ORIGINAL RESEARCH

Stress in undergraduate nursing students

Celia Caldeira Fonseca Kestenberg^I; Bárbara Marins Santos Rosa^II; Alexandre Vicente da Silva^III; Janaina Mengal Gomes Fabri^IV; Isabel Cristina Ribeiro Regazi^V

^I Nurse. PhD in Psychology. Post-Graduation Professor in Nursing of the Universidade do Estado do Rio de Janeiro. Brazil. Email: celiaprofuerj@gmail.com
^II Nurse and Former Scholarship of the Vivendo Vivências Extension Project. Universidade do Estado do Rio de Janeiro. Brazil. E-mail: b barbaramarins@gmail.com
^III Nurse. Doctorate Student and Nursing Schools Professor of the Universidade do Estado do Rio de Janeiro. Brazil. E-mail: alexvicentesilva35@gmail.com
^IV Nurse. Master in Nursing. Assistant Professor of the Nursing School of the State of Rio de Janeiro. Brazil. E-mail: janamgfabri@gmail.com
^V Nurse. PhD in Biosciences. Professor, Universidade Federal Fluminense. Rio de Janeiro .Brazil. E-mail: violetafloral@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.26716

ABSTRACT

Objectives: to identify the degree of stress in 1st to 9th period nursing students, and ascertain its physical and psychological manifestations. Method: transversal, descriptive study of a chosen sample of 190 1st to 9th period undergraduates at a public school of nursing in Rio de Janeiro. Data were collected from April to May 2014, using the Lipp Inventory of Stress Symptoms for Adults (LISS). Research ethics committee approval No: 688344 (CAEE 30406914.8.0000.5282). Results: 79.5% of the students showed stress. The most evident physical symptoms were constant tiredness (77.3%) and feeling constant physically drained (76.8%); psychological symptoms were excessive fatigue (70.5%) and excessive irritability (58.4%). Conclusion: undergraduate students show high levels of stress and need to develop coping mechanisms.

Keywords: Stress; symptoms; nursing; undergraduates.

INTRODUCTION

The admission into higher education is associated with a transition process that needs to be well founded. This stage is full of sources of stress that require students to constantly adaptat in order to overcome the difficulties. Several factors influence the mental health of university students, from the motivation regarding the course, the separation of family and friends, autonomy in learning, new relationships, as well as professional and career perspectives^1,2. When starting college, the student begins another stage of his/her life, which promotes change and demands the adaptation to this new environment and circumstances of life^3,4.

At university, students are faced with a new environment, different and far from their life context. The need to adapt to new school requirements and obligations contributes to the emergence of anxiety and stress situations⁵. Thus, stress can arise when the demands of a situation exceed the capacity to cope with it⁶.

Several authors agree on the presence of stress among nursing students during university life, stating that undergraduates are subject to stress and their physical and psychological manifestations, which causes impairment in their academic development and personal life^{3,7- 9}.

From the initial considerations made, this study intends to investigate: do nursing students from the 1^st to the 9^th period present stress? It is expected that this study may contribute to broadening the understanding about this topic. The objectives were to identify the degree of stress of the nursing students from the 1^st to the 9^th period and to verify the physical and psychological manifestations presented by the undergraduates.

LITERATURE REVIEW

Stress is conceptually defined as the nonspecific reaction of the organism to a pressure exerted on the organic system, which occurs through the interaction of the individual with the inner and outer environment, which can generate physical, psychic, emotional and behavioral changes³. Thus, it is the need of the organism to manifest itself when there is something that threatens its homeostasis⁶.

Stress can be divided into four phases: Alarm phase - contact with the source of stress, with its typical sensations in which the organism loses its balance and prepares to face the established situation due to its adaptation. Resistance phase - the organism seeks the return to homeostasis. It may occur at this stage the adaptation or elimination of stressors and consequent rebalancing and harmony or progress to the next stage due to the non-adaptation and/or elimination of the source of stress. Near exhaustion phase - weakening and inability of the individual to resist or adapt to the stressor, and slight health problems may arise, which do not impair him or her. Exhaustion phase - the causative agent remains and the organism is not able to eliminate it or to adapt adequately, there is a kind of return to the first phase, however, aggravated and with physical impairments in the form of diseases¹⁰.

Stress is a process in which the body responds to the everyday events that lead the individual to adapt or not, constantly challenging their threshold in adjusting to a new balance⁶. Thus, the response to stress depends to a large extent on how the individual filters and processes the information and its assessment of the situations or stimuli in order to be considered relevant, enjoyable, terrifying, or otherwise. This assessment determines how to respond to the stressful situation and how it will be affected by stress¹¹.

Man, when facing a stressful situation, has two ways: to adapt positively or negatively to that situation. A positive adaptation to aggressive agents represents a health situation from the biopsychosocial point of view. However, the disease comes from a negative result from the poor adaptation to a stressful circumstance¹².

If there is no resoluteness to the stress situation or stress relief, the body will be more exhausted and without energy. In the ineffective resolution of the problem and the overloading of stressors during university education, the premise is that nursing students are likely to present evidence of stress^12,13.

As for the most frequent physical signs and symptoms of stress: increased sweating, pain in the stomach, muscle tension, tachycardia, hypertension, teeth grinding, hyperactivity, cold hands and feet, and nausea. And the psychological ones: anxiety, tension, anguish, insomnia, alienation, interpersonal difficulties, doubts about oneself, excessive worrying, inability to focus on subjects other than stressors, difficulty to relax, boredom, anger, depression , emotional hypersensitivity, and allergic (psychosomatic) problems^9,14,15.

The health area students experience high levels of stress, and the nursing student is immersed in the process of teaching and learning¹⁶. Thus, the environment that would contribute to the building of knowledge and to be the basis for their professional training experiences becomes, at times, the trigger of pathological disorders, when an exacerbation of the problem of stress in students occurs¹².

This student, in the process of preparing to perform the several actions that integrate the nursing work, with technical, dialogic, and political competences, faces situations of suffering that may contribute to the triggering of the stress process. These situations arise from the practical stages, the conflicts between the academic works, when they experience moments of personal and interpersonal difficulty, conflicts related to affective relationships, as well as the wear and tear associated with the contact with illness and death⁸.

METHODOLOGY

This is a descriptive study of quantitative approach, with field research. A public university of the State of Rio de Janeiro was used as field of study, and 190 students of all the periods of the Graduation Course in Nursing participated. Undergraduates who were regularly enrolled and attending the course and who were over 18 years old were included.

The data collection took place between April and May of 2014 and the Inventory of Stress Symptoms for Adults – ISSL, from Lipp, published in 2000 was used. The ISSL contains 23 closed questions and it is divided into three stages referring to the four stages of stress, covering the characteristic symptoms of each phase. In total, the ISSL includes 37 items of somatic nature and 19 of psychological nature, and the symptoms are often repeated, being that only their intensity and seriousness differ.

In the data analysis, techniques from the descriptive statistics have been used; to describe and synthesize the data and to estimate the parameters, statistical calculations have been performed¹⁷.

The study complied with the ethical principles and obtained approval from the UERJ Research Ethics Committee through the number 688.344; and the Free and Informed Consent Term was read and signed in two copies, one being in the possession of the undergraduate student.

RESULTS AND DISCUSSION

Out of the 190 nursing students taking part in the study, 151 (79.5%) were identified at some stage of stress, and 39 (20.5%) did not present the stress phases evaluated by the ISSL instrument, according to Table 1.

TABLE 1: Distribution of nursing undergraduates by level of stress. Rio de Janeiro, 2014. (N=190).

The phases of stress (alertness, resistance, near exhaustion, and exhaustion) were identified in 151 students (79.5%). Most of the subjects presents some degree of stress which corroborates with other studies ^7,12,18,19 . Stress manifests itself as a public health problem when it affects a large part of the population, overloading the health system and representing relevant impacts in the individual and social sphere²⁰. It should be highlighted that some characteristics present in the academic life can be considered stressors, emphasizing the demands of performance, routine of studies, concentration in the classes, fulfillment of an extensive weekly workload, action in the field of practice, among others.

Identified with a higher percentage in this study, in 90 (47.5%) students, the resistance phase is characterized by the attempt to combat stressors and reestablish homeostasis, which was broken after the imbalance suffered in the alert phase. This wear can be physical and/or emotional, causing health damage, and it can also lead to reduced productivity. Another relevant aspect when it comes to the resistance phase, it is to think that it is characterized by the increased production of cortisol making the organism more susceptible to diseases¹³. It is the moment when somatizations can arise.

The term somatization is used by clinicians and researchers for a variety of phenomena and processes, and it refers to the presentation of somatic complaints arising from psychological causes, but that are attributed by the patient to an organic cause. Somatizers, therefore, would be those patients who have a tendency to experience and communicate personal difficulties in the form of discomfort and somatic complaints for which an organic substrate is not found²¹.

The exhaustion phase presents the second high percentage, it is the most critical phase. In it, 59 (31%) undergraduates are starting the process of illness and the most vulnerable organs are affected due to the decrease of the immune system¹³.

Regarding the resistance phase, of the students in the nine academic periods analyzed, four (1^st, 2^nd, 3^rd and 7^th) presented levels above or 50%, corresponding to 51.5%, 55%, 55%, and 50%, respectively, corroborating previous studies that evidenced the predominance of the resistance phase¹³. See Figure 1.

FIGURE 1 – Distribution percentage of nursing undergraduates according to stress level by academic period. Rio de Janeiro, Brazil, 2014.

When the resistance and exhaustion phases are evaluated together, all the students present stress levels above 50%, in some cases as in the 6^th and 2^nd periods, they reach 95.2% and 95%, respectively, followed by 90,9% at the 1^st and 90% at the 3^rd. Thus, the first three periods (1^st, 2^nd and 3^rd) and the 6th period have the most undergraduates with a high degree of stress when compared to the other periods. This result calls attention, since the students of the first three periods are still in the phase of adaptation to the university life.

The entrance into higher education represents a change in the social, family and school environment that can generate, in some cases, feelings of anxiety that are potentially stress inducing^3,4. The student begins a new phase in his/her life and this is a fact clearly characterized as change, and therefore is considered as a stressful situation. In this course, the student attends two classes, which potentiates stress, confirming the results presented in Figure 1.

Regarding the stress situation, the International Code of Diseases (ICD10) describes as an adaptation disorder a particularly stressful event that triggers an acute stress response and carries unpleasant and lasting consequences. The stressful event or persistent painful circumstances constitute the primary and essential causal factor, in the absence of which the disorder would not have occurred²².

In the 6^th period, the graduate starts the internship in the intensive care area and is faced with the manipulation of complex equipment and the need for security in the execution of techniques. Such characteristics are sources of pressure, intensifying the physical and psychological wear and tear¹⁹. It should be added that this is the moment in which the student deals with the severity of the illness, the increase of the suffering, and the possibility of the death of the patient, which constitutes a stressor factor.

In nursing graduation, in addition to the adaptation to the university life, in the second period there are a large number of disciplines. Classes begin at 8 a.m. and end at 6 p.m. Then, they face the time and distance of the commute to their homes. Many live far from university. When they get home, they still take time to prepare seminars, papers, and study for tests. The third period is characterized by the beginning of practical classes in the hospital. At this moment, the student has his/her first contact with human illness, their physical and psychosocial determinants, besides pain, suffering, and death. All this context contributes to the high levels of stress found in these periods.

Interestingly, undergraduates of the last periods (8^th and 9 ^th grades) show more controlled levels of stress when compared to the other periods, and it differs from previous studies^8,23 which have shown that the supervised internship in the different fields of practice, the course completion paper, and the increased responsibility for the approximation of the professional life, tend to raise the degree of stress of the undergraduates of the last nursing periods. It is possible to think that the undergraduates of this study have developed during the graduation some mechanisms for facing the stress and, due to that, they are coping with internal and external stressors.

These coping mechanisms are called resilience, which comprise the healthy development of the individual even in the face of adversity, and aims to understand the individual and environmental characteristics that can be modified, so that individuals can deal with adverse situations²⁴ .

Thus, resilience refers to a positive adaptation, or the ability to maintain or recover mental health after an adverse experience, that is, it refers to the capacity that the human being has in demanding situations, and even potentially traumatic, keeping the person relatively stable and healthy²⁵.

It should be highlighted that it is exactly in the 8^th and 9^th periods that the graduating student undergoes the "Extensão Vivendo Vivências" Project, which proposes, through the experiential method, to develop care practices in the caregiver. These experiences enable the improvement of interpersonal relationships through the development of social skills, especially the empathic ability, as well as strategies to deal with stress. It is possible that this group process is contributing to the stress reduction of these undergraduates, by making it possible to increase resilience. However, this possibility needs to be systematically verified.

The stress symptoms may involve physical or psychological status or both, as shown in Table 2. In assessing these symptoms, those who appear most often indicate the most vulnerable area to stress.

TABLE 2: Students distribution by stress symptoms. Rio de Janeiro, 2014. (N=151)

The data show that the number of undergraduates with a predominance of physical symptoms = - 63 (41.7%) - almost approximates that of psychological symptoms - 68 (45%) -, suggesting mixed vulnerability when physical and psychological fields present almost the same prevalence.

Mixed vulnerability is the tendency to somatize along with emotional vulnerability, because the body's attempt to resist psychologically against stressors is occurring^10,23.

If students cannot adapt to stressors, they can trigger a set of restrictive responses that may be psychological, physiological and behavioral that favor a decrease in the health and well-being of the student¹⁸. Thus, when stress levels are in excess it can become a risk for the individual¹⁴.

The confrontation of the unknown by the nursing graduate, as well as the assignment to him/her of tasks in assisting patients at greater risk of suffering, death, and or dependence, generates a stress that can be characterized in a physical and emotional way, manifesting itself from different shapes and intensities¹⁹.

The students presented in their totality similar physical symptoms, such as constant fatigue (77.3%), constant physical exhaustion (76.8%), problems with memory (68.4%), muscular tension, and change in appetite (42.1%).

These findings reinforce previous studies, which address the symptoms of constant physical exhaustion, constant fatigue, muscle tension and memory problems such as those that appear the most^23,26. It is necessary to consider that these symptoms probably influence the personal and academic performance of the graduates.

The most prevalent psychological symptoms were: excessive tiredness (70.5%), excessive irritability (58.4%), constant thinking about one subject (52.6%), and irritability with no apparent cause (46.8%); these are also the ones that appear the most in a previous study²⁶. Besides these, There is still the desire to escape from everything (54.7%), to constantly think about only one subject (52.6%), excessive emotional sensitivity (47.9%), and irritability without any apparent cause (46.8%).

Thus, these results confirm previous research²³, in which it was pointed out that physical and psychological symptoms may hinder the performance of academic skills required by students. The undergraduate assumes routine activities that involve high performance and concentration of efforts aimed at a routine of constant and increasing studies, and it can become a source of stressful stimuli. A study with nursing undergraduates showed that 52.4% do not practice physical activity, and 95.5% have less than 8 hours of sleep, which may contribute to increased stress²⁷.

These factors can lead to problems of stress, such as poor concentration and memorization, in the undergraduate students, favoring a decrease in the academic performance and quality of the nursing care during the internships ¹². Therefore, the presence of stress among nursing undergraduates is related to the exposure to a growing number of situations common to the academic environment to which they need to adapt, in addition to the demand and pressure coming from the family and the social environment⁷.

CONCLUSION

According to the objectives, the study made possible the understanding of the formation moments in which the student presents the symptomatology of a determined phase of the stress, as well as the most frequent physical and psychological symptoms.

However, there is a limit in this research regarding the identification of the coping mechanisms used by these undergraduates. It is essential to know how students are dealing with stress in personal and academic life, in order to promote appropriate strategies.

Knowing the severity and extent of stress in the lives of nursing undergraduates, future nurses, it is surely appropriate and necessary to learn coping strategies. The appropriation of this knowledge can enable them to deal more adequately with the demands of the professional context. This favors healthier relationships between professionals and individuals who require nursing care.

It is concluded that the research evidenced stress in the majority of the students, being that one third of them are in the exhaustion phase, which is alarming, since this is the most worrisome phase, in which there is a greater propensity to the illness.

It is recommended that the training institution pay attention to these results, since future professionals will be entering the job market with stress symptomatology, which can generate personal impacts, reduce the quality of the customer service and withdrawal of the profession.

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