11

CHAPTER II

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents a review of related literature and studies that are connected

to the present study. The knowledge and information gotten from these literature

and studies provided valuable insight which will help validate the research.

Stressors

College students experience stress whether it’s academical or personal,

psychological or social. College students, especially freshmen are prone to stress

due to change in environment and nature of college life. Many of the students

have to leave home and everything they know to move to a new place and start a

new life with new friends and new challenges. Nursing students experience stress

as well due to clinical rotations and final exam preparations. These causes stress,

both internally and externally to the students which may also affect their overall

health.

Academic factors were the predominant cause of stress in most students,

followed by physical, social, and emotional. Majority of students with stress

reported high scores of poor self-esteem, and about half scored high on depression

scales (Baste and Gadkari, 2014). Results from the literature suggest that higher

level of stress to be associated with poor academic performance (Sohail, 2013).

 12

Authors recommended that parents need to be counseled against forcing their

children to join an educational program, not of their choice (Tangade et al., 2011).

Also, receiving criticism from supervisors about academic or clinical work was one

of the sources associated with significant stress among dental students (Kumar et

al., 2009).

In their study, Talib and Zai-ur-Rehman (2012, p. 129) found out that majority

of the students (53%) claimed that course load is the source of their stress which

in turn affected their GPA. Further students report that the prospect of having to

sit for examinations is stressful because of the pressure to review all the learned

material within a given period of time (Mani, 2010).

Among the students, there are mature students with a family who experience

different type of stress from being single parents to being the breadwinner of the

family. Kenny, Kidd, Nankervis and Connell (2011) conducted a research study on

mature age students. The study focused on steps educators could take to

strengthen educational access for mature students. The study included flexibility

of class scheduling, clinical placement during school hours or on weekends, and

financial support as stress reducing strategies. Older students entering the nursing

profession often already have degrees in other fields, such as in psychology or

biology. These students were academically successful and highly competitive.

Research by Montgomery, Tansey and Roe (2009) found mature students

entering the nursing field were highly desirable, especially as many of the students

had previous experience working in the healthcare field. The mature students
 13

presented their own set of stressors. The most significant concern these students

identified was financial stress, followed by the financial burden of childcare, from

a financial perspective and time management.

Melincavage’s (2011) research agreed with Smedley and Morey (2010) that a

positive clinical atmosphere, provided by both staff and faculty, decreased student

anxiety and increased self-esteem.

Unfortunately, hospital staff nurses are often part of nursing students’ stress.

Researchers (Hichberger, 2009; Thomas & Burk, 2009) found evidence of

horizontal violence or hostility from experienced nurses towards student nurses.

Descriptive terms used by the students included words like sarcastic, patronizing,

degrading, overbearing, and condescending. Hinchberger’s (2009) research

demonstrated violence was observed by student nurses. All of the student nurses

who responded to the survey had either personally experienced violence or

observed it.

Three main themes emerged from Nelwati and Plummer’s research (2013) on

nursing students’ perceptions of stress in the clinical setting. Feelings of pressure

were described as most stressful, and included preparing for clinical patients, lack

of sleep, overlapping assignments, and timely submission of assignments to

instructors. Challenging relationships was the second theme noted, and included

interactions with patients and families, communication with clinical staff, co-

operative peer work, and social relationships with families and the community. The

use of coping strategies was the third theme of the study. Students described their
 14

response to a stressful situation, and what coping strategies they utilized to relieve

the stress. Responses were both physiological and psychological. Sleep

deprivation, altered appetite, and headaches were reported physiological

responses while Psychological responses to stress were noted as being upset,

panic, anxiety, sadness, withdrawal, sensitivity, and mood changes.

Stress levels in nursing students range from moderate to high. Main stressors

identified included stress through the caring of patients, assignments and

workloads, and negative interactions with staff and faculty. Common coping

strategies utilized by nursing students included problem-solving strategies such as

developing objectives to resolve problems, adopting various strategies to solve

problems, and finding the meaning of stressful events. (Labrague, McEnroe-

Petitte, Gloe, Thomas, Papathananasiou and Tsaras 2016).

Additional stress may come from a continually changing clinical environment.

Students need some time to develop a working relationship with a new clinical

advisor, settle into a new environment, become familiar with the routines and

norms on the new clinical area, and become acquainted with friendly supportive

floor staff to develop a sense of belonging (Levett-Jones, Lathlean, Higgins, &

McMillan, 2007, 2009; Levitt-Jones & Lathlean, 2007, 2009).

Based on the study entitled “Stressors and Stress Responses of Filipino College

students” Dy et. al. (2015), the study determined the stressors and stress

responses of Filipino college students in relation to sex, course and academic

classification. There were 258 respondents for the study. Of the respondents, 68%
 15

were females and 32% were males. According to their degree, 42% belonged to

the soft sciences and 58% to the hard sciences. In terms of academic classification,

10% were freshmen, 36% sophomores, 33% juniors and 21% seniors. The top

five overall stressors of the respondents were academic difficulty of subject matter,

workload due to subjects, time management because of subjects, responsibilities

due to being on one's own, and time management because of both subjects and

organizations. The most frequently occurring stress responses were affective

stress responses followed by cognitive responses. For both male and female

respondents, the top stressors were academics, workload due to subjects and time

management concerns. Overall, the males reacted to stress through affective

responses and females through cognitive responses. Students enrolled in the hard

and soft sciences both considered academics, workload due to subjects and time

management concerns as their top stressors. Those in the soft sciences reacted

with cognitive stress responses while those in the hard sciences reacted with

affective stress responses. Generally, all students, regardless of their academic

classification pointed out that academics, workload due to subjects, and time

management were their main stressors. They all reacted to stress with affective

stress responses. These patterns can be monitored to maintain the psychological

and physical well-being of adolescent students.

Coping strategies

Students deal with stressors both internal and external everyday in their

personal and school life but are able to minimize or take their mind off the stress
 16

by employing various coping strategies. Earnest and Dwyer (2010, p. 3) define

stress coping skills as “the ability to apply strategies that minimize and manage

the stress response.

Aun et.al (2011) opined that coping skills improve class attendance,

participation, persistence even when faced with setbacks or failure in general, and

arm them with stronger more resilient self who can lead to a much more positive

learning experience. Similarly, academic coping strategies helped undergraduate

students to perform in their academic through academic coping strategies factors

i.e. approach, avoidance, and social support (Sullivan, 2010). In addition,

academic coping strategies was also design to help undergraduate students to

cope their life those that include physical well-being, emotional, spiritual, and

psychological well-being (Yasin & Dzulkifli, 2009). Normally, emotional coping

strategy is usually practiced in the first year of undergraduate students while in

later years the trend is changing towards cognitive, confrontive and painful

problem solving (Mahajan, 2010).

Based on the study of Mazo (2015) entitled, “Causes, Effects of Stress, and

the Coping Mechanism of the Bachelor of Science in Information Technology

Students in A Philippine University” this study sought to determine the causes of

stress, the effects of stress, and the stress coping mechanisms of Bachelor of

Science in Information Technology students in the Leyte Normal University,

Tacloban City. It tested some assumptions using the descriptive survey method

with 51 respondents. Thesis writing/research and school requirements/projects

 17

were the most common causes of stress. Sleepless nights and irritable/moody

feeling were the common effects of stress. There was disparity on the causes and

effects of stress between the male and female respondents. The use of computer

and praying to God were the common stress coping mechanisms. There was an

observed disparity between the male and female responses.

Alberto, Karen and John Frederick(2018) shared the view that college can be

a very stressful period in the lives of most students; however, some students cope

with stress better than others. Many students who are able to handle stress well

have effective stress coping skills. When college students are facing stressful life

events, they typically use many kinds of coping strategies to deal with them. They

use various coping strategies simultaneously, and strategies are also likely to

change over time, depending on the effectiveness of the applied strategy.

Academic stress is known to be deleterious to adolescents’ health by promoting

maladaptive behavioural coping responses such as smoking and alcohol intake

(Glozah & Pevalin, 2014). Research has demonstrated that, nursing students

employ a variety of coping strategies (Jan LK, Popescu, 2014).such as; talking to

friends, sports, crying, ignoring stress, feelings of sadness/misery and the use of

alcohol, which may be adaptive or maladaptive ( Reeve, Shumaker, Yearwood,

Crowell & Riley, 2013)

Some studies have pointed to problem solving as the most utilized strategy in

nursing students (Shaban, Khater, Akhu-zaheya, 2012).Others refer to emotion-

focused coping methods,( Fornés-vives, Garcia-banda, Frias-navarro, Rosales-

 18

viladrich, 2015:2016)while some believe that transference, optimism and problem

solving are the most used strategies among nursing students (Zhao, Lei, He W,

Gu YH, Li DW, 2015)

There were also qualitative research studies done to explore the Filipino psyche

of coping. The 2009 Philippine Star news article written by Dr. Nina Halili-Jao

entitled, “Coping mechanisms of Pinoys” cited the book, From Victims to Survivors

of Lourdes Ladrido-Ignacio and Antonio Perlas (1995) which identified some coping

mechanisms that Filipinos engaged in when they experienced extreme difficulties.

It is a combination of both healthy and unhealthy ways of adjusting. Spirituality is

the most frequently observed coping style. Filipinos turn to religion and accept the

reality. There are some utterances of bahala na or behaviors like ipinapasa-Diyos

while there are other who stay positive that God will never leave them in these

times of crisis. The bayanihan or pakikipag-kapwa is also a well-observed coping

behavior by which Filipinos empathize and help each other. Seeking emotional,

physical, and financial support from family is also evident. There are also ways by

which Filipinos lessen the emotional burden of their problems by engaging in

activities that would relax them, make them happy, and feel at ease even if it is

just temporary. Creativity and humor are said to be the strengths of Filipinos that

facilitate life improvement after a stressful life event.

SYNTHESIS OF THE STATE-OF-THE ART

 19

According to a significant amount of related studies done by multiple researchers

in the past few years, most identified two main stressors that affect nursing

students, which are academic factors; increasing difficulty in course load, studying

large amount of material for exams and learning of new material and clinical

rotation/clinical settings to another main stressor which stems from the horizontal

violence that comes from hospital staff towards nursing students. As for the

mature nursing students, time management and family responsibilities as a major

stressor as they try to keep up with the pace and energy of the younger students.

Earnest & Dawyer (2010, p.3) define stress coping skills as the “ability to apply

strategies that minimize & manage the stress response”. Previous studies shows

that emotional and spiritual coping mechanisms such as crying and praying are

the firsy used coping strategy when dealing with stress and later the use of alcohol

which maybe adaptive or maladaptive.

The current study and previous studies have a lot in common; coming from the

fact that stress is a universal phenomenon that occur in every aspect of life, and

in the nursing field it tends to occur in every institution.

Although in previous studies, every aspect of stressors and coping strategies

had been discussed but this studies aims to bridge the gap; that is a significant

number of the respondents being to the demographic profile of the generation

“millennials” and have a strong tendency towards posting about stressors on social

media for online support and depression. This study aims to understand the
 20

relationship between the stressors and coping strategies of the respondents who

belong to the younger demographic group and the mature students.

Theoretical Paradigm

The theory helps the researchers to understand the stages that the first year

nursing student undergoes during stress. This theory was used to come up with

coping strategies based on the identified stages.

This study was guided and supported by following theory:

Selye's general adaption syndrome: This theory focuses on the individual

physiological response He developed the general adaption syndrome (GAS) that

the human body moves through the stages when confronted by stressors.

Alarm reaction stage: This stage produces a burst of energy, the fight and flight

response w/c occurs when the person is exposed to freighting or threatening

stimuli.

Resistance Stage: The body attempts to resist or attempt to the stressor. The

period which the person adopts to external stressors of stress improves or

disappears.

Exhaustion stage: follows if the stressor is severed or prolonged that person no

longer adapt.
 21

Mason's theory of specificity of the stress response. Psychological factor in

stress Jhon Mascon argued in the physiologic response of the body is specific in

nature, while the non specific response studied by Selye is actually a psychological

reaction. Mason theorized that the stress respond on psychological factor, i.e., the

organism’s perception of stressor itself. From his research, Mason concluded that

stress is primarily a psychologic phenomenon rather than physiologic one. The

physiologic response if one develops secondarily to the psychologic responses.

Neuroendocrine Responses to stressors, Mason research indicates that

hormonal responses tend to be highly specific to a particular stressor rather than

to a nonspecific by Selye.

Stress and illness. Mason also researched the complexity of the interaction of

the stress and study, he examined corticosteroid and catecholamine elevation in

relationship to viral illness. In one respiratory illness.

Mason continue to demonstrate that the neuroendocrine system defends us

against illness. His research offers further evidence that disease result from

disruption in hormonal patterning that develops in response to stress, i.e., one

pattern becomes over active or deficient. In addition, he identified the importance

of psychological factors in homeostatic responses and disease causation.

The figure 1. below shows the theoretical framework of how the internal and

external stressors can lead different responses according to Seyle and Mason and

in turn lead to the selection of a coping strategy.

 22

Adaptation Theory
Internal and Coping Strategies
External
Stressors Specificity of stress
response

Figure 1. Theoretical Framework

 23

Conceptual Framework

From the theories used in study, a conceptual framework was arrived and shown

in figure 2, it showed the different variables affecting the respondents

Independent Variables: This contains the demographic profile such as age,

gender, civil status and monthly income. It also contains different factors affecting

the respondents such as perceived internal and external stressors.

Dependent Variables: These variables are as a result of the independent

variables, they are based on how the respondents react and process said variables.

They are the coping strategies the respondents utilize to cope with said

independent variables

Output: Intervention programs that can be proposed to improve the coping

strategies of the respondents.

 24

Perceived Stressors and coping strategies of third year nursing students of Naga
College Foundation, Naga City

Demographic Profile

a. Age; Perceived Internal and Coping Strategy Intervention

b. Gender; External Stressors
c. Civil Status;
d. Monthly Income

Figure 2. Conceptual Framework

 25

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