Stress and coping mechanisms among nursing students on the three year diploma programme in Malta : a case study approach

Abstract

Introduction: Research suggests that nursing students undergo stress during their studies and they use various coping mechanisms and attitudes for adaptation. In spite of changes as introducing the Mentorship Programme and Clinical Placement Portfolio to reduce their stress levels, significant constant levels of attrition from unknown cause continued within the Diploma nursing course programmes in Malta. The theories of Cognitive Transactional Theory of Stress and Coping (Lazarus and Folkman, 1984), Multidimensional Process of Student Retention (Jeffreys, 2004) and Novice to Expert (Benner, 1984) in education guided this study. Purpose of the study: The higher attrition rate of Diploma nursing students when compared to the B.Sc. students may occur due to failure to resolve stress. Aims: (1) To explore stress that may cause attrition of a three year Diploma programme. (2) To find out the coping mechanisms and attitudes used by the same students. (3) To identify strategies to help students’ retention. Outcome: A model with recommendations for reviewing the curriculum. Setting: Faculty of Health Sciences, University of Malta and Mater Dei Hospital, Malta. Research Question: What stress factors and coping mechanisms are implicated in pre-registration nursing students and what strategies are required to support a reduction in nursing student attrition and enhance retention on the course programme? Methodology: Scoping through relevant literature using an inclusion and exclusion criteria through databases the search included a list of international studies. Pre- and Post- 2000 studies were identified for comparisons to identify how changes were affecting nursing education. An evidence-based inductive study was pursued after copyright permission from the authors of questionnaires was obtained, and consent gained from Mater Dei Hospital, Faculty of Health Sciences and University of Malta ethics boards. A cross-sectional pilot study and test-retests were followed by a participatory, descriptive, correlation exploratory, and longitudinal single case study. The mixed method approach was conducted through questionnaires, focus groups, interviews and students’ Clinical Placement Portfolio with triangulation of participants. Findings: Stress: SINE (Rhead, 1995) and PSS (Cohen et al, 1983) mean scores slightly increased insignificantly throughout the three years, highest being 2nd year (M = 2.08 for academic p = > 0.05), and 3rd year (M = 2.04 for clinical, M = 2.28 for perceived stress; p = > 0.05). Coping: JCS (Jalowiec, 1977, 1987) mean scores during 3rd year were lower than those for 1st and 2nd year but confrontive, optimistic and self-reliant factors were not significant (p = > 0.05). SINE and PSS stress scores demonstrated no significant correlation (r = < 3.0; p = > 0.05) to JCS and SCS (Baldacchino et al., 2003). Attitudes: IPPA-32R (Kass, 1989) scores had statistical significant positive correlation between its factors LPS and SCDS with an increase during 3rd year. Total SCS and its non-religious factors were significantly correlated to LPS and SCDS factors, whereas religious factors were not significantly correlated (r < 3.0; p = > 0.05). SINE and PSS scores had significant negative correlation to LPS and SCDS, meaning that when stress increased, coping tended to decrease. Focus groups with educators, mentors and students, together with students’ Clinical Practice Portfolio confirmed stress, in contrast to interviews with patients/relatives who perceived that students had no stress as they always saw them with smiling faces. Resilient students managed to continue the course programme. Recommendations: Consider a holistic caring/nursing curriculum from primary, secondary and tertiary education to develop a healthier society. Employ a nurse ethicist at the Faculty of Health Sciences to boost reflection in care. Provide an authentic image of nursing and upgrade confidence in students so that they would be able to bridge theory and practice in a positive lifelong learning environment. Modern technological devises help in profiling at risk students and providing an andragogical person-centred method of learning. Reward incentives of students to enhance the internal and external motivations of students for empowerment and energizing students with assertiveness. Further research is identified.