NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS

A Thesis

Presented to the faculty of the School of Nursing

California State University, San Marcos

Submitted in partial satisfaction of

the requirements for the degree of

MASTER OF SCIENCE

in

Nursing

Public Health Clinical Nurse Specialist

by

Mary Lelia Baker

SPRING
2012
 © 2012

Mary Lelia Baker

ALL RIGHTS RESERVED

ii
 CALIFORNIA STATE UNIVERSITY SAN MARCOS

THESIS SIGNATURE PAGE

THESIS SUBMITTED IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE DEGREE

MASTER OF SCIENCE

IN

NURSING

THESIS TITLE: Nursing Student Stress and Demographic Factors

AUTHOR: Mary Lelia Baker

DATE OF SUCCESSFUL DEFENSE: April 25, 2012

THE THESIS HAS BEEN ACCEPTED BY THE THESIS COMMITTEE IN

PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING.

iii
Student: Mary Lelia Baker

I certify that this student has met the School of Nursing format requirements, and that this thesis
is suitable for shelving in the Library and credit is to be awarded for the thesis.

School of Nursing
College of Education, Health, and Human Services
California State University San Marcos

iv
 Abstract

of

Nursing Student Stress and Demographic Factors

by

Mary Lelia Baker

Statement of Problem
Nursing students experience high levels of stress (Beck, Hackett, Srivastava, McKim, &
Rockwell, 1997), have been shown to be at increased risk for physical and psychiatric illnesses
(Beck & Srivastava, 1991) and stress has been shown to increase dropout rates (O’Regan, 2005).
No prior published studies that focus on the relationship between demographic variables and
reported stress levels in nursing students have been published.

Sources of Data
Data was collected from a convenience sample of all nursing students currently enrolled at
California State University San Marcos. Students completed an online survey that included
demographic data, the Student Nurse Stress Index (SNSI) (Jones & Johnston, 1999), and the
Marlowe-Crowne Social Desirability Scale (Strahan & Gerbasi, 1972).

Conclusions Reached
Two independent variables, GPA (p=.001) and Study Time (p=.013) showed statistical
significance in affecting the self-reported stress levels as measured by the SNSI.

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 ACKNOWLEDGEMENTS

I have been indebted in the preparation of this thesis to my committee, Dr. JoAnn Daugherty, Dr.
Linnea Axman, and Professor Ilene Dunagan of California State University San Marcos. Each
contributed to this project in their own unique way. I wish to thank each one immensely for their
support, kindness, and patience.

I would also like to thank my spouse, Debra Kossler who has been my rock in the storm. I could
not have done this without you.

vi
 TABLE OF CONTENTS
Page

Preface............................................................................................................................ i
Abstract .........................................................................................................................v
Acknowledgments ........................................................................................................vi
List of Tables ................................................................................................................x
List of Figures .............................................................................................................. xi
Chapter
1. INTRODUCTION ..................................................................................................1
Background and Significance ............................................................................1
The Problem ......................................................................................................2
Purpose of the Research ....................................................................................2
Research Question ............................................................................................3
Research Variables ............................................................................................3
2. LITERATURE REVIEW .......................................................................................4
Introduction .......................................................................................................4
Major Variables Defined ...................................................................................7
Theoretical Framework .....................................................................................8
Summary .........................................................................................................11
3. METHODOLOGY ...............................................................................................13
Introduction .....................................................................................................13
Research Question ..........................................................................................13
Identification of Setting ..................................................................................13
Research Design ..............................................................................................14
Population and Sample ...................................................................................15
Measurement Methods ....................................................................................16
Data Collection Process ..................................................................................18

vii
 Coding and Scoring .........................................................................................19
Data Analysis ..................................................................................................19
Bias .................................................................................................................21
Ethical Considerations ....................................................................................22
Summary .........................................................................................................23
4. RESULTS ............................................................................................................. 24
Introduction .....................................................................................................24
Sample .............................................................................................................25
Data Collection and Preparation .....................................................................30
Instruments ......................................................................................................31
Results by Research Question .........................................................................31
Summary .........................................................................................................36
5. DISCUSSION .......................................................................................................37
Introduction .....................................................................................................37
Major Findings ................................................................................................37
Limitations ......................................................................................................38
Generalizability ...............................................................................................39
Implications for Research ...............................................................................39
Recommendations for Future Research ..........................................................39
Summary .........................................................................................................40
Appendix A. Student Nurse Stress Index ................................................................41
Appendix B. Marlowe-Crowne Social Desirability Index ........................................44
Appendix C. Online Survey ......................................................................................45
Appendix D. IRB Approval Letter ............................................................................54
Appendix E. Student Recruitment Flyer ...................................................................55
Appendix F. Sample Didactic Instructor Email Request ..........................................57
Appendix G. Permission to Use SNSI .......................................................................58
Appendix H. Permission to Use Graphic ...................................................................59

viii
References ...................................................................................................................60

ix
 LIST OF TABLES

Tables Page

1. Relationship between the Transactional Model and variables ........................12

2. Comparison of Available Demographic Factors of Sample and Population ...22
3. Frequency of Participants by Student Type ....................................................25
4. Frequency of Participants by Semester ...........................................................26
5. Frequency of Participants by GPA .................................................................26
6. Frequency of Participants by Gender ..............................................................26
7. Frequency of Participants by Age ...................................................................27
8. Frequency of Participants by Marital Status ...................................................27
9. Frequency of Participants by Household Living Situation .............................27
10. Frequency of Participants by Number of Children .........................................28
11. Frequency of Participants by Number of Children Residing in Household ...28
12. Frequency of Participants by Employment Status ..........................................28
13. Frequency of Participants by Household Income ...........................................29
14. Frequency of Participants by Ethnic or Cultural Background ........................29
15. Frequency of Participants by Amount of Daily Study Time ..........................30
16. Frequency of Participants by Weekly Hours Spent in Class or
Clinical Setting ..........................................................................................30
17. Frequency of Participants by Daily Hours of Sleep ........................................30
18. Model Summary...............................................................................................33
19. ANOVA ...........................................................................................................34
20. Coefficients ......................................................................................................35

x
 LIST OF FIGURES
Figures Page

1. Lazarus and Folkman’s model of psychological stress ...................................... 9

2. Power analysis prior to data collection ............................................................ 16
3. Power analysis post hoc ................................................................................... 24
4. Distribution of SNSI total stress score ............................................................. 32

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 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 1

Nursing Student Stress and Demographic Factors

CHAPTER ONE: INTRODUCTION

Nursing students frequently complain of being “stressed-out” and “overwhelmed”

during their time in nursing school. Previous studies have assessed the stress levels of

nursing students; however, there is a gap in the literature regarding research about the

relationship between demographic factors and self-reported stress levels. This study was

designed to determine if a specific group of demographic variables could explain self-

reported stress levels.

This research study was based on the theoretical framework of Richard Lazarus

and Susan Folkman’s Transactional model (Lazarus & Folkman, 1984). The model has

three themes associated with it: “(1) relationship or transaction, (2) process, (3) a view of

emotional as an interdependent process” (Lazarus & Folkman, 1987, p. 142). This

theorem will be more thoroughly discussed in Chapter Two.

Background and Significance

Baccalaureate nursing students, regardless of year, experience higher levels of

stress and have higher levels of physiological and psychological symptoms than students

in other health fields (Beck, Hackett, Srivastava, McKim, & Rockwell, 1997). Research

has indicated that stress can cause a higher drop out rate for student nurses (O’Regan,

2005). Additionally, previous studies have identified the increased sources of stress such
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 2

as academic load, clinical problems or personal problems (Pulido-Martos, Augusto-

Landa, & Lopez-Zafra, 2012).

There have been few studies examining the relationship between nursing student

demographics and self-perceived stress levels even though other healthcare student

populations have been studied. Prior research has explored demographic factors such as

gender differences (Shih & Eberhart, 2010; American College Health Association, 2011),

financial concerns (Gibbons, Dempster & Moutray, 2008), relationship concerns (Gray,

2011) and age differences (Whitman, 1985). Thus, a gap in research focused on nursing

students was identified. Further study in this area was considered beneficial in order to

identify factors for which interventions could be designed in order to ameloriate the

negative effects of stress on nursing students.

The Problem

Nursing students experiencing high levels of stress (Beck, et al, 1997), have been

shown to be at increased risk for physical and psychiatric illnesses (Beck & Srivastava,

1991) and stress has been shown to increase drop out rates (O’Regan, 2005). At this

writing, there have been no studies that investigate the relationship between demographic

variables and reported stress levels in nursing students.

Purpose of the Research

The purpose of the study is to evaluate the relationship between selected student

demographic variables and the sources of stress experienced by students currently

enrolled in any nursing program at California State University San Marcos (CSUSM).
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 3

Research Question

The research question was “How much of the variability in stress is explained by

student demographic factors in student nurses currently enrolled in any CSUSM School

of Nursing program?”

Research Variables

The dependent variable in the study is the students self-reported stress levels as

calculated by the Student Nursing Stress Index (SNSI) (Jones & Johnston, 1999). The

independent variables explored were the type of nursing student, current semester,

current grade point average (GPA), gender, age, marital status, household living

arrangement, number of children, number of children residing in the household at least

75% of the time, employment status, household income, cultural background, study time,

class time, and amount of sleep.

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 4

CHAPTER TWO: LITERATURE REVIEW

Introduction

The databases reviewed for this literature review included CINAHL, PubMed,

and Google Scholar. One hundred and twenty-seven (127) article abstracts were reviewed

for inclusion, from that list, 32 were selected for further review, and 14 were included in

this thesis. Literature search terms included nursing student, student, stress, demographic,

demographic factors, age, gender, marital, Marlowe-Crowne, Student Nursing Stress

Index, and SNSI. The search was limited to English, peer-reviewed articles published

after 1980. The researcher focused on journal articles that concentrated on the causes of

student nursing stress rather than coping skills, interventions or curriculum changes.

Beck and Srivastava (1991) conducted a descriptive correlation study (n=94) that

indicated baccalaureate-nursing students had stress levels that put them at increased risk

for physical and psychiatric illnesses. In addition, the researchers indicated that “Overall,

the prevalence of psychiatric symptoms was higher than that found in the general

population” (p. 131). The instruments utilized for this study were the Stress Inventory

(Firth, 1972) and the General Health Questionnaire (GHQ) (Goldberg, 1972). The Beck

Srivastava Stress Inventory (BSSI) (1991) developed from this study.

In 1997, Beck, et al. compared the stress levels nursing students of two

baccalaureate-nursing programs (n=552) to groups of students enrolled in other health-

related programs (medicine, pharmacy, and social work). The significant findings

indicated that “baccalaureate nursing students, regardless of year in program or university

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 5

of attendance, experienced higher levels of stress and more health and psychological

symptoms than students in other health related disciplines” (p.184). The instruments used

for this study were the BSSI (Beck & Srivastava, 1991), the GHQ (Goldberg, 1972), and

a demographic section.

In 1997, Jones and Johnston published “Distress, stress and coping in first year

students.” This cross-sectional descriptive study (n=220) focused on the levels and

sources of stress, along with the coping strategies reported by first year nursing students.

The study utilized the GHQ (Goldberg, 1972), the BSSI (Beck & Srivastava, 1991), the

Ways of Coping Questionnaire (Coyne, Aldwin & Lazarus, 1981, adapted by Parkes,

1984) and the Marlowe-Crowne Social Desirability Scale (1960) to survey two cohorts of

nursing students enrolled in a diploma-nursing program that had transitioned into a

university setting. The research indicated that 50.5% of cohort 1 and 67.9% of cohort 2

suffered significant affective distress. Academic sources of stress were the most

frequently reported. “The levels of distress found in these two cohorts of student nurses

are higher than levels of distress found in degree nursing students, fourth-year medical

students and the general female population” (p. 481).

The Student Nurse Stress Index (SNSI) (Jones & Johnston, 1999) (Appendix A)

was developed to provide an improved measure of nursing student stress. The developers

constructed the tool from the BSSI (Beck & Srivastava, 1991) and 15 additional

questions. The final tool contains 22 questions partitioned into four subscales Academic

Load, Clinical Sources, Interface Worries, and Personal Problems. The SNSI (Jones &

Johnson, 1991) has demonstrated and concurrent and discriminant validity. The
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 6

researchers have recommended that the SNSI be administered along with the Marlowe-

Crowne Social Desirability Scale (MCSDS) (1960). Jones and Johnston’s (1999) study

indicated that some participants’ answers might be biased toward increased social

desirability. Therefore, the MCSDS (1960) was included in this study to assess for

answer bias.

Pulido-Martos, Augusto-Landa, and Lopez-Zafra (2012) published a systematic

review of 23 quantitative studies that utilized several, different standardized instruments

for assessing student levels of stress and compiled the results into two major categories.

The majority of the studies were conducted in Europe, had a median sample size of 205,

and 70% were of a cross-sectional design. Only three instruments were used in more than

one study and in some subsequent studies, the instrument was modified. One instrument

was the Lindop (1991) which was modified in two subsequent studies. Three studies

utilized the Perceived Stress Scale (Sheu, et al., 1997) in their research. The Perceived

Stress Scale was originally produced in Chinese. The SNSI (Jones & Johnson, 1999) was

used in two subsequent studies. Many studies assessed the nursing students for increased

stress using other factors such as general personal problems, family and economic issues.

Two studies used instruments not specifically designed for nursing students. In most

studies, the clinical and academic stressors were considered conjointly. Many studies

examined aspects of curriculum and coping strategies employed by nursing students. The

researchers concluded that the two most common categories of increased stress in nursing

students were the academic load (workload, grades) and clinical experiences (fear of the

unknown, harming patients, technical equipment).

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 7

Major Variables Defined

Demographic Variables. The variables are defined as follows. The type of

nursing student refers to which nursing program the participant is currently enrolled in at

CSUSM. The semester refers to which semester the participant is currently enrolled it.

The semester can vary by the nursing program the student is enrolled in as the number of

semesters can vary from five to eight depending on the cohort. The grade point average

(GPA) is defined as the student’s current grade point average on a 4-point scale listed in

their university transcript. Gender is defined as self-reported male or female or other.

Other refers to individuals who self-identify as intersex or transgendered. Age refers to

the chronological age of the participant. Marital status denotes the legal relationship

status of the participant as defined by the State of California. The household living

arrangements refers to the participants living arrangements and with whom the

participant resides.

The number of children refers to the number of natural, step, adopted and foster

children that the participant has. The number of children residing in the household

represents to the number of natural, step, adopted and foster children that reside with the

participant more than three-quarters of the time. Employment status refers to whether the

participant is employed outside the home and the number of hours spent working.

Household income signifies the amount of income that is produced by all members of the

household. Cultural background indicates the participants' self-identified ethnic

background. Study time refers to the average number of hours per day that the participant

spends studying for university classes. Class time denotes the number of hours per week
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 8

that the participant attends a university class including didactic and clinical time. The

amount of sleep describes the average number of hours that the participants sleep nightly.

Stress. Richard Lazarus and Susan Folkman (1984) defined stress "a particular

relationship between the person and the environment that is appraised by the person as

taxing or exceeding his or her resources and endangering his or her well-being.” This

study utilizes this definition.

Social desirability. Polit and Beck (2008) define social desirability as the

tendency to of respondents to provide biased answers based on perceived expectations or

prevailing social values. This is congruent with the Marlowe and Crown definition of

presenting oneself in a favorable light (1960). This study utilizes this definition.

Theoretical Framework

As introduced in Chapter One, this research study will be based on the theoretical

framework of Richard Lazarus and Susan Folkman’s Transactional model (Lazarus &

Folkman, 1984). The model has three themes associated with it: “(1) relationship or

transaction, (2) process, (3) a view of emotional as an interdependent process” (Lazarus

& Folkman, 1987, p. 142).

The Transactional model (Lazarus & Folkman, 1984) (Figure 1) focuses on the

imbalance between the environmental demands and perceived resources that the

individual has available to meet those demands. If the demands exceed the resources,

stress can occur in the individual. The transaction or relationship between the person and

the environment is what determines the emotional reaction (including stress). The

individual makes a cognitive appraisal of the environmental situation and reacts with an
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 9

emotion. The emotion will vary from individual to individual even though the

environmental trigger remains constant. The model suggests that one of three types of

primary appraisals is made. The individual assesses the situation and decides, is it

irrelevant, is it good, or is it stressful? After that initial appraisal, if the individual

determines that situation is stressful than there is a further analysis so determine if there

is any harm or loss, if it a threat, or if this is a challenge (Lazarus & Folkman, 1987).

Concurrently, a secondary appraisal occurs as the individual determines their

capacity to manage the environmental demands (Lazarus & Folkman, 1987). The

individual asks him or herself “Can I handle this?” then determines “No, I will fail.”

“Perhaps I can.” “I might if someone would help me.” “I will try some different ways to

resolve this.” “If I work hard enough it could be possible.” “I can do this.” These are all

responses indicative a secondary appraisal (Krohne, 2002).

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 10

Figure 1. Lazarus and Folkman’s model of psychological stress adapted by Lovallo and

Gerin (2003).

Note: Permission to use obtained from author. (Lovallo & Gerin, 2003) (Appendix H).

The process involves the individual adapting to situations over time. Individuals

endeavor to change that which is distressing or unpleasant and learn to process or cope

with environmental demands. The individual must first perceive the environmental

demand as a threat not as a desired outcome or even as a challenge. The individual may

use their coping skills to halt or blunt the development of stress. The theory states that

coping skills may be learned and that stress reduction occurs in individuals who improve

their coping methods. The individuals must change their perception, learn strategies, and

increase their confidence level and this will result in improved coping skills and reduced

stress levels (Lazarus & Folkman, 1987).

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 11

Summary

The relationship between the Transactional Model (Lazarus & Folkman, 1984)

and the major variables in this study is illustrated in Table 1. Some variables could be

categorized in both the “Primary: Beliefs and Commitments” and the “Biological

Responses: Autonomic, Endocrine, Immune” (Lovallo & Gerin, 2003). For example,

gender could be described as a strictly biological category but there are certain beliefs

societies hold about gender that could affect stress.

The review of available literature indicates that nursing students are at higher risk

for increased levels of self-reported stress and this stress can have a detrimental effect on

their physical and psychological stress. In addition, information assessing any

relationships between demographic factors and increased self-reported stress are absent

or minimally reported.
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 12

Table 1.

Relationship between the Transactional Model (Lazarus & Folkman, 1984) and the
major variables in this study.

Primary: Beliefs and Commitments

Type of Nursing Student
Current Semester
GPA
Gender
Age
Marital Status
Household Living Arrangements
Number of Children
Number of Children Residing in Household
Employment Status
Household Income
Cultural Background (Ethnicity)
Study Time
Class Time
Biological Responses: Autonomic, Endocrine, Immune
Age
Gender
Number of Children
Cultural Background (Ethnicity)
Hours of Sleep
Primary: Threat or Challenge
Stress as measured by the SNSI Total Score
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 13

CHAPTER THREE: METHODOLOGY

Introduction

Prior research looking at student nursing stress have used a variety of instruments

to measure self-reported student nurses’ stress levels (Pulido-Martos, et al., 2012). The

SNSI (Jones & Johnston, 1999) (Appendix A) was chosen for this research because it

focused on nursing students and measuring the types of stress particular to the target

population. Jones & Johnston (1999) also recommended that the MCSDS (Crowne &

Marlowe, 1960) (Appendix B) be administered in conjunction with the SNSI and this

research complied with that recommendation.

Additionally, utilizing Lazarus & Folkman (1987) theory regarding how

individuals perceive stress was important in the discussion area of this research. As

previously discussed, Table 1 describes the theoretical relationship between the variable

demographics and perceived stress. The relationship between particular demographics

and the perception of stress will be explored using inferential methods.

Research Question

“How much of the variability in stress is explained by student demographic

factors in student nurses currently enrolled in any CSUSM School of Nursing program?”

Identification of Setting

The setting for the study was California State University San Marcos School of

Nursing in either San Marcos or the satellite campus in Temecula, California. CSUSM is

part of the State of California University system comprised of 23 universities throughout

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 14

the state. In the fall semester of 2010, the total enrollment of the university was 9722

students. The main campus consists of 304 acres located 35 miles north of San Diego,

California. The small Temecula satellite campus is located 60 miles north of San Diego.

The most popular undergraduate programs at CSUSM were Business

Administration (n=2056), Liberal Studies (n=670), Psychology (n=624), Nursing

including Pre-Nursing (n=621), Communication (n=549), Human Development (n=444),

Criminology (n=423), Biology (n=324), Sociology (n=321), and Kinesiology (n=315).

The gender of the Fall 2011 students were male (n=3710) (38%) and female

(n=6012) (62%). Ethnicity was African-American (n=258) (3%), Asian/Pacific Islander

(n=984) (10%), Latino/a (n=2670) (28%), Native American (n=65) (<1%), White

(n=4352) (45%), Other (n=1109) (11%), and Multiple races (n=284) (3%).

Undergraduate students’ age was distributed as 22 or younger years of age (64%), 23-25

years of age (19%), 26-35 years of age (13%), 36 or older years of age (4%). Graduate

students’ age was distributed as 22 or younger years of age (5%), 23-25 years of age

(24%), 26-35 years of age (41%), 36 or older years of age (30%) (CSUSM, 2011).

Research Design

The study design used was cross-sectional with the intent to explain any

relationship between student demographic factors and reported stress levels. An online

survey approach (Appendix C) was used to collect self-reported information on student

demographics, and administer the SNSI (Jones & Johnston, 1999) and the MCSDS

(Strahan & Gerbasi, 1972) .

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 15

Population and Sample

The participants were recruited using convenience sampling methodology.

Nursing students, currently enrolled in any nursing cohort at CSUSM School of Nursing

during the spring semester of 2012, were approached by the principle investigator at the

end of their didactic class for recruitment. Prior approval to approach students was

obtained from the didactic instructor. The cohorts include Generic Bachelor of Science

Nursing (BSN), Accelerated BSN Temecula, Accelerated BSN San Marcos, Licensed

Vocational Nurse (LVN) to BSN, Registered Nurse (RN) to BSN and Master’s students.

The target population included was 463 student nurses. All students enrolled in any

CSUSM nursing cohort are over the age of 18 and proficient in English.

The required sample size for this study was calculated to be 135 of the 463

currently enrolled students at CSUSM nursing students in the Spring 2012 semester in

order to achieve a power of 0.80 (Faul, Erdfelder, Buchner, & Lang, 2009) (Figure 2).

The calculated sample size (n=135) provided for a .15 effect size in a multiple regression

analysis with a significance level of .05. An additonal 40% was added for loss factors

(e.g. failing to complete the survey). Therefore, the desired number of participants was

set at 189.
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 16

Figure 2 Power analysis prior to data collection

(Faul, et al, 2009)

Measurement Methods

The online survey covered the following demographic information: type of

nursing student (ie ABSN, traditional BSN, LVN-BSN, RN-BSN, Master’s), current

semester enrolled in, current GPA, gender, age, martial status, domicile information,

number of children, employment status, household income, cultural background, study

habits, class time, and hours of sleep and also includes a reliable and validated tool SNSI

(Jones & Johnson, 1999 p.177).

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 17

In addition a short version of the the MCSDS MC-1 (10) was included in the

online survey (Strahan & Gerbasi, 1972). The MCSDS is included in order to replicate a

previous study and to assess for answer bias or social response set bias. The MCSDS is in

the public domain.

The SNSI (Jones & Johnston, 1999) and the MCSDS (Strahan & Gerbasi, 1972)

have been previously tested for validity and reliability. The SNSI was developed using

Beck and Srivastava’s (1991) 35 question Stress Inventory and 15 additional questions

selected by Jones and Johnston. The SNSI is a 22-item self-report instrument designed to

measure the sources and levels of stress in student nurses. The authors of the SNSI have

structured the instrument to cover four areas validated as affecting nursing student self-

reported stress levels: 1) Academic load; 2) Clinical concerns; 3) Personal problems; 4)

Interface worries. Responses were rated on a 5-point Likert scale from 1-Not stressful to

5-Extremely stressful. The tool was determined to have “cross-sample factor congruence,

good or acceptable levels of reliability for each of the four subscales, and of the

concurrent and discriminant validity” (Jones & Johnson, 1999, p. 177). Although

predictive validity has not been demonstrated to date in the SNSI, evidence of

discriminate validity has been provided (Jones & Johnson, 1999, p. 178). The Cronbach

alpha exceeds .70 with the exception of personal problems (Cronbach ). The

minimal acceptable level for a new instrument is .70; a preferable level would be .80.

Permission from the author was obtained to use the SNSI in this study (Appendix G).
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 18

Data Collection Process

Institutional Review Board (IRB) approval was requested and an approval was

obtained prior to beginning data collection (Appendix D). The didactic instructors for

each of the 10 cohorts were contacted and permission to recruit participants was

requested (Appendix F). The researcher visited cohorts during the last 15 minutes of their

class, explained the study, and requested the student’s participation. An information sheet

(Appendix E) was supplied to each student that explained the study, any risks or benefits

and how to obtain the results. The information sheet was assessed to be at a Flesch-

Kincaid Grade Level of 11.7, which was deemed appropriate for college level

participants. Time allowed for questions and answers during the orientation period.

During the next class period in the following week, the didactic instructor gave the

students a URL address so that they could access and complete an online questionnaire.

No personally identifiable information was collected.

The online survey covered the following demographic information: type of

nursing student, current semester enrolled in, current GPA, gender, age, martial status,

domicile information, number of children, employment status, household income,

cultural background, study habits, class time, and hours of sleep. The demographic

factors listed are commonly included in other research studies and used to describe the

populations being studied but have not been separately evaluated as to determine if there

is a relationship between the demographic factors and the self-reported stress levels of

student nurses.
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 19

Coding and Scoring

The SNSI (Jones & Johnston, 1999) and the MCSDS (Strahan & Gerbasi, 1972)

were scored as directed by the authors of these research tools. The SNSI has four

subscales that could be totaled separately for scores in each of the following areas:

Academic load: questions 1, 2, 3, 8, 14, 18, and 20 with totals ranging from 7 to 35

points. Clinical concerns: questions 13, 14, 16, 17, 18, 19, and 20 with totals ranging

from 7 to 35. Personal problems: questions 9, 10, 11, and 12 with totals ranging from 4 to

20. Interface worries: questions 4, 5, 6, 7, 15, 21, and 22 with totals ranging from 7 to 35.

The total score from the SNSI is calculated by summing the answers from each of the 22

questions with the total score possible of 22 to 110. The total score was utilized in data

analysis. A more detailed discussion of scoring can be found in Appendix A.

In the MCSDS, (Strahan & Gerbasi, 1972) one point was given for each socially

desirable response with a total possible score of 0 to 10 as per author’s instruction. A

detailed scoring guide can be found in Appendix B. The total score was utilized in data

analysis.

Data Analysis

IBM SPSS Statistics 20 software (2011) was used to perform the data analysis.

The analyses consisted of descriptive statistics, frequency distributions, bivariate

correlation, and multiple regression analysis using the F-test. Psychometric analysis to

include Cronbach’s alpha ( ) of the SNSI (Jones & Johnston, 1999) and the MCSDS

(Strahan & Gerbasi, 1972). The level of significance was set at .05.
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 20

Despite the fact that there is controversy about the level of measurement (ordinal

or interval) when performing the analysis of data obtained from the instruments using

Likert-type scales. The proposed analysis will consider the 5-item Likert scale and scale

score as interval level data. The nominal and ordinal data (primarily from demographic

data) was converted into dummy variables and entered into the regression equation.

Regression analysis was used to determine if there was a relationship between

demographic factors and self-reported stress levels.

Descriptive statistics were used to describe the sample being tested and determine

the mean, median, and mode for each question where appropriate. Frequency distribution

was performed to determine if the data was normally distributed or if the data was

skewed, J-shaped or bimodal. Multiple regression analysis utilizing the F-test was

performed to determine if and/or which student demographic factors had an effect on

self-reported stress levels in the students where effect was a function of the variability in

the dependent variable was explained by the independent variables. Utilizing this

research design allowed the researcher to understand how combinations of factors

influenced the self-reported stress levels.

Regression analysis is used to produce an equation that will predict or explain a

dependent variable using one or more independent variables. In this study, regression

analysis was used to explain the relationship between selected demographic variables and

students nurses reported stress levels. The regression equation was given by:

Y = b1X1 + b2X2 + ...b14X14 + A

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 21

Where Y was the dependent variable, Reported Stress and A is the value Y, is predicted

or explained to have when all the independent variables are equal to zero (The Trustees

of Princeton University, 2007)

Bias

The use of a convenience sample was a source of possible bias due to the

participants self-selecting to participate in the research study. The resulting sample may

not be representative of the target population. However, the following statistics (Table 2)

illustrate that the sample group is similar to the population of nursing students at

CSUSM. The sample did not demonstrate any statistically significant differences from

the target population as evaluated using the t-test statistic (p<.05) and therefore

representativeness of the sample can be assumed. All students were encouraged to

participate in the research on several occasions by their didactic instructors.

An additional source of bias may have occurred because the principle investigator

is also a clinical instructor at California State University San Marcos. In order to mitigate

this source of bias the principal investigator was not present when the students completed

the survey to ensure that her presence did not influence or bias the students into feeling

pressured to participate.

The final aspect considered in the original research by Jones & Johnston (1997)

was whether certain participants may slant their responses toward increased social

desirability. This possible bias was addressed in two ways, the surveys do not collect any

personally identifiable information, and the MCSDS was administered to assess for this

bias in the collected data.

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 22

Table 2.

Comparison of available demographic factors of sample and population

Sample Population
Gender
Female 86.4% 82.5%
Male 13.6% 17.5%
Age
18-25 years 37.7% 33.5%
26-30 years 24.7% 33.5%
31-40 years 20.1% 21.5%
41-50 11.7% 8.7%
51-Over 5.8% 2.8%
Ethnic or Cultural Background
Caucasian 66.2% 52.3%
African-American 1.9% 2.5%
Asian/Pacific Islander 18.8% 29.7%
Mexican American/Latino/Hispanic 7.8% 10.9%
Native American .6% 0%
Other 1.9% 2.8%
Decline to State 2.6% 1.8%

Ethical Considerations

The CSUSM Institutional Review Board (IRB) approval was obtained and the

approval number is IRB #: 2011-181.No participants were under the age of 18 were

included in the research. No participants were considered part of an at-risk population,

such as prisoners or mentally disabled, where full, and freely given consent could be

problematic. No incentives were offered for participation. Each possible participant

received a recruitment flyer (Appendix D) one week prior to expected participation. The

online survey’s first page contained a consent form that had to be electronically signed in

order to proceed. The students were informed that the online survey would collect
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 23

Internet Protocol (IP) addresses that could be traced back to the location where the

participant completed the survey. The participants were asked to complete the survey on

either the San Marcos or Temecula campus to ensure complete anonymity.

Summary

Data collection proved more challenging than anticipated as some instructors

inadvertently released students from class earlier than anticipated even though they had

received reminder emails the day prior to the principal investigator site visit. Originally,

all recruitment was scheduled to be done within one week but this period was extended to

two weeks to ensure participation from all cohorts. In addition, initial responses were low

and after all classes had been recruited additional recruitment flyers were placed in the

lunchrooms of both campuses to increase participation.

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 24

CHAPTER FOUR: RESULTS

Introduction

Chapter Four provides the results for the research question “How much of the

variability in stress is explained by student demographic factors in student nurses

currently enrolled in any CSUSM School of Nursing program?”

An ad hoc power analysis was performed using GPower (Faul, & et al., 2009)

with the total number included participants. The actual sample size (n=154) provided for

a .15 (R2) effect size in a multiple regression analysis with a significance level of .05 and

a power of .86.

Figure 3. Power analysis post hoc.

(Faul, & et al., 2009)

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 25

The data was examined using IBM SPSS Statistics 20 software (2011) for

frequency, mean, median, mode, and distribution if applicable. Following frequency

distribution analysis, data were analyzed for correlations using Pearson’s correlation.

Regression analysis was then performed entering all independent variables into the

module simultaneously.

Sample

All variables were examined for normality using mean, median, and mode. Study

participants were described using frequency distribution. The three most frequent type of

students (Table 3) responding were ABSN Temecula (n=55) (35.7%), Generic (or

traditional) (n=46) (29.8%), and ABSN San Marcos (n=36) (23.4%).

Table 3

Frequency of Participants by Student Type

Frequency Percent

Generic-San Marcos 46 29.9

ABSN-Temecula 55 35.7
ABSN-San Marcos 36 23.4
MSN 10 6.5
LVN to BSN 1 .6
RN to BSN 6 3.9
Total 154 100.0

The participants were most frequently enrolled (Table 4) in the second semester

(n=48) (31.2%), fifth semesters (n=40) (26%), and fourth semesters (n=36) (23.4%). The

majority of participants (n=140) (90.9%) reported a current GPA of 3.00-3.99 (Table 5).

The student’s gender (Table 6) was reported as female (n=133) (86.4%) and male (n=21)
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 26

(13.6%). The participant’s age (Table 7) ranged between 21-59 years of age, with a mean

age of 31 and a median age of 27 years.

Table 4 Table 7
Frequency of Participants by Age
Frequency of Participants by Semester
Frequency Percent
21 8 5.2
Frequency Percent 22 10 6.5
First 1 .6 23 12 7.8
Second 48 31.2 24 11 7.1
Third 4 2.6 25 17 11.0
Fourth 36 23.4 26 13 8.4
Fifth 40 26.0 27 8 5.2
Sixth 3 1.9 28 8 5.2
Seventh 3 1.9 29 5 3.2
Eighth 19 12.3 30 4 2.6
Total 154 100.0 31 6 3.9
32 5 3.2
Table 5 33 2 1.3
34 5 3.2
Frequency of Participants by GPA 35 2 1.3
36 4 2.6
Frequency Percent 37 1 .6
38 1 .6
2.00-2.99 1 .6
39 2 1.3
3.00-3.99 140 90.9
40 3 1.9
4.0 or above 13 8.4
41 1 .6
Total 154 100.0
42 2 1.3
43 2 1.3
Table 6 45 3 1.9
46 5 3.2
Frequency of Participants by Gender 47 3 1.9
48 1 .6
Frequency Percent 50 1 .6
Male 21 13.6 51 2 1.3
Female 133 86.4 54 3 1.9
Total 154 100.0 56 1 .6
57 1 .6
58 1 .6
59 1 .6
Total 154 100.0
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 27

The majority of the participants’ marital status (Table 8) was described as never

married (n=82) (53.2%). The most common household living arrangements (Table 9)

were reported as “live with spouse or significant other” (n=36) (23.4%), “live with

parents” (n=35) (22.7%), and “live with spouse or significant other and children” (n=34)

(22.1%).

Table 8

Frequency of Participants by Marital Status

Frequency Percent

Never Married 82 53.2

Married 56 36.4
Divorced 12 7.8
Widowed 1 .6
Domestic partner/Same sex Marriage 3 1.9
Total 154 100.0

Table 9

Frequency of Participants by Household Living Situation

Frequency Percent
Live by myself 14 9.1
Live with roommate(s) 26 16.9
Live with spouse or significant other 36 23.4
Live with spouse or significant other and children 34 22.1
Live with parents 35 22.7
Live with children only 9 5.8
Total 154 100.0

The majority of respondents (n=104) (67.5%) reported having no children (Table

10). The majority of respondents (n=105) (68.2%) reported no children living in the

household (Table 11). A slight majority of participants (n=78) (50.6%) reported no

employment (Table 12).

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 28

Table 10

Frequency of Participants by Number of Children

Frequency Percent
None 104 67.5
One 13 8.4
Two 21 13.6
Three 11 7.1
Four 3 1.9
More than five 2 1.3
Total 154 100.0

Table 11

Frequency of Participants by Number of Children Residing in the Household

Frequency Percent
None 105 68.2
One 18 11.7
Two 20 13.0
Three 9 5.8
Four 2 1.3
Total 154 100.0

Table 12

Frequency of Participants by Employment Status

Frequency Percent
None 78 50.6
Less than 10 hours a week 20 13.0
Between 10-20 hours per week 28 18.2
Between 21-30 hours per week 12 7.8
Between 31-40 hours per week 12 7.8
More than 40 hours per week 4 2.6
Total 154 100.0

Yearly household income (Table 13) tended to be at either end of the scale with

respondents reporting income under $15,000 (n=36) (23.4%) or reported income $90,000
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 29

per year or more (n=26) (16.9%) most frequently. The majority of respondents were

Caucasian (n=102) (66.2%) (Table 14).

Table 13

Frequency of Participants by Household Income

Frequency Percent
$15,000/year or less 36 23.4
$15,001-$30,000/year 21 13.6
$30,001-$45,000/year 12 7.8
$45,001-$60,000/year 13 8.4
$61,001-$75,000/year 9 5.8
$75,001-$90,000/year 11 7.1
$90,000/year or over 26 16.9
Decline to state 26 16.9
Total 154 100.0

Table 14

Frequency of Participants by Ethnic or Cultural Background

Frequency Percent

Caucasian 102 66.2

African American 3 1.9
Asian/Pacific Islander 29 18.8
Mexican American/Latino/Hispanic 12 7.8
Native American 1 .6
Other 3 1.9
Decline to state 4 2.6
Total 154 100.0

The most frequent response from participants regarding amount of daily study

time (Table 15) was 3-4 hours per day (n=60) (39%). The number of hours in class

(including clinical time) (Table 16) reported by respondents most frequently was 12-25
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 30

hours per week (n=56) (36.4%). The vast majority of respondents (n=126) (81.8%)

reported 5-7 hours of sleep nightly (Table 17).

Table 15

Frequency of Participant by Amount of Daily Study Time

Frequency Percent
Less than 2 hours 27 17.5
3-4 hours 60 39.0
5-6 hours 37 24.0
More than 7 hours 30 19.5
Total 154 100.0

Table 16

Frequency of Participants by Weekly Hours Spent in Class or Clinical Setting

Frequency Percent

Less than 10 hours per week 12 7.8

11-15 hours per week 9 5.8
16-20 hours per week 35 22.7
21-25 hours per week 56 36.4
More than 26 hours per week 42 27.3
Total 154 100.0

Table 17

Frequency of Participants by Daily Hours of Sleep

Frequency Percent
Less than 4 hours 6 3.9
5-7 hours 126 81.8
8-10 hours 22 14.3
Total 154 100.0

Data Collection and Preparation

After three weeks of data collection, the survey was closed to new input. The data

was exported into an Excel spreadsheet, where all nominal and ordinal data were
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 31

converted to numerical values for analysis in SPSS. The data was imported into SPSS 20,

double-checked for accuracy and data analysis performed. All variables were examined

for distribution.

The participants self-selected to be included in the study. Data from any

participant who failed to complete the survey was excluded from data analysis.

Instruments

The SNSI tool has been determined to have cross-sample factor congruence, good

or acceptable concurrent, and discriminant validity in previous studies (Jones & Johnson,

1999). For each of the subscales, the Cronbach alpha has been reported to exceed .70

with the exception of the personal problems subscale (Cronbach .68). In this study, the

reliability coefficient for the 22-item SNSI was calculated to have a Cronbach’s alpha of

.89 (n=154).

Strahan and Gerbasi (1972) derived a Kuder-Richardson formula 20 (K-R 20)

reliability coefficients ranging from .59 to .70 for the MCSDS MC-1 (10 item) version

utilized in this study. In this study, the MCSDS-1 was calculated to have a Cronbach

alpha (for dichotomous data) of .57 (n=154). The data was analyzed using IBM SPSS

Statistics 20 software (2011) and the alpha for dichotomous data is equivalent to the

Kuder-Richardson 20 (KR20) coefficient (IBM, 2011).

Results by Research Question

The research question was “How much of the variability in stress is explained by

student demographic factors in student nurses currently enrolled in any CSUSM School

of Nursing program?”
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 33

two factors, which suggests that as self-reported stress went up there was a decrease in

social desirability response or conversely as stress went up, social desirability went down.

A linear regression analysis was performed. Two variables GPA (p=.001)

(n=154) and Study Time (p=.013) (n=154) were found to statistically significantly affect

the dependent variable, Self-Reported Stress. For the regression model that included GPA

and Study Time, (the R or Pearson’s Product Moment Correlation was .437.) (Table 18)

This value suggests that there was a moderately strong correlation between the observed

sample values and the predicted values for the dependent variable, Self-Reported Stress.

The effect size (R-squared) for the model was .19. This suggests that the model explains

19% of the variation in stress levels. This means that 81% of the reported stress level is

explained by other unknown factors.

Table 18.

Model Summary

Model Summaryb
Model R R Square Adjusted R Square Std. Error of the Estimate
1 .437a .191 .096 13.079
a. Predictors: (Constant), Crowne_Marlow_Total, GPA, Gender, Household Income,
Hours in class, Hours of Sleep, Children Living at Home, Culture, Semester, Marital
Status, Study time, Student Type, Housing Situation, Employment, Number of Children,
Age
b. Dependent Variable: SNSI_Total

When the analysis of variance was performed (Table 19), the F statistic was

significant at .016. This result indicated that the independent variables entered into the

model reliability predicted the reported stress levels.

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 34

Table 19.

ANOVA

ANOVAa
Model Sum of Squares df Mean Square F Sig.
Regression 5527.493 16 345.468 2.020 .016b
1 Residual 23434.357 137 171.054
Total 28961.851 153
a. Dependent Variable: SNSI_Total

b. Predictors: (Constant), Crowne_Marlow_Total, GPA, Gender, Household Income,

Hours in class, Hours of Sleep, Children Living at Home, Culture, Semester, Marital
Status, Study time, Student Type, Housing Situation, Employment, Number of Children,
Age

The standardized coefficients (b) for the independent variable GPA was -.270 (t-

3.267, p.001). This suggested that for every one unit the GPA increased the reported

stress level decreased by .27 units. The standardized coefficient (b) for the independent

variable Study Time was .225 (t 2.514, p. 013). This result suggested that for every one

unit of increase in study time the reported stress level increased by .225 units (Table 20).
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 35

Table 20.

Coefficients

Coefficientsa
Model Unstandardized Standard. t Sig. 95.0% Confidence
Coefficients Coefficient Interval for B
B Std. Beta Lower Upper
Error Bound Bound

(Constant) 99.002 17.712 5.589 .000 63.977 134.027

Student Type -.973 1.095 -.084 -.888 .376 -3.138 1.193

Semester -.072 .612 -.010 -.118 .906 -1.283 1.138

GPA -12.697 3.886 -.270 -3.267 .001 -20.382 -5.013

Gender 4.999 3.184 .125 1.570 .119 -1.297 11.295

Age -.031 .183 -.021 -.169 .866 -.394 .332

Marital Status -.134 1.438 -.009 -.093 .926 -2.977 2.710

Housing Situation .114 .885 .012 .129 .898 -1.635 1.864

No. of Children -2.704 1.392 -.243 -1.943 .054 -5.457 .048

Child. Lvg. Home 2.407 1.563 .176 1.540 .126 -.683 5.497

Employment 1.833 1.028 .193 1.783 .077 -.200 3.866

Household Income .629 .422 .123 1.491 .138 -.205 1.464

Culture .253 .771 .027 .327 .744 -1.273 1.778

Study time 3.100 1.233 .225 2.514 .013 .662 5.538

Hours in class .317 1.219 .027 .260 .795 -2.095 2.728

Hours of Sleep -3.924 2.675 -.118 -1.467 .145 -9.213 1.366

MC Total -.031 .750 -.003 -.042 .967 -1.515 1.452

a. Dependent Variable: SNSI_Total
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 36

Summary

The independent variables entered into the regression model simultaneously

explain 19 percent of the variability the dependent variable, Self-Reported Stress with

GPA being the only independent variable to reach statistical significance. The

relationship between the positive correlation between study time and stress and the

negative correlation between GPA and stress will be discussed in the next section.
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 37

CHAPTER 5: DISCUSSION

Introduction

Only two independent variables, GPA and Study Time, demonstrated a

statistically significant effect on the dependent variable SNSI (Jones & Johnston, 1999)

total stress score. Other factors such as semester, age, marital status, household living

arrangements, culture, or hours in class clearly indicated that they had no statistically

significant relationship to the SNSI total stress score; however, when they were removed

from the model, the model was no longer statistically significant or explained the

dependent variable. This find suggests that there may have been interaction between the

independent variables and the decision was made to leave them in the model. A few

factors such as number of children (p=.054) and employment status (p=.077) were

shown to be close to statistical significance.

Major Findings by Research Question

The research question was “How much of the variability in stress is explained by

student demographic factors in student nurses currently enrolled in any CSUSM School

of Nursing program?” The data indicates that approximately 19% of the self-reported

stress could be explained by the tested demographic factors.

The inverse relationship between GPA and the SNSI total stress score is similar to

what has been reported previously for other health professional students (Stewart, Lam,

Betson, Wong, & Wong, 1999). A study done by Stewart, et al, (1999) reported “In other

words regardless of whether students enter the programme academically weak or strong,
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 38

and whether they had high levels of stress when they entered the programme, the quality

of the grades they acquire in medical school independently affects their stress level.”

(p.249.) Other research explored the level of perceived stress in junior medical students

before and after clinical rotation and found that increased stress scores correlated

significantly with poor test scores at the end of the rotation (Linn & Zeppa, 1984). This

research indicates similar results.

The positive relationship between Study Time and the SNSI total stress score

found in this study has also been demonstrated in other studies also. Nicholl and Timmins

(2005) researched the relationship between “trying to balance work commitments and the

required study time” (p. 95) and stress levels in part time undergraduate nursing students.

The study indicated that this individual item had the highest mean score of any item

tested.

In common with previous research (Jones & Johnston, 1999), the SNSI had an

inverse relationship with the MCSDS with defensive students more likely to report fewer

stresses than other students.

Limitations

Internal validity could be influenced by additional demographic factors not being

tested in this study. Due to the limited number of previous studies, the questions chosen

for this research were specifically designed to cover a broad section of demographic

factors. There are possibly more specific questions or questions focusing on different

demographic factors that could have statistical significance.

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 39

A longitudinal repeated measure study design is recommended to enhance the

evaluation of reported stress over time. This design should reduce the bias inherently

associated with a cross sectional study and increase the reliability of the study.

Finally, a larger sample size may allow for the statistical significance of some of

the factors such as number of children and employment status that were close to

significance to demonstrate significance.

Generalizability

The research generalizability is limited to nursing students with similar

demographic populations as students attending CSUSM School of Nursing.

Implications for Nursing Research

There is not sufficient evidence to change policies or to focus on designing an

intervention to reduce the self-reported stress levels of student nurses. This research adds

to the body of knowledge about which broad demographic factors can be correlated to

changes in self-reported stress levels.

Recommendations for Future Research

As of this writing, no other studies have reported results discussing a relationship

between self-reported stress in student nurses and expanded demographic factors. Student

nurses report significantly higher levels of stress (Beck, et al., 1997) than many other

types of students and the general public. Demographic factors other than GPA and study

time do not seem to be related to this increased stress. A research project which includes

time also would add to the body of knowledge if incorporated into a future design

exploring student nurse repeated stress. A research project which includes the time frame
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 40

and the amount of material the student is expected to learn as independent variables may

be an appropriate follow-up. Additional factors yet to be identified but which increase

stress levels may require a qualitatative investigation.

Summary

In conclusion, student nurse’s experience stress at higher rates than other types of

students. Many factors influence the amount of stress experienced by the students. Lower

GPA and increased Study Time are two of the factors. Nursing schools tend to have

rigorous programs and students are expected to complete the didactic and clinical

portions simultaneously, while maintaining a minimum level of competency. This can

prove to be difficult.
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 41

Appendix A

Student Nurse Stress Index:

Below is list of items that may be associated with stress by students such as yourself.

Think of real events which have occurred in the past month in your role as a student. For each item please
circle the rating that applies to YOU. Answer all 22 items.

ITEM NOT EXTREMELY

STRESSFUL STRESSFUL
1 Amount of classwork 1 2 3 4 5
material to be learned
2 Difficulty of classwork 1 2 3 4 5
material to be learned
3 Examination and/or grades 1 2 3 4 5
4 Peer competition 1 2 3 4 5
5 Attitudes/expectations of other 1 2 3 4 5
professionals towards nursing
6 Lack of free time 1 2 3 4 5
7 College/School response to 1 2 3 4 5
student needs
8 Fear of failing in course 1 2 3 4 5
9 Actual personal health problems 1 2 3 4 5
10 Physical health of other family 1 2 3 4 5
members
11 Relationships with parents 1 2 3 4 5
12 Other personal problems 1 2 3 4 5
13 Relations with other 1 2 3 4 5
professionals
14 Too much responsibility 1 2 3 4 5
15 Lack of timely feedback about 1 2 3 4 5
performance
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 42

Answer the following questions from your reflections on your clinical experience:

ITEM NOT EXTREMELY

STRESSFUL STRESSFUL
16 Client attitudes towards me 1 2 3 4 5
17 Client attitudes towards my 1 2 3 4 5
profession
18 Atmosphere created by teaching 1 2 3 4 5
staff
19 Relations with staff in the 1 2 3 4 5
clinical area

Other academic and related items:

ITEM NOT EXTREMELY

STRESSFUL STRESSFUL
20 I am not sure what is expected 1 2 3 4 5
of me
21 I have no time for entertainment 1 2 3 4 5
22 I do not have enough time for 1 2 3 4 5
my family
 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 43

Scoring instructions for Student Nurse Stress Index (S.N.S.I.)

The S.N.S.I. has a four factor structure (Jones & Johnston, 1997), with “Academic load”, “Clinical
concerns”, “Personal problems” and “Interface worries” as underlying variables.

Evidence regarding the factor congruence across independent data sets, and the reliability and validity of
the measure can be obtained from Martyn Jones (m.c.jones@dundee.ac.uk).

The S.N.S.I. subscale and total scores are calculated using the unit weighting method of scoring.

S.N.S.I. Total

Sum scores on items 1-22 to give an overall total, ranging from 22 to 110.

“Academic load”

Sum scores on items 1, 2, 3, 8, 14, 18, 20 to give a subscale total ranging from 7 to 35.

“Clinical concerns”

Sum scores on items 13, 14, 16, 17, 18, 19, 20 to give a subscale total ranging from 7 to 35.

“Personal problems”

Sum scores on items 9, 10, 11, 12 to give a subscale total ranging from 4 to 20.

“Interface worries”

Sum scores on items 4, 5, 6, 7, 15, 21, 22 to give a subscale total ranging from 7 to 35.

DO NOT SUM SUBSCALE SCORES TO OBTAIN

AN OVERALL S.N.S.I. TOTAL.

Confirmatory factor analysis shows that S.N.S.I. has a less simple factor structure, with several variables
loading onto more than one factor, contact Martyn Jones for more details (m.c.jones@dundee.ac.uk).

N.B. Following validation of the measure, the administration of the S.N.S.I. alongside a measure of
social desirability, e.g. (Crown & Marlowe, 1960), is recommended particularly in named
reporting conditions.

MCJ Jan 2000

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 44

Appendix B

Marlowe-Crowne Social Desirability Index Version MC-1 (10)

1. I like to gossip at times.

2. There have been occasions when I took advantage of someone.

3. I am always willing to admit it when I make a mistake.

4. I always try to practice what I preach.

5. I sometimes try to get even rather than forgive and forget.

6. At times, I have really insisted on having things my own way.

7. There have been occasions when I felt like smashing things.

8. I never resent being asked to return a favor.

9. I have never been irked when people expressed ideas very different from my own.

10. I have never deliberately said something to hurt someone’s feelings.

Scoring

1. No = 1 point, Yes = 0 points

2. No = 1 point, Yes = 0 points
3. Yes = 1 point, No = 0 points
4. Yes = 1 point, No = 0 points
5. No = 1 point, Yes = 0 points
6. No = 1 point, Yes = 0 points
7. No = 1 point, Yes = 0 points
8. Yes = 1 point, No = 0 points
9. Yes = 1 point, No = 0 points
10. Yes = 1 point, No = 0 points

Total number of points is score.

NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 45

Appendix C
NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 46
NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 47
NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 48
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Appendix D
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Appendix E
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Appendix F

Sample Didactic Instructor Email Request

Dear (Name of Instructor)

I am conducting research on student nursing stress levels as part of my Master’s research
project. I would like to request 10 minutes at the end of your (level of class) on (day and
date) at (time) in (location). If you agree to allow me a few minutes, I will be presenting
the project and explaining and distributing the consent form during at that time. I would
also request that during the following week you distribute a sheet of paper that has the
URL for the students to complete the survey. The survey does not have to be completed
during class time. The total time required would be less than 10 minutes. Please let me
know if this is acceptable and if I have the correct time and room number.
Thanks.
Mary Baker

"Be the change you want to see in the world" - Mahatma Gandhi

Mary Baker
Nursing Clinical Instructor
CSUSM School of Nursing
mbaker@csusm.edu
760-822-8264
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Appendix G
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Appendix H
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References

American College Health Association. (2011). Fall 2010 reference group executive

summary. In http://www.achancha.org/docs/ACHA-NCHA-

II_ReferenceGroup_ExecutiveSummary_Fall2010.pdf.

Beck, D. L. & Srivastava, R. (1991). Perceived level and sources of stress in

baccalaureate nursing students. Journal of Nursing Education, 30(3): 127-133.

Beck, D., Hackett, M., Srivastava, R., McKim, E., Rockwell, B. (1997). Perceived level

and sources of stress in university professional schools. Journal of Nursing

Education, 36(4), 180-6.

California State University San Marcos (CSUSM). (2011, January 7). Cougar stats 2011.

In CSUSM Campus Facts.

Coyne J.C., Aldwin C., & Lazarus R.S. (1981). Depression and coping in stressful

episodes. Journal of Abnormal Psychology, 90, 439–447.

Crowne D.P. & Marlowe D.A. (1960) A new scale of social desirability independent of

psychopathology. Journal of Consulting Psychology, 24, 349–354.

Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical power analyses

using G*Power 3.1: Tests for correlation and regression analyses. Behavior

Research Methods, 41, 1149-1160.

Firth, J. (1986). Level and sources of stress in medical students. British Medical Journal.

292, 1177-1180.

Gibbons, C., Dempster, M., & Moutray, M. (2008). Stress and eustress in nursing

students. Journal of Advanced Nursing, 61(3), 282-290.

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 61

Goldberg, D.P. (1972). The detection of psychiatric illness by questionnaire. London:

Oxford University Press

Gray, J. (2001). Student breaking point... the experiences of Project 2000 nursing

students. Nursing Standard, 15(48), 3-6.

IBM. (2011). SPSS statistics 20 brief guide. Chicago, IL: IBM Corporation.

Jones, M., & Johnston, D. (1997). Distress, stress and coping in first-year student nurses.

Journal of Advanced Nursing, 26(3), 475-482. doi:10.1046/j.1365-2648.1997.t01-

5-00999.x

Jones, M., & Johnston, D. (1999, April). The derivation of a brief Student Nurse Stress

Index. Work & Stress, 13(2), 162-181.

Krohne, W. H. (2002). Stress and coping theories. Retrieved February 15, 2012

Lazarus, R.S., & Folkman, S. (1984). Stress, Appraisal and Coping. New York: Springer.

Lazarus, R.S., & Folkman, S. (1987). Transactional theory and research on emotions and

coping. European Journal of Personality, 1, 141-170.

Lindop, E. (1991). Individual stress among nurses in training: why some leave while

others stay? Nurse Education Today, 11, 110–120.

Linn B.S., & Zeppa R. (1984) Stress in junior medical students: Relationship to

personality and performance, Journal of Medical Education. 59, 7-12.

Lovallo, W., & Gerin, W. (2003). Psychophysiological reactivity: mechanisms and

pathways to cardiovascular disease. Psychosomatic Medicine, 65(1), 36-45.

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 62

Nicholl, H., & Timmins, F. (2005). Programme-related stressors among part-time

undergraduate nursing students. Journal of Advanced Nursing, 50(1), 93-100.

doi:10.1111/j.1365-2648.2004.03352.x

O'Regan, P. (2005). Students under pressure. World of Irish Nursing & Midwifery, 13(9),

16-18.

Polit, D. F., & Beck, C. T. (2008). Nursing research (8th ed.). Philadelphia, PA:

Lippincott Williams & Wilkins.

Pulido-Martos, M. M., Augusto-Landa, J. M., & Lopez-Zafra, E. E. (2012). Sources of

stress in nursing students: a systematic review of quantitative studies.

International Nursing Review, 59(1), 15-25. doi:10.1111/j.1466-

7657.2011.00939.x

Sheu, S., et al. (1997). The development and testing of perceived stress scale of clinical

practice. Nursing Research (Republic of China), 5(4), 341–351(in Chinese).

Shih, J. H., & Eberhart, N. K. (2010). Gender differences in the associations between

interpersonal behaviors and stress generation. Journal of Social and Clinical

Psychology, 29(3), 243-255.

Stewart, S., Lam, T., Betson, C., Wong, C., & Wong, A. (1999). A prospective analysis

of stress and academic performance in the first two years of medical school.

Medical Education, 33(4), 243-250.

Strahan, R., & Gerbasi, K. C. (1972). Short, homogeneous versions of the Marlowe-

Crowne Social Desirability Scale. Journal of Clinical Psychology, 28(2), 191-

 NURSING STUDENT STRESS AND DEMOGRAPHIC FACTORS 63

193. doi:10.1002/1097-4679(197204)28:2<191::AID-

JCLP2270280220>3.0.CO;2-G

The Trustees of Princeton University. (2007). Interpreting regression output. In Data and

Statistical Services. Retrieved April 22, 2012

Whitman, N. A., (1985) Student stress: Effects and solutions. Association for the Study of

Higher Education. ERIC Digest 85-1.