Running head: HIGH STRESS LEVELS IN NURSING STUDENTS

High Stress Levels in Nursing Students

Dustin Phelps

Brigham Young University-Idaho

Nursing 420:01

Dr. Bennion

December 7, 2018
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High Stress Levels in Nursing Students

Background

Nursing students experience high volumes of stress during their education. Students have

verbalized stressors relating to lack of competence and relationship difficulties (Radamés et al,

2018). When students are exposed to stressful situations, they feel inadequate in performing

tasks that are put in front of them, causing an increase in stress levels. Feelings of difficulty

when exposed to new situations and patient relationships can also cause more stress. For

example, if a nursing student is exposed to a patient of an unfamiliar culture, stress levels will

rise as they adapt to treating and effectively communicating with the patient.

High levels of stress are demonstrated during simulations through physical signs. Heart

rate is a specific and measurable sign of stress. Student heart rates were measured during

different phases of simulation and documented to show which phases were most stressful.

Increased heart rates correlated with student testimonies to show which phases produced the

highest amount of stress (Nakayama, Arakawa, Ejiri, Matsuda & Makino, 2018). Since

simulations occur often in nursing school, this continually subjects students to repeated stressors.

For example, a simulation event can include running a code situation in which students are

expected to perform adequately within the time frame given.

Nursing students experience stress during clinical education. A clinical setting requires

students to adapt to different levels of stress and varying stressors (Alzayyt & Al-Gamal, 2014).

A clinical setting provides new experiences for the students and may subject them to unknown

situations. For example, students may not have yet been introduced to a disease in the classroom

setting that they are then exposed to in a clinical setting. Clinical rotations take place

periodically throughout the semester forcing students into stressful situations regularly.
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Significance

Increase of stress in students has damaging effects of the emotional health of students.

The insufficient resources of students and coping mechanisms for stress often lead to negative

emotions such as anger, fear, and anxiety (Radamés et al, 2018). Psychological health is

essential to the overall health of a student. When the emotions get out of hand due to stress, the

student’s well-being is put in jeopardy. Decrease of emotional health in students can affect their

success in education, their socialization and ability to form relationships, and their ability to deal

with further stressors outside of nursing school.

The high levels of stress in nursing students results in decreased physical health. Stress

can lead to increase of headache, infection, and influence sleep patterns (Alzayyt & Al-Gamal,

2014). When students are physically feeling their best, this can lead to problems in other areas.

For example, stressed students can start to struggle academically, leading to decreased

knowledge retention and understanding. Another example is when a student is not adequately

rested, they are more likely to have decreased cognition and make mistakes in the clinical

setting. A decrease in physical health can also affect the emotional and spiritual health of the

nursing student.

Exposure to repeated stressors can lead to harm in the decision-making abilities of a

student. Stress is shown to increase addictive behaviors, increase drug use, and to changes goal-

oriented behaviors to habitual ones (Ehlers & Todd, 2017). Although not all effects of acute

stress are known, the ones that are known can have damaging effects on the future career of a

nursing student. For example, drug use and addiction damage career opportunities, impair

decision-making, and decrease health. In additional, a decrease in goal-setting and achievement

puts students in jeopardy of not finishing their degree, not entering the nursing field of choice,
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and having a decrease in job satisfaction once they do begin working. Nursing students

experience increased stress leading to decreased emotional health, physical health, and decision-

making capabilities.

Pender’s Health Promotion Model Theory

Nola Pender created a nursing theory that encompasses the ideas that contribute to health.

It focuses on three areas: individual experiences and factors, perceived benefit for the individual,

and the outcomes of behaviors (Pender, 2011). The definition of health not only means the

absence of sickness but an overall positive state of being. The 14 theoretical statements

proposed in the article show the major ideas that make up overall health. In studying these

statements, one gains a clearer idea of health components, and therefore has a better chance in

achieving true health. When the individual parts of health are identified and pursued, a healthy

lifestyle is then attained by the individual.

The emotions an individual has while performing a specific action influences their view

of the experience. Health promotion is aimed at increasing the total well-being of a person, not

just treating them when physical sickness arises. When a desired outcome is linked to a specific,

positive behavior, that behavior is more likely to be repeated (Pender, 2011). In other words,

when one performs a specific action and finds the result appealing, the action will be repeated

because of the positive stimuli received. For example, if a person begins a new exercise routine

and feels better physically and emotionally afterwards, the routine will continue into a habit.

The positive emotional experienced through this action drives the person to pursue the feeling

again.

Previous experiences influence the future behaviors of an individual. Health promotion

encourages the adoption of new habits to achieve good health (Heydari & Khorashadizadeh,
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2014). Therefore, an individual who was taught health promoting behaviors in the past, is more

likely to continue those habits in the future. For example, a parent can teach a child during early

years to eat nutritious food and avoid consuming prepackaged food. Then, when the young adult

moves away from home, the healthy eating habits will likely continue. This shows have

previous experiences influence the present decisions an individual is making.

Pender describes self-efficacy as an individual’s belief in themselves to achieve personal

goals. When an individual has a positive experience with goals, it reflects greater self-efficacy.

A greater self-efficacy then promotes an optimistic mindset. Research was conducted to focus

on strategies that increase self-efficacy. This included sharing positive experiences, group

discussions, and relating successes with other participants (Dehdari, Rahimi, Aryaeian, &

Gohari, 2014). When higher self-esteem is achieved, confidence is gained and triumphs that

were before out-of-reach are now attainable. For example, when a diabetic patient meets a

desired blood glucose range, the nurse will complement the efforts, therefore promoting further

compliance. The positive reinforcement between the two will increase the self-efficacy of the

patient.

Effects of Stress on Health Promotion

Emotional health is greatly influenced by the outcomes of one’s actions. An increase of

stress for students causes emotions such as anger, fear, and anxiety to be felt (Radamés et al,

2018). Stress effects emotional health of an individual and therefore limits one’s overall health.

In addition, Pender’s health promotion model states that when a desired outcome is achieved, the

action leading to the outcome will be repeated (Pender, 2011). From this statements, one can

then conclude just the opposite: if a student has a negative experience with a task, they will be

less likely to repeat that task. Since stress in nursing school causes negative emotions to be felt
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by students, the stress felt will be associated with negative outcomes. These negative outcomes

lead to decreased desire to repeat the tasks responsible for them and therefore students are less

likely to want to continue with the tasks in the programs they are involved in.

Nursing students are likely to create new habits during their time in school. Pender’s

theory supports forming new, healthy habits to achieve overall health (Heydari &

Khorashadizadeh, 2014). For example, developing the health-promoting habit of healthy eating

will contribute to the overall health of an individual. As with any new program or routine,

nursing students are required to form new habits in order to keep up with the accelerated pace

and unfamiliar environment they are presented with. One of the unfamiliar environments

presented is simulation. Simulations produce high amount of stress in students (Nakayama et al.,

2018). Therefore, these simulations can cause the opposite of Pender’s health promotion goals to

take place. Instead of forming new behaviors to maximize health, students are routinely stressed,

leading to a decrease in overall health. For example, instead of making it a habit to get eight

hours of sleep a night, a nursing student may worried about simulations the following day and

only get five hours. This leads to worse performance the following day and yet another increase

in stress-inducing behaviors.

Students have reduced self-efficacy when they are exposed to repeated stressors. Part of

the health promotion theory is increasing self-efficacy. An optimistic mindset and increased

confidence is achieved when positive experiences and successes are shared with others (Dehdari

et al. 2014). This optimism results in increased self-esteem and more frequent success.

However, in a clinical setting, students feel a lack of competence and adaptation (Alzayyt & Al-

Gamal, 2014). When a clinical setting leads to such feelings of inadequacy, this then decreases

the confidence level in a student. As the confidence level decreases, one becomes less likely to
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want to share this experience with others. As a result, self-efficacy is reduced and students have

a negative mindset about the clinical experience.

Research Methods

The stress level of nursing students directly influences their performance during

simulation exercises. Pender’s health promotion theory says that an increase in self-efficacy

reflects a better performance and more frequent success, especially when these successes are

shared with others (Dehdari et al. 2014). Since self-efficacy is affected by one’s emotions, the

emotions then play a role in the performance of an individual. Stress has a direct impact on the

emotional health of a student and therefore has an effect on the self-efficacy of that student.

Therefore, since simulations require a student to perform their skills and be tested on their

knowledge, the outcome of the performance will be correlated with the stress they feel before

and during simulation.

Research Design

The researched performed in this study will be done using a quantitative correlational

research method. Quantitative research focuses on producing numerical information that

describes a phenomenon. It is directed towards describing new situations, relationships between

variables, and to determine the effectiveness of implemented interventions in research studies.

Quantitative research is a structured way or gathering and categorizing data from different

sources. (Grove, Gray, & Burns, 2015). Correlational research is the study of a relationship

between two variables. It describes the type of relationship between the two factors and the

strength of relationship. A positive relationship means the two variables increase or decrease

together while a negative relationship means they work oppositely to each other, or one increases

while the other decreases. How closely they reflect each other determines the strength of the
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relationship. The focus of a correlational study is to identify and describe relationships, not try

to change them. A quantitative correlational study will work more efficiently for this experiment

because the level of stress in students isn’t trying to be increased or decreased, it is just trying to

be linked to how it effects performance of the student. Neither variable is trying to be controlled,

researchers just want to know if they are linked.

Research Population

The population of this experiment is current nursing students who have no yet attained

their degree. The inclusion criteria for the study is full-time nursing students attending a four-

year university in Arizona, who are currently enrolled in a BSN pre-licensure program, and who

are exposed to at least one simulation every two weeks. The exclusion criteria include those who

do not have English as a primary language, those who have one or more children at home they

help provide for, and those who are within two semesters of graduating. The students who

haven’t had English as their primary language are excluded because they are likely to be

experiencing additional stress unrelated to simulations because of a language barrier. The

students who have children at home are excluded because they will also have increased family

stress and responsibilities. The students who are in their last two semesters of nursing school

have been exposed to repeated simulations and are likely to have already developed coping

mechanisms and stress-reducing habits related to the pressures of simulation. The sample size

will range 50-100 participants.

Methods and Measurements

In order to recruit participants for the research, an email will be sent to each of the

universities that fit the inclusion criteria. After obtaining IRB approval from the universities in

the study, the research team will contact the head of each nursing department. The head of the
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department and researchers will then discuss the study with the teachers and gain permission to

conduct the experiment during several of their simulation times. After following all criteria set

forth by the universities IRB, students will then be asked via email to participate in the study.

They will be offered a free lunch in the school cafeteria payed for by the research group as an

incentive to participate. The research team will also communicate with the teachers involved in

the study and see if they would be willing to offer a small value of extra credit to the students

who participate in the study.

Information will be gathered from each student through a survey taken before each

simulation experience. Students will be asked to rate their stress level before simulation on a

numerical scale of 1-10, with the higher numbers reflecting a higher amount of stress. There will

then be a 1-10 scale on how much the student believes this stress will affect their performance

during simulation. Students will then proceed to the simulation experience previously arranged

by the teaching staff. Staff will then be asked to observe and grade the performance of the

student using a simulation evaluation tool. This tool will include a 1-10 grade scale on how well

students perform in the following categories: implement the nursing process, execute holistic

care, perform safe mediation administration, provide education appropriately to the patient,

communicate professionally, and accept responsibility for personal growth. Two staff members

will be asked to complete the evaluation tool on each student that participates in the simulation.

Researchers will observe students from another room using video monitoring to note non-verbal

signs of stress that may not previously have been documented by students. Researchers will

remain out of sight to limit any additional stress variables on the students. This process will be

repeated with the same students on four different simulation occasions using the same evaluation
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tools and survey. The data will then be collected at the end of the fourth simulation and be

subjected to analysis.

Once the data has been collected and the participant involvement in the study has

terminated, statistical analysis will then take place to draw conclusions from the data. This will

be done through descriptive statistics to organize the data in way that will give the researchers

insight as to how the two variables are correlated (Grove et al., 2015). The data will be graphed

out on a correlation scatter graph to determine relationship type and strength. It will include

overall score of the student provided by the teacher on the y-axis and the stress score each

student provided on the x-axis. With all of the results plotted, the relationship will then be

determined by evaluation of symmetry of the graph. Using the Pearson Correlation Analysis, the

correlation coefficient (r) can be determined and the relationship can be labeled either positive or

negative (Grove et al., 2015). With the r value, strength of correlation can then be determined as

weak, moderate, or strong. Research results will then go through a publishing process and be

included in journals or periodicals that focus on the education of students and/or the effects of

stress on individuals.

Ethical Considerations

Several of the population who fit the criteria will not wish to participate in the study at

all. Even more, some participants will wish to withdraw themselves from the study after

beginning. This ethical consideration is called the right to self-determination, or respect for

persons (Grove et al., 2015). In this study, participants will have the option to withdraw at any

point in the study. They will not be required to fill out the survey completely or answer any

questions against their desires. Coercion will be avoided by limiting the incentives given to

participants. Participants will also be fully aware of the data being collected by going through a
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debriefing session before the first simulation to explain how the experiment will be run and to

answer any questions. Participants will sign a consent for giving permission for their

involvement and the publishing of the results.

Participants will not want to be identified by name during and after the study. This

ethical consideration is called the right to privacy (Grove et al., 2015). An invasion of privacy

will be avoided by collecting a consent form from each of the participants before beginning and

each participant will be given the opportunity to ask questions. The data use will be explained to

participants by showing how the data will be used and how their information will be protected.

Participants will also be assigned a number during the study to be identified by to avoid the use

of names. The names and correlating numbers will not be accessible to the public or published.

Participants will want to remain safe and be protected from harm. This ethical principle

is called right to protection from discomfort or harm, or beneficence (Grove et al., 2015). In the

study, participants will not be asked to give any additional emotional information other than the

numerical stress scale and the optional written description of their stress. This will protect them

from any additional discomfort during the study since the additional steps of data collection are

included in their normal class routines. Participants will not be questioned about previous

history of stress or negative experiences. They will be given the opportunity to withdraw at any

time. Though the risks are few, they will be properly identified to participants during the

explanation period before the initiation of the study. Benefits and risks will be included in the

consent form.
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Annotated Bibliography

Bodys-Cupak, I., Majda, A., Skowron, J., Zalewska-Puchała, J. & Trzcińska, A. (2018). First

year nursing students' coping strategies in stressful clinical practice situations. Journal of

Education in Science, Environment and Health, 4(1), 12-18. doi:10.21891/jeseh.387474

The authors include professors and nursing faculty of Jagiellonian University Medical

College in Krakow with many years of nursing and teaching experience. The type of

study conducted was quantitative descriptive research. Strengths of the study include over

30 survey questions about stressful situations and coping skills. Data is also directly to

almost all nursing programs throughout the world. Weaknesses include only self-reported

experiences that might skew results and lack of information on possible outside stressors

student might have been experiencing which also might skew stress levels. The quality of

the study is high because it is directly applicable to the main population and can easily be

generalized to other programs around the world. It also includes limitation of extraneous

variables and was conducted with an appropriately-sized participant number. This

research is useful for students because it is shows most commonly used coping skills for

stressful situations, something they are commonly subject to. The intended audience is

nursing education staff and program designers as well as behavioral health professionals.

This study has the same population as the intended study, both include research on

nursing students in a four-year program who are subject to increased stress.

Regehr, C., & LeBlanc, V. R. (2017). PTSD, acute stress, performance and decision-making in

emergency service workers. Journal of the American Academy of Psychiatry and the

Law, 45(2), 184-192. Retrieved from

http://jaapl.org.byui.idm.oclc.org/content/45/2/184#sec-12
HIGH STRESS LEVELS IN NURSING STUDENTS 13

This research was conducted by Cheryl Regehr and Vicki R. LeBlanc. Both are

professors at the University of Toronto with experience in forensic social work and

administration in emergency mental health. The type of study conducted was a

quantitative correlational study. One strength of the study is the multiple populations,

including police, paramedics, child protection workers, and police communicators. This

allows a wider generalization to all emergency professionals instead of just one branch. It

also included both physical and verbal signs of stress instead of just one, allowing the

results to not be skewed by inaccurate representation of stress. Weaknesses include a

small sample size, especially within the paramedic category, and the limited ability to

produce realistic workplace situations through mannequins. The quality of the study is

moderate because there was a high amount of information collected and analyzed but the

results may not accurately reflect the workplace performance accurately. These findings

will be used to further study and understand how stress and PTSD effect the performance

of emergency responders. When these concepts are better understood, future education

and stress management can be emphasized. This research is intended for emergency

responders, mental health professionals and course designers for emergency education.

This study has the same outcome/goal of relating stress to performance as the research

study being performed among nursing students.

Savage, D. A., & Torgler, B. (2012). Nerves of steel: Stress, work, performance and elite

athletes. Applied Economics, 44(19), 2423-2435.

https://doi.org.byui.idm.oclc.org/10.1080/00036846.2011.564150

David Savage is a professor and the University of Newcastle and has participated in over

30 studies on decision-making and behavior. Benno Torgler is also a professor at QUT

Business School and is a recipient of a Nationally Competitive Research Fellowship.

Research was done using quantitative descriptive study methods. Strengths include

assessment of over 30 years of data and use of only observed data, not self-reported

information. Weaknesses include a non-traditional working environment/career and a

large number of demographic variables including age, experience, nationality, and

athletic ability. The quality of the study is moderate because it presents clear results of

the effects of stress but has many uncontrolled variables and will be hard to generalize to

bigger populations. These finding can be useful to analyze the effects of both positive and

negative effects of stress on the performance of an individual, especially for nurses and

students who are looking to increase positive workplace experiences. The intended

audience is behavioral researchers, employers and psychological researchers interested in

stress studies. This study has the same desired outcome of further understanding stresses

effect on performance and results of positive and negative stress as the included study.

Shudifat, R. M, & Al-Husban, R. Y. (2015). Perceived sources of stress among first-year nursing

students in Jordan. Journal of Psychosocial Nursing & Mental Health Services, 53(6),

37-43. doi:10.3928/02793695-20150522-01

This research was conducted by Ra’ed Shudifat and Raya Al-Husban. Ra’ed Shudifat is a

nursing professor at the University of Jordan with a PhD in nursing and is Assistant Dean

for Academic Affairs. Raya Al-Husban has a PhD in nursing and is on the nursing

education staff at Mut’ah University. The type of study conducted was quantitative

correlational. One strength of this study is it analyzes stress not only in regards to nursing

assignments, but to the overall changes ones goes through as a nursing student. It was

also the first of its kind in its setting so it will pave the way for following studies to be
HIGH STRESS LEVELS IN NURSING STUDENTS 15

conducted. Its weaknesses include the research participants only being females and that it

was only conducted in one setting, therefore the population is very limited. The quality of

this study is moderate because it had limitations on participants but still provides useful

information about the holistic health of nursing students and where they perceive

stressors in nursing school. The findings can be used as a guide to staff at nursing

colleges to understand how stress is impacting the performance of their students. The

intended audience is nursing education staff, program developers, and behavioral

researchers. This study has the same population (nursing students), the same time (during

the first half of nursing school), and outcome (relate stress to health of students) as the

study being performed currently.

Research Implications

Nursing Knowledge

After this study concludes, nurses will know the effects of stress on their performance.

They will know whether stress impedes the work they do or if it helps them perform better

because they are under pressure. Stress is a common topic through many different fields, but

since the study includes nursing students, it will relate directly to the nurses that they become.

Nurses will gain a better knowledge of recognizing stress and how it affects them personally,

especially in events where they are under observation, being evaluated or in intense situations.

For example, during the study, students were asked to rate stress and then participate in a high-

intensity simulation and evaluate for signs of stress during the sim. Nurses could potentially

evaluate their levels of stress before entering a patient’s room in the same way and see if it

results in a change of their performance, allowing them to gain a better understanding of the

personal effect it has on their work.

Nursing Theory

The goal of this study is to improve overall health of nurses and nursing students by

helping them recognize stress. Health promotion encourages the adoption of new habits and

ideas to achieve overall health of an individual (Pender, 2011). This study will support this

theory by showing the impact that stress has on overall health and the consequences it has on

individuals. This study will also expand on the theory by giving researchers a greater

understanding of stress and therefore not only evaluate its effects on performance, but possibly

linking it to changes in physical, emotional, and spiritual wellness. This study supports Pender’s

health promotion model by emphasizing the influence that one aspect of health can have on its

whole. This is important in further expanding health promotion because as understanding

develops, new habits will form and overall health will be gained in nurses and students.

Nursing Practice

Upon completion, this study will influence nursing practice by influencing the nurses

themselves. As nurses gain a better understanding of stress and the impact it has on their work,

they will change habits they have that increase stress in their lives. Nursing practice will be

improved as fewer mistakes are made and overall health improves. As stress is better understood

in the nurses, hopefully they will make efforts to decrease it. This influences their practice by

improving their work performance. For example, if a nurse is stressed, they may not sleep well

and will not have a clear mind as they arrive at work. This can result in mediation errors and

missing vital assessment data. But, if the amount of stress is decreased, the nurse will have a

clearer mind and can focus on the necessary interventions for their patient. As a result, the study

will impact nursing practice by not only increasing the health of patients, but of the nurses

themselves.
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Improve Patient Care

This study promotes quality in the care given to patients. As nurses are able to better control

the stress levels in their work, they will give better patient care. When stress levels are identified,

they can be shown to affect the outcome of nursing care. Once nurses see the results of stress on

their work, they will look for means to decrease levels. This will improve the nursing care given

and patients will be able to enjoy safer, higher quality care. Nurses will work with a clearer

mind, make fewer mistakes, and increase their performance in stressful situations.

This study will improve patient care by improving nursing knowledge. Throughout

nursing school, students are shown to be under high levels of stress. This is shown to decrease

the amount they learn and retain while in school if they are not able to control the levels of stress

they are subjected to. As an overall result, students are less prepared to enter the nursing field

and will take longer to learn the appropriate skills needed to become a competent nurse. For

example, if a student experiences a decreased amount of stress while going through school, they

will enjoy it more and have more energy to better learn the information presented to them. The

more knowledge they gain in school, the broader base they will have as they enter the workforce

and begin patient care.

This study will improve the knowledge base of nursing leadership roles and nursing

program instructors. It will achieve this by allowing nursing leaders and instructors to better

understand the outcome of stress on their subordinates. In better understanding them, leaders can

design programs to decrease stress and promote overall health in those they teach. They can find

ways to teach about the outcomes of stress and brainstorm with their learners how to be more

effective when dealing with high-intensity situations. In turn, this will improve patient care by
HIGH STRESS LEVELS IN NURSING STUDENTS 18

allowing nurse leaders to more fully comprehend those under their charge and in promoting a

better overall situation for all involved with nursing.

Recommendations

One recommendation that can be made at the conclusion of this study is to further the

knowledge base of stress by conducting another study. A firm suggestion would be to expand on

this study by gathering more information through a qualitative study. This would allow

researchers to get a detailed description of stress in a first person point of view from nursing

students. With more information about how students are feeling, further generalizations will be

able to be made on the effects of stress. Another study would widen the perspective of stress and

could even be conducted on another population to verify the ability to generalize information.

Another recommendation for the data collected in this study would be to use the

information gathered to expand the outcomes on to another population. For example, if nursing

students decrease their performance level when they are highly stressed, one can expand this

information to include anyone who is highly stressed. It can be applied to ICU, NICU, ER, and

OR nurses, and even be expanded to other areas of work where the employees are under

increasing amounts of job stress. In expanding the data to other populations, others would

understand the effects of stress on their performance and better job satisfaction and performance

would be prevalent in not only nursing students, but in other areas of the medical field. The more

informed these populations become, the better chance they have at lowering stress and increasing

the safety of their routines.

The information gathered in this study can be used for developers of nursing programs

and for instructors in charge of dealing with nursing students. When these professionals gain a

better understanding of their students, they will be able to relate to them on a more personal level
HIGH STRESS LEVELS IN NURSING STUDENTS 19

and increase the efficiency of their programs and students. For example, if a program developer

notices that students tend to get stressed about one aspect of the program in particular, such as

simulations, then they can better prepare their students before this experience by finding ways to

decrease stress. This can be done in many ways such as more efficient instruction before or

better debriefing afterwards to help students note the positive things that took place even when

they were under stress. As designers and teachers gain a better idea of what the students are

facing, they will be able to enhance understanding and better prepare the students emotionally

and mentally for the nursing workforce.

References

Alzayyt, A., Al-Gamal, E. (2014). A review of the literature regarding stress among nursing

students during their clinical education. International Nursing Review, 61(3), 406-415.

http://dx.doi.org.byui.idm.oclc.org/10.1111/inr.12114

Dehdari, T., Rahimi, T., Aryaeian, N., & Gohari, M. R. (2014). Effect of nutrition education

intervention based on Pender's health promotion model in improving the frequency and

nutrient intake of breakfast consumption among female Iranian students. Public Health

Nutrition, 17(3), 657-666. https://www-cambridge-

org.byui.idm.oclc.org/core/journals/public-health-nutrition/article/effect-of-nutrition-

education-intervention-based-on-penders-health-promotion-model-in-improving-the-

frequency-and-nutrient-intake-of-breakfast-consumption-among-female-iranian-

students/C6FB6958CA236074B746831DBA2F16CF/core-reader

Ehlers, M. R. & Todd, R. M. (2017). Acute psychophysiological stress impairs human

associative learning. Neurobiology of Learning and Memory, 145, 84 – 93.

http://dx.doi.org.byui.idm.oclc.org/10.1016/j.nlm.2017.09.003

Grove, S. K., Gray, J. R., & Burns, N. (2015). Understanding nursing research: Building an

evidenced-based practice (6th ed.). St. Louis, MO: Elsevier.

Heydari, A., & Khorashadizadeh, F. (2014). Pender's health promotion model in medical

research. Journal of Pakistan Medical Association, 64(9), 1067-1074. Retrieved from

http://jpma.org.pk/full_article_text.php?article_id=6937

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