINI N****

*Msc, Nursing and Midwifery College, Yasuj University of Medical Science, Yasuj, Iran **Msc, Nursing and Midwifery College, Shiraz University of Medical Science, Shiraz, Iran

***Anesthesiologist, Yasuj University of Medical Science, Yasuj, Iran ****Nursing and Midwifery College, Yasuj University of Medical Science, Yasuj, Iran, (Corresponding Author)

ABSTRACT

The present research is a cross-sectional descriptive study. The sampling method was

total counting and the samples in the research were consisting of 152 nursing students. The

data collecting tools included a two part researcher- made questionnaire for assessing

stressors of clinical environment, Spilberger questionnaire and Beck questionnaire. The

finding showed that in a majority of students(33.3%) anxiety was moderate and Pearson test

showed a positive correlation between the general mark of stressors and anxiety (p=0.003 and

r=0.5).Also 39.0% of students were suffering from depression and Pearson test showed a

significant statistical correlation between depression and anxiety(p=0.001 and r=0.68). But

the same test did not show a significant correlation between the mark of stressors and

depression. It is necessary for the instructors of nursing field to show more accuracy to

mental circumstances of students in the clinical environment and minimize the stress-bearing

factors in clinical environments for the students.

KEY WORDS: Stress, Anxiety, Depression, Nursing, Students

INTRODUCTION

Stress is an inevitable matter in daily life (Long, Phipps, Cassmeyer, 1993) which

could cause a lot of physical, mental and psychological effects on individuals (Timby, 2008).

Education and learning are considered as stressful experiences (Jones, Johnston, 1997) and

nursing students remember the clinical education course as the most tension bearing period

(Yonge, Myrick, Haase, 2002).

In addition to the stresses caused by subjective education environments the students of the

course (field) are also influenced by different stresses of clinical training. Clinical education

is a vital component of curriculum and has a fundamental role in the formation of basic skills

and vocational abilities of students (Barimnejad, Azarkerdar, Hajimiri, Rasouli, 2004).


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Studies show that a high rate of tension during clinical training may negatively affect the

learning and success of the students (Sarikaya, Civaner, Kalaca, 2006; Khan, Mahmood,

Badshah, Ali, Jamal, 2006). Numerous cases could cause stress in nursing students some of

which are probably common in the students of the field originated from the nature of nursing

profession and some also could vary in different educational environments (Thelan Lynne,

Davie, Urden Linda, 1990). The nursing staffs are among those who are exposed to the

injuries caused by anxiety. Working environment and the activities related to nursing profession are among the threatening factors and creating anxiety (Pryjmachuk, Richards, 2007).

Results of some studies reveal that one third of nursing students are suffering from

serious stress which leads to psycho-mental problems such as anxiety and depression in them

(Mayer, Saovey,1990). The results of a research in Egypt show the prevalence of anxiety in

nursing students to be 46.6 %( Amr, El-Gilany , El-Moafee, Salama, Jimenez, 2011). The

incidence of anxiety could have undesirable effects on the abilities of nursing students and

influence their function. Also, the existence of a direct correlation between anxiety and

reduced learning has been mentioned in the results of studies (Edelman, Ficorelli, 2005).

Depression is also one of the psychological disorders which is more prevalent in some fields.

The results of a research in Greece (2011) shows that 44.0% of nursing students have

experienced symptoms of depression (Melissa-Halikiopoulou, Tsiga, Khachatryan, Papazisis,

2011). The results of another research in Iran reveal the prevalence of depression in 60.o% of

nursing students (Rafati, Ahmadi, 2004). Suffering from this psychological disorder could

also be along with many complications for students. Although the afore said studies have

shown the status of stress anxiety and depression in nursing students, no study was found

showing the correlation of stressors of clinical environment with anxiety and depression.

Therefore, the present research was carried out with the aiming to determine the correlation

between stressors of clinical environment with anxiety and depression in nursing students.

Methods

The present research is a cross-sectional descriptive study. The method of sampling

was total counting and the samples in the research were consisting of all nursing students of

B.Sc level at Yasuj faculty of nursing and midwifery who were spending their field training

during the span the research was being carried out. The students in the first trimester of

nursing were excluded from the research because they had no field training unit. In total 152

students were participated in the research as samples.


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Data collecting was performed at a time when all the students having conditions of being

admitted as samples were spending their training course and were present in the ward. All

questionnaires were distributed within one week and the samples were asked to fill the

questionnaires at the same place and hand over to the researcher. Collecting the data

pertaining the stressors of clinical environment was performed using researcher made

questionnaire. The questionnaire including demographic data of the samples and some

questions regarding stress-bearing factors (factors related to individual, environment,

instructor, patient, the nature of nursing, the skills of students and educational system) studied

the items in clinical environment from the view point of nursing students. The questionnaire

had 52 questions and was classified on the basis of Likert scale (5 degrees) in the range of

very high effective to effect less. The acquired marks in each domain were put in the range of

zero to 100. The higher marks showed the higher role of the factors in incidence of stress

among the nursing students. The scientific credibility of the afore mentioned tools was

specified through admissibility of content in the manner that 10 faculty members of Shiraz

and Yasuj school of nursing and midwifery studied the tools and confirmed it. Stability of the

tools in the present research was obtained 80.0% using a method of renewed test. The level of

depression in the samples was also assessed using Beck questionnaire based on which the

level of depression among nursing students was classified in the range of 1 to 62, so that if

the obtain figure was in the range of 1 and 15 showed the status of no depression, 16-31, mild

depression, 32-47, moderate depression and 48-62, profound depression.

Also, Spielberger questionnaire was used to assess the level of anxiety in the samples. Based

on the questionnaire the level of anxiety is divided by four, in a manner that by assessing

anxiety in cases a figure is obtained in the range of 20-80, if the obtained figure is in the

range of 20-32, it shows that, the patient is suffering from a low level of anxiety, the figure

32-42, relatively low anxiety, 43-52, moderate, 53-62,relatively serious, 63-72,serious,and

higher than 73,shows very serious anxiety. The collection data were analyzed using statistical

descriptive test, independent T, Post Hoc and F tests.

Results

Out of total 152 distributed questionnaires, 131 were given back. Among the students, 8, in

the 7th trimester, 6, in the 8th trimester, 4, in the third trimester, and 3 in the 5th trimester,

refused to answer the questions. The result of the research showed that, the average age of

samples is 21.5±1.35 years and in the age-range of 20-27 years. 45% of samples were male


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and 55% were female. In total of answers, 26(19.8%), 19(14.5%), 21(14%), 18(13.7%),

29(22.1%), 8(6.1%), and 10(7.7%) were in the 2nd, 3rd, 4th, 5th, 6th, 7th and 8th trimester of

nursing respectively. Among the samples, 119(91%) were single and 12(9%) were married.

The average marks of samples in the research were 15.12±1.34 and the average marks were

between 12.31 to 18.91.

With respect to the results of the research in the view point of nursing students the stressors

of clinical environment were in frequency including the factors related to instructors

(73.0±17.56), educational system (48.0±13.18), nature of nursing (64.0±19.2), patient

(62.0±17.44), skills of students (59.0±14.51), environmental factors (56.0±17.17), and the

factors related to individual characteristics of students (45.0±18.65).

A comparison of the general average of stressors in the students, in different academic years

showed the rate in the students of second year 452.98±87.3, students of third year(444±90.5)

and students of the 4th year 372.93±77.9 and the F test showed the existence of a statistically

significant difference in this field(p=0.03). Based on Post Hoc test, the highest difference has

been in the students of the 4th academic year.

A study on the average stressors in terms of sex, showed that the average was higher in

females(63.8±12.5) than males (59.1±12.5), and the independent T test showed the difference

to be significant(p<0.007). Moreover although the general average of stressors in married

cases (M=66.3 and SD=12.4) was higher than single cases (M=61 and SD=12.6), the

difference was not significant.

A study on the level of anxiety in the students showed that in a majority of students, anxiety

was moderate (Diagram 1).

Also, the Pierson test showed a positive correlation between the general marks of stressors

and anxiety, and the difference was significant with r=0.5, and p=0.003(table 1).

A study on the level of anxiety in the students during different academic years showed that,

the rate was 60.0±20.2 in the students of second year, 57.47±13.3 in the students of third

year, and 55.43±11.2 in the students of 4th year.

The finding showed a significant correlation between the level of anxiety in the students and

their academic year and the LSD test showed the reason of the difference reduced anxiety in

the students of the fourth year.

Comparison of anxiety in terms of sex showed that, although the average anxiety in males

(M=58.4 and SD=9.1) was higher than females (M=54.2 and SD=12.1) no significant


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difference was found between the level of anxiety and sex. Also no significant difference was

found between average anxiety in single and married students.

A study on the level of depression in the students revealed that 39.0% of the students were

suffering from depression, so that 32(24.4%) had mild depression, 9(6.8%) moderate, and

10(7.6%) were suffering from intensive depression. The finding did not show a significant

correlation between depression and the academic year of the students. Although the level of

depression in males (M=13.6 and SD=11.7) was higher than females (M=11.2 and SD=9.1),

the independent T test showed that the difference was not significant.

Although the average level of depression in single cases (M=12.4 and SD=10.6) was also

higher than married cases (M=9.3 and SD=7.8) the difference was not significant.

The Pearson test showed a positive correlation between depression and anxiety and the

difference was also significant (P=0.0001 and r=0.67), but the same test did not show a

significant correlation between the marks of stressors and depression. Also with respect to the

findings, although stress, anxiety and depression had increased by reduction of average, the

Pearson test did not show a significant difference between average and stress, anxiety and

depression.

Table 1: Correlation between anxiety and stressors in nursing students.

variable stressor r p

Anx

iety

Factors related to individual

characteristics of student

-0.13 0.17

Ambient factors -0.15 0.12

Factors related to instructors -0.3 0.o1

Factors related to patients -0.13 0.18

Factors related to the nature of nursing -0.19 0.05

Factors related to skills of students -0.12 0.22

Factors related to educational system -0.09 0.34

Total rate of stressors 0.5 0.003


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Diagram 1: Level of anxiety in the nursing students

Discussion

With respect to the results of the research, the factors related to instructors had the

highest average among the stressors of clinical environment. In different studies, numerous

factors have been mentioned as the stressors of clinical environment in nursing students.

Among the stressors, inconsistency between theoretical lessons and clinical task unspecified

objectives of clinical training tense environment, low propensity of more experience

educators to attend clinical training environments, unreal evaluations shortage in welfare and

educational facilities(Aabedini, Aabedini, Aghamolaii, Jomeazade, Kamjo, 2008), lack of

necessary opportunities to perform standard procedures and inappropriate clinical

circumstances in accordance with theoretical principles could be mentioned(Dehghani,

Dehghani , Fallahzadeh, 2005). The results of a study by Christian et al (2009) shows that

lack of knowledge and professional skills have been the most important stressors of clinical

environment in view of the students(Christine, Chan,, Winnie, Daniel, 2009). In a research by

Nazari et al (1997) a reminder by the educator in presence of personnel and physicians was

mentioned as the most important source of creating stress in nursing students (Nazari,


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Beheshti, Arzani ,Hajihossaini , Saatsaz ,Bizhani, 1997) which is in consistency with the

results of the present research.

In clinical environment a more scientific knowledge and theoretical information is not

sufficient and experience and repetition have basic roles in providing the patients with

necessary cares. Therefore, the nursing students need to be supported by their educators to be

able to perform their duty and if the educators do not play the supportive role well it will

become a source of stress for the students and hamper skill acquiring process in the students.

A study on the results of research cases in different educational environments reveals the

existence of different stressors which are sometimes similar and with different intensity but

what is important is that the existence of these stressors could be accompanied by unpleasant

outcomes for the students. The incidence of continuous stress with any reason will be

accompanied by unpleasant out comes for individuals among which physical and

psychosomatic effects could be mentioned.

As it was mentioned in the results of the research, a majority of students had experienced a

moderate to intensive level of anxiety in clinical ambiences. The results of a research by

Asadi Sadeghi et al on 400 students showed the prevalence of anxiety to be 83.0 %( Asadi

Sadeghi, Basirani , Asadi Bidmeshki, Panahi Mirshekar, Amirshahi, Salehin, 2010). In this

research the average marks of stressors had a statistically significant correlation with the level

of anxiety. Also,the results of a study by Ratanasiripong (2012) reveals the existence of a

positive significant correlation between stress and anxiety in the students of nursing field

(Ratanasiripong, 2012). High stress and anxiety impedes the individuals concentration,

reduces memory and ability of solving problems, the items which in turn negatively affect

learning and educational function (Beddoe , Murphy, 2004).

The anxiety which occurs in students during education is the most important type of anxiety

of the age which threatens their mental health and seriously affects their efficiency aptitudes

and formation of their character and social identity (Inder bitzen, 1995). Therefore, reducing

the stressors of clinical environment could play an important role in protecting the mental

health of students and reduce anxiety.

Moreover the findings of the research showed that by raising the educational level the

average of stressors and anxiety decreased in the students of 4th year.

In lower level students, the stressors are manifested more intensively because of their lower

experience in comparison to the students of higher levels and the same thing could also cause

rising anxiety in them. Based on the educational curriculum in Iran, from the second semester


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the nursing students attend clinical environments for training including hospital and health

centers and the trend continues until the 6th semester. In the 7th and 8th semesters, the students

have educational units in these centers in the form of field training. During these training

courses, the students are accompanied by educators and perform all services and procedures

under direct supervision of educators. But in the 7th and 8th semesters, which are in the form

of field training, the students have the duty to provide independently the procedures and other

services to aid seekers under indirect supervision of educators. The students of 7th and 8th

semesters (fourth year) have acquired approximately most skills during the six semesters,

therefore, their reduced stress and anxiety in comparison to other students is not beyond

expectation. Moreover, absence of educators, which was the most important stressor in

results, may be effective in the finding.

More acquaintance of students with clinical environments and the staff, their rising

experience in the nursing domain and dealing with patients could also be among other

effective factors. The results of the research also revealed 39.0% prevalence of a depression

in the students. The results of the research by Melissa Halikiopoulo et al (2011) on the

nursing students show that, 43.9% of them had experienced symptoms of depression

(Melissa-Halikiopoulou, Tsiga, Khachatryan, Papazisis, 2011). The results of another

research in the country reveal the experience of depression symptoms in 52.4% of nursing

students (Papazisis, Tsiga , Papanikolaou, Vlasiadis, Sapountzi-Krepia, 2012). Therefore a

high prevalence of the symptoms of depression in nursing students has been observed not

only in Iran, but also in other countries and a study on its reasons seems to be necessary.

Although no significant correlation was found between the average of stressors and

depression in the present research the significance of the difference between anxiety and

depression could be considered as an alarm and a great threat, because anxiety is one of the

symptoms of depression.


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CONCLUSION

It is a fact that the nursing students are dealing directly with the patients during their

educational period. Therefore it is necessary for them to be in a good spirit to be able to give

proper care to the patients. Because the patients need both mental support and physical care

accurately and without error. This is while if the student himself is suffering from stress,

anxiety or depression on the one hand the students skills fall and on the other hand badly

affects the quality of care for the patients and consequently it will be possible for him to play

his protecting role for the patients. Therefore it is necessary for the instructors in this field

especially in clinical environments to play more accurate attention to the mental status of the

students and minimize the stress bearing factors of clinical environment for the students.

Also, it seems necessary to give training to the students of the field on the ways of reducing

stress and anxiety.

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clinical education in viewpoint of nursing and midwifery students of Hormozgan Nursing and Midwifery of Medical Sciences. Journal of Hormozgan Medical University, 4,249-253in Persian.

2. Amr, M., El-Gilany, AH., El-Moafee, H., Salama, L., Jimenez, C.(2011). Stress among Mansoura (Egypt) baccalaureate nursing students. The Pan African Medical Journal,8:26.

3. Asadi Sadeghi, A., Basirani, N., Asadi Bidmeshki, E., Panahi Mirshekar, A., Amirshahi, M., Salehin, S.(2010). Prevalence of anxiety and its relationship with self-esteem among Zabol University students,Iran. Educational research,1(5):140-144.

4. Barimnejad, L., Azarkerdar, A., Hajimiri, P., Rasouli, F.(2004). The investigation of the point of view of nursing students in term five and afterward about affective factors on the development of clinical education. Iranian journal of medical education , l (10): 64-65. [In Persian].

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