Measuring stress and eustress in nursing students

Abstract

Stress and coping form one of the most researched areas within health psychology. Most efforts to measure stress, both the sources of stress and its effects on the individual, focus on the disease model or the degree to which stress disrupts well-being. There have been only limited attempts to measure those sources of stress that contribute to eustressor experiences that enhance opportunities to achieve. This thesis sought to develop a measure of both types of stress.

There is considerable evidence that nurses and nursing students experience considerable distress. The relatively recent transition from the apprenticeship based programme of education to an academic one is also associated with heightened distress. Such stress effects student learning, clinical performance and attrition, and, for both nursing students and nurses, there are implications to patient care and safety. This thesis developed an inventory – the Index of Stress in Nursing students (ISSN) - to measure sources of stress likely to lead to distress and eustress in nursing students and five studies were carried out.

The first took a qualitative approach and involved a series of focus groups with sixteen final year nursing students. The research question sought to identify those university based and placement based experiences that contributed to distress and experiences that had helped the student achieve. A thematic analysis revealed that peer support was critical, along with the support from personal tutors who adopted a particular style of pastoral care. Placement experience was an important source of eustress and it was the appraisal perspective adopted by some students that marked them out as good at coping.

The second study involved generating items from the transcribed focus groups. The items focused on different sources of stress and formed the first version of the ISSN. This was piloted on 120 final year nursing students. The students were asked to rate each source of stress twice – once from the extent to which it was likely to contribute to distress or was a hassle and once from the extent to which it was likely to help one achieve or was an uplift. Additional items were included to measure support and well-being, and the Transaction model of stress was used to inform the hypotheses to test construct validity. The results underwent an exploratory factor analysis as the second means for assessing validity. The principal component factor analyses suggested three factors – learning and teaching; placement-related and course organisation demands and together with internal (Alpha coefficient estimates) and external (test retest) tests of consistency the ISSN reported strong reliability and validity. The exploratory factor analysis reduced the ISSN to 29 items. The hypotheses underpinned by the Transactional model were confirmed – the more a source of stress was rated as a hassle the higher or more adverse were scores on well-being. The more sources of stress were rated as uplifting, eustress opportunities the healthier was reported well-being and support positively correlated with uplifts and negatively with hassles. Those reporting casenesson the GHQ did not report more distress but did report significantly fewer opportunities to achieve compared to those not reporting caseness. This provided strong support for the positive psychology focus adopted in this thesis.

The third study administered the ISSN to a new sample of 180 final year nursing students and the results were subjected to a confirmatory factor analysis using LISREL.The results suggested the model proposed by the exploratory factor analysis offered a good fit for the items measured as uplifts and an adequate fit when measured as hassles.

The fourth longitudinal study explored stress and coping in 28 final year nursing students. The Index of Sources of stress and Coping in Nursing students (ISCN) was administered in the first and second semester of the students’ final year. The ISCN consisted of the 29 item ISSN; measures on support and dispositional and context dependent control; self-efficacy, coping style and a range of well-being measures – the GHQ, three components of burn-out and measures on course and career satisfaction;along with items measuring demographics. There was little change in the hassles ratings across time, though there was a moderate increase in course organisation hassles. Therewas, however, a sharp reduction in the extent to which the sources of stress were perceived as providing opportunities to achieve. Measures on control, support, self-efficacy and well-being remained unchanged over time and, given the decline in potential eustress or uplifting opportunities, the coping resources might have been effective in helping to avoid adverse changes in well-being. The high mean accorded to support suggests that this coping resource is particularly important.

The final study used the ISCN with 171 final year nursing students. The results were subjected to hierarchical multiple regressions along with tests for moderation and mediation. Some of the results fitted with the Transactional model – the factors as hassles were strong predictors of adverse well-being, as was avoidance coping, even if used only infrequently. Self-efficacy was a strong predictor of well-being – as it increased it predicted healthier well-being scores. Dispositional control was more predictive than state-dependent control. Some counter intuitive results included the observation that approach coping was not a significant predictor of well-being; that dispositional control combined, as a moderator, with course organisation hassles, was a predictor of adverse scores on well-being; and those who reflect more on why a source of ineffective support is not helping experience a more adverse well-being. Self-efficacy and avoidance coping were also important mediators.

The findings from the research conducted with the instrument suggested it was able to explain a considerable amount of the variance in GHQ and emotional exhaustion. Avoidance coping was one of the strongest correlates of these outcome variables and other variables considered to be strongly related were: self-efficacy, perceptions of support, dispositional control and academic hassles. These variables need to be addressed among the nursing student population in an attempt to improve their psychological well-being and the ISSN can be used by educators and course managers to help achieve this goal.

Date of Award	Jul 2008
Original language	English
Awarding Institution	Queen's University Belfast
Supervisor	Martin Dempster (Supervisor)