Stress Management among Nursing Students and those in Placement

Stress Management among Nursing Students and those in Placement

Abstract

This submission plans on reviewing the existing research and asses stress management in nursing students and those in placement. Also, it tries to get attitudes regarding stress management from a student’s perspective through a survey to ascertain areas for service improvement. This undertaking assumes that executing a service improvement plan by training and grooming nursing students and those in placement for potential stressors could help them to develop coping mechanisms in their future practice, including stress management function as one of their responsibilities. Besides, it will assist them in completing their studies successively.

The submission plans to employ a mixed-method approach for data collection. The first approach will be a critical review of peer-reviewed journals using a literature search in databases such as EMBASE and Google Scholar. Secondly, it plans on surveying nursing students and those who are at the placement level to collect their views on how they cope with stressors. The submission aims at collecting evidence from pieces of works of literature using a search strategy that shows all positive and negative evidence of the subject and will make a conclusion out of them. This will be done through a structured inclusion and exclusion criteria that is all-encompassing. The research findings will be communicated to several audiences, including the participants, nursing students in schools, and those in placement, institutions operating in the nursing profession, and the general public. The dissemination of information will employ several strategies, including formal presentations, reports, and publishing in online sites.

Keywords

Nursing students, stress management, clinical placements, nursing schools

Introduction

Students who are studying nursing deal with anxiety and high levels of stress throughout the learning process. In substance, these students experience more stress than any other group of students in the healthcare domain. Various factors contribute to the intensity of stress in nursing students due to the existence of competing priorities. Financial aid for college students is on the decline, and this factor implies that more nursing students have to get involved in income-generating activities to sustain themselves in college (Tagher & Robinson, 2016). Having to juggle clinical and academic courses, while also managing social, financial, and other life aspects raise the possibility of increased anxiety and stress levels. The rigorous nature of the nursing curriculum is also a cause of stress because failing the program or one of its courses translates to lost time and resources invested in student training. This retrogression delays the realization of other outcomes in life, such as career life, and in an unfortunate turn of events, students drop out of the nursing degree program (Tagher & Robinson, 2016).

Academic stress is a type of stress that nursing students experience encounter while they are in college. For instance, freshly inducted nursing students struggle with learning how to tackle nursing examinations. Assessment tests in the program are seldom straightforward, and students must engage in critical thinking as opposed to ‘downloading’ memorized content. When students are handling examinations, especially multiple-choice questions, they always find themselves narrowing the answer pool down to two potentially correct answers. Still, they choose the wrong one in the end, which implies that their learning techniques are not as effective as they should be.

Personal experience and research studies reveal that as students progress in their academic life, the material that requires to be learned increases in density and complexity. As such, students who are in the home run of their learning process need to hone their academic multiplexing capabilities if they stand any chance of passing evaluation tests in the last phase of nursing training. As such, students in the third and fourth years of their training cycle experience more stress compared to their junior counterparts in the first or second years (Semee, 2019). Numerous investigations about student retention and dropout rates in nursing schools in many places across the world indicate that the dropout rates among nursing students have increased significantly over the years. For instance, the United Kingdom recorded a massive nursing student dropout rate of about 20% in 2015. In 2011 (Bakker et al., 2018), Italy reported about 32.5% of academic failure rates among nursing students in Italian universities. Countries like the Netherlands reveal grimmer statistics about nursing training, where a net increase in the rate of dropouts was recorded between 2005 and 2013 (Bakker et al., 2018). How significant is stress as a contributing factor to the damning statistics about the dropout rate among nursing students in Europe and the UK?

According to an article published by Sarah Marsh for The Guardian, ‘mental health problems’ are to blame for ‘the number of university dropouts.’ Reliable information from HESA (Higher Education Statistics Agency) indicates that a staggering 1,180 students who were grappling with ‘mental health’ issues dropped out of university early between 2014 and 2015, representing a threefold increase from 380 between 2009 and 2010 (Marsh, 2017). Stress that is related to clinical practice is the other primary type of stress that nursing students encounter.

Nursing students, especially the ones on placement, tend to experience higher stress levels compared to other students in health-related sciences. The clinical or practical segment of the nursing course is more challenging relative to the theoretical part (Labrague, 2014). Numerous studies conducted in countries such as Bahrain and Iran have undoubtedly demonstrated that student nurses grapple with exceptional stress levels. For instance, an inquiry conducted in Bahrain uncovered that all nursing students on placement endured average to severe stress while discharging their duties (Bindu & Munira, 2015). Similar research carried out in Iran showed that more than 99 percent of student nurses recorded the level of perceived stress ranging from moderate to high (Pourafzal et al., 2013). Strain in a clinical setting can be attributed to a variety of causes. In nursing students, clinical stress can be occasioned by factors such as the fear of executing many tasks for the first time, incivility from patients, faculty, and colleagues, utilizing medical equipment, the disparity between theory and hands-on experience, maintaining professional conduct, as well as communicating with staff, patients and peers (Driscoll et al., 2009). Stress drains enormous amounts of energy from the body. Student nurses are predisposed to stressful situations such as cumbersome paperwork, overwhelming appointments, or caring for patients. Stressful events induce the body to engage a defense mechanism known as fight or flight. The student nurse is required to decide on whether to deal with the situation or walk away from it. The latter option is the easiest way of stress management. For instance, when a student feels overwhelmed by activities such as meetings or conversations, they can excuse themselves. Stress has detrimental effects on the outcome of student nurses because it can precipitate, among other things, disease, a decline in health, deterioration of academic results, withdrawal from the learning program, and it can negatively impact the quality of care received by patients (Shaban et al., 2012). Essentially, dropping out of nursing school might be set up by the additive effect of both academic stresses as well as clinical stress.  The competence of nurses is premised on the skills and knowledge they learn in school as well as the clinical setting. The clinical environment is the host of a large part of nursing training. Besides, this phase of nursing education plays an essential role when student nurses are deciding whether or not they will take up the nursing profession.

Background

As indicated in the introductory text, stress among nursing students has existed for as long as the program has been in existence. As such, the curricula for nursing education contains sufficient material to guide students on how to alleviate stress, whether academic stress or stress encountered while on placement. Even though solutions to the problem of stressors among nursing students are not limited, most scholarly sources recommend virtually identical techniques of pressure alleviation. The most popular methods for stress management include practicing self-care, meticulous time management, keep track of goals and objectives to realize achievements or shortcomings, cultivate robust social interactions, practicing meditation, engage in reflective practice, seeking professional advice from certified counselors (RegisteredNursing.org Staff Writers, 2018), among other techniques. These mechanisms are collectively referred to as stress coping mechanisms. Coping mechanisms can be defined as the combination of various elements such as thought, behavior, and emotion relative to the stressor that an individual is facing. Coping techniques must not be mistaken for defense mechanisms. Defense mechanisms are involuntary, unique coping mechanisms whereby the subjects are purposeful and conscious (RegisteredNursing.org Staff Writers, 2018).

Coping mechanisms can be emotion-focused or problem-focused, also known as instrumental. Problems-focused strategies of stress management are typically associated with ways of modifying a problem to step down the stress intensity (Carroll, 2016). Emotion-focused methods of stress mitigation, on the other hand, help the victims of stress manage any feelings of discomfort associated that result from a problem. Besides, coping mechanisms can be characterized as avoidant or active. Active coping methods typically involve the acknowledgment of a stressor and resolute attempts to undermine the stressor, while avoidant methods of stress management involve evading the stressor altogether (Carroll, 2016). Some coping mechanisms appear to accomplish de-stressing, but their efficiency is short-lived. The ineffective stress management methods are mostly counterproductive and exert negative impacts, hence the term ‘maladaptive coping.’ Adaptive coping mechanisms are those methods that ultimately yield a desirable outcome when applied (adamgerbman, 2017).

Emotion-focused coping comprises taking measures to counter the obstructive emotional responses that are associated with stressful situations such as anxiety, depression, fear, frustration, and embarrassment (Stress Management Techniques | Simply Psychology, 2019). Whenever a stressor is beyond the manipulation of an individual, this approach is more pragmatic. Drug therapy falls under this classification because it focuses on the stress-induced arousal and not the stress factor itself. Other emotion-focused stress management methods include distraction, whereby the individual engages in an activity that diverts their attention from the stressor. Emotional disclosure is another emotion-focused technique that involves the expression of intense feelings through writing about gloomy events that occasioned those negative feelings (Cheng, Tsui & Lam, 2015). It is imperative to state that emotional disclosure is an essential part of psychotherapy. Some nursing students turn to spiritual means such as meditation and prayer, which enhance mental calmness. Reflective practice and journaling are also examples of emotion-focused techniques alongside massive food intake, alcohol consumption, drug usage, suppression of negative emotions, and cognitive reappraisal (Stress Management Techniques | Simply Psychology, 2019). A rigorous analysis uncovered that emotion-based strategies of stress management mostly is less effective when compared to problem-focused approaches considering the adverse health effects. Therefore, most emotion-focused strategies are maladaptive. According to a study conducted by Sarafino and colleagues, individuals who resorted to destructive techniques such as alcoholism, drug usage, and more food consumption reported adverse health outcomes (Sarafino, 2012). Such strategies are unsustainable because they disregard the root cause of the etiology of the stress. Besides, other studies indicate that a person who applies avoidance as a way of dealing with stress is more likely to experience stress deterioration. Generally, the emotion-focused approach is discouraged unless the problem is beyond the control of an individual.

Problem-focused stress management strategy targets the stressor in pragmatic ways that neutralize the stress-causing factor, leading to mitigation stress. Examples of problem-focused techniques include time management, cultivating robust social interactions, and problem-solving (Stress Management Techniques | Simply Psychology, 2019). This approach is recommended because it tackles the cause of the stress, thereby dealing with the origin of the problem, presenting a reliable solution. Stress management techniques listed here have been proven to deal with high-impact stressors such as discrimination and low self-esteem, as documented by (Pascoe & Richman, 2009). Nonetheless, the problem-focused approach is not always applicable to all stressful situations. For instance, bereavement should be dealt with through the application of emotion-focused coping strategies. Problem-focused techniques have a limited application depending on personalities. For example, not everyone can manage or take control of a situation or resolve controllable situations. Optimistic people tend to harbor positive expectations; hence they are more inclined to apply problem-focused stress management strategies, while pessimistic individuals are more likely to prefer emotion-based strategies.

Since student nurses cannot avoid the causes of stress whenever they dispense clinical duties in health facilities or when studying theoretical material in college, they need to devise ways to cope with these causes. If they are unable to manage their stress, their performance, attitude, health, as well as role accomplishment as a nurse are adversely affected. When students are in nursing school, they are taught about best practice, ethical behavior, as well as the importance of selflessness to improve their efficiency and enable them to dispense the best service possible. As such, when the students are on placement, they are very eager to conduct themselves prudently, which makes it easy for them to get caught up in the simulation of professional life and neglect their personal needs. For the student nurses to remain healthy, they must not look at caring for their needs as something they should engage in occasionally or as a luxury. As a student, taking care of one’s needs is essential, even in a clinical setting. This is a prerequisite that students must practice routinely. The strategy has great potential to alleviate stress when fatigue is a causative factor. In a stress-management plan, the ability of an individual to cope with stress is the imperative aspect. Feasible coping strategies limit the frequency of injuries related to stress (Shriver & Scott-Stiles, 2000). Cognitive and behavioral efforts are crucial in the regulation of external and internal pressure. Numerous strategies of coping with stress for nursing students on placement have been proposed. Every student nurse employs either approach considering the nature of the threat, beliefs, or temporary factors like shifting policy based on feedback type (Bargiel-Matusiewicz et al., 2005). Scientific studies have proven that nursing students employ various coping strategies such as; sharing their experiences with close friends, engaging in sporting activities, ignoring stressful situations, crying, feeling sad/miserable and using alcohol, which may improve their stress situation or exacerbate it (Reeve et al., 2013). Other studies have touted problem-solving as the strategy that most student nurses use while others cite emotion-focused coping methods.

Also, optimism, transference, and problem-solving are among the most applied strategies among nursing students. It is imperative to note that the coping methods preferred by different student nurses affect their general health, as well as the quality of care provided they provide. As such, the ability to single out pragmatic coping strategies for nursing students is critical when it comes to early interventions (Chumping et al., 2012). Coping ought to be considered in the context of handling a particular type of stress (Glazer & Gyuark, 2008). Glazer and Gyuark advocate for qualitative studies as a utility to better understand coping strategies. It is undeniable that coping with stress is a phenomenon that depends on context; however, research on the topic in clinical settings has been mostly quantitative. Quantitative research employs methods such as general questionnaires that do not provide a robust understanding of coping strategies that are preferred by nursing students on placement.

Stress is one of the primary factors that impede any positive outcome for nursing students. The various approaches to countering this counterproductive phenomenon are probably not as effective as they ought to be, which necessitates research undertakings to come up with a more efficient means of countering stress in nursing students. Numerous sources cited in this text indicate that nursing students begin dealing with stress as soon as they are inducted into nursing school. This fact led me to realize there are very few studies, if any, that emphasizes the importance of mitigating stress among nursing students from as early as the first year of learning. During the initial stages of nursing training, most students are fresh from high school, and they hardly wield any substantial information about going through nursing, primarily academic wise. New male students in nursing school are likely to experience a few surprises on realizing that female students dominate the course in which they enrolled.

Holley Gabrielle is a nursing student who documented her experience as a first-year nursing student by interviewing a number of her colleagues on how they ‘survived.’ One of the questions that Holley asks her colleagues during the interviews is, if you could give one piece of advice to future nursing students revolving around school, what would that be? Gregg, the only male student in Holley’s class, states that the biggest issue is time management and knowing that you cannot study the night before a test and expect good results. On the question of how much joining nursing school has changed his social life, Gregg says that in his previous degree program, he used to go out and have lots of fun even in the final year, an unsustainable behavior in the nursing first year. For this male respondent, learning how to ‘prioritize things’ is difficult than what most people think (“Surviving Your FIRST Semester of Nursing School,” 2016). Another female respondent, Abby, gives a piece of advice to prospective nursing students, ‘don’t let how hard nursing school is discouraging you because it is only worth it,’ (“Surviving Your FIRST Semester of Nursing School,” 2016). Holly interviews several classmates who provide a snippet into the popular opinion that nursing students have regarding their training program. Generally, all respondents cite busyness and program complexity as the reasons why getting through is not an easy task. This interview, which was documented on video footage that is available on YouTube, is essential to my research because it corroborates the assertion that nursing students start to deal with stress very early in their learning cycle. More importantly, these respondents were only halfway into the first semester of their first academic year when they took part in Holley’s survey, which means that it took the students only a few weeks to realize the enormous commitment and sacrifice that is required to earn a nursing degree.

This study aims to demonstrate how nursing students can have better outcomes through being protected from stressors from the onset of their training program. If nursing students experience fewer problems from the beginning of their learning period, they are more likely to register better academic results, which will, in turn, step down the intensity of academic stress. Academic stress plays a significant role in the build-up to clinical stress, which implies that less academic stress translates to less clinical stress. By protecting newly enrolled nursing students from the causes of stress, significant progress can be achieved on this issue and probably strip off this threat the identity of ‘major’ concern among nursing students. In realizing this goal, the causes of stress among new students must be identified, and feasible ways to help these individuals subdue or manage the stress factors must be devised.

For new nursing students, the main problems encountered, which cause academic stress, include inadequate information about the complexity of the program, inadequate knowledge on how to tackle nursing exam questions, financial difficulties, lack of exposure to deep studying techniques, among others. In efforts to improve student outcomes in nursing, it is necessary to ensure that newly recruited students have slim chances of encountering stressors that have the potential to impact their academics significantly negatively. When new students can concentrate on their studies, they stand better chances of excelling in their academics as well as future practice. Students who excel in class are more likely to be confident than students who registered inferior grades when heading on to the clinical setting, which is the practical part. As such, this research proposes that first-year nursing students should receive as much assistance as possible to get good grades from stakeholders such as senior students, faculty, and the government. In the proposal, senior nursing students who are at most four semesters away from completing their courses are the central pillar in the plan of protecting new nursing students from stressors. Learners who are in their third or final year of the nursing program have amassed a wealth of experience, and they can share essential information on how to get through the program smoothly.

Learners who are nearing the completion of their studies can help their juniors in the first year through various methods. First, they can help the newbies to process course questions and grasp critical material in the stem and understand question requirements. This undertaking can help curb some of the stress that is generated by course assessment tests, more so at the outset of the program. New students can also acquire deep learning skills to deter tendencies of studying by cramming and memorization. Deep learning is essential because a student maintains the knowledge acquired throughout their nursing school. This will, in turn, help them in nursing practice or passing board exams. Other stakeholders, such as faculty, can protect first-year nursing students from stress through encouraging learning methods such as group work and encouraging mentorship among students. The government can play a significant role by providing adequate student financing to discourage students from taking jobs to earn upkeep money. In substance, the battle to protect first-year nursing students from causes of stress ought to be fought from numerous fronts.

Improvement

This section discusses the role of the service improvement aspect and its transformation in reducing stress among nursing students in placement. It employs the Plan, Does, Study, and Act methodology (PDSA) in structuring and implementing the service improvement strategy (Pietrzak et al., 2015); appendix A shows the PDSA cycle.

The pressure to invest time and financial resources in a highly sought after degree program, attain lucrative grades and pass board exams are just the onset—then there is the lurking fearfulness of working with patients in a clinical setting after graduating from nursing school. Needless to point out, there are so many more extra-academic issues weighing on the mind of a regular nursing student. Since the complete elimination of stress from the lives of nursing students cannot be realized, there are ways to assist the process of pressure alleviation.

One of the best ways to learn strategies of stress alleviation is to consult the individuals who have made it through nursing school, or those who have spent more time in nursing training, that is, the nursing students who are in their final years. This study gathered information from nursing school senior students to help the younger ones navigate the intense course of nursing training without bowing to the pressure.

Plan

The plan involves implementing stress management tutoring to heighten an individual’s ability to manage stress levels, identify stress symptoms, and coping with stress. This undertaking could assist them when they transition from students to registered nurses (Allen et al., 2017).

The National Health Service needs to offer a service to their workforce to support their mental health more, especially listening to their grievances and create an open door policy where the service is easily accessible. The NHS report (2017) suggests this action will enable staff members to cope with various stressors and offer better service to patients.

In this case, students as from year one should take part in this exercise, lectures and seminars will be employed on various strategies to manage stress. These sessions will entail

1. The effects of stress
2. How to deal with stress that happens during placement
3. Speakers from the nursing professions such as registered nurses and how they deal with stress
4. Coping strategies.

Do

The first step for managing nursing school stress is training the students on practicing after-class-recaps. Most senior nursing school students, as well as graduates, agree that ‘marathon’ studying is not a wholesome way of internalizing material learned in class or for purposes of revision. The experienced lot can ascertain that short study periods beat lengthy and intensive periods of cramming. Students should ensure that they review their notes after lecture sessions on a daily basis. Students are advised to take a glance at their notes when they are on the bus or stuck in traffic, waiting in a queue at the convenience store, on the bench outside a lecture venue instead of engaging in activities that have less or no contribution to their aspirations of joining the nursing profession. Secondly, new nursing students should be trained on how to formulate reliable study groups to extend their academic knowledge scope. Students can organize weekly study group meetings, compare their notes, demonstrate essential skills, and rehearse board-style questions — this approach to studying and enhances the memorability of information learned. Apart from being an efficient way of reviewing course material, study groups are a fun way of learning because they involve light moments such as laughter. Thirdly, students should be motivated to engage in physical exercise before partaking of study activities, after studying or incorporate exercise into their studying sessions. Exercise undoubtedly relieves stress and potentially bolsters the information retention capacity of a student when he or she is reading. Like study groups, incorporating exercise into studying sessions is an atypical and exciting learning method, and new nursing students should capitalize on these perks early in their training. Recommended exercises include jogging, walking, and rope jumping. The fourth entry into the list of how nursing school junior students can minimize stress is starting study sessions with short meditations. Devoting a little time to the so-called little things can be beneficial to a nursing student. Simple meditation should is more suitable when one is studying alone because it mitigates stress and enhances concentration. The practice of journaling is also an excellent way of reducing stress.

Nursing students are advised to journal their experiences, thoughts, and concerns in an event where they, for instance, find themselves lying awake pondering on activities slated for the day ahead. Documentation of thoughts in a journal is a way of dismissing them. Students can also eliminate stress by identifying what improves their mood. Even when students are faring well in nursing school, negative interactions in college have enormous potential to ruin their mood. Furthermore, since the field of nursing is people-centered, a student should understand the factors that contribute positively to his or her attitude, which is applicable even after graduation. Students should strive to incorporate mood boosters in their daily routine to increase optimism. Finally, students in nursing schools should be taught on the benefits of adopting healthy eating habits and nurture their bodies. Catering to all aspects of wellness is probably the most important thing for a nursing student.

Although stress is majorly retrogressive, it can be a utility if it prompts nursing students who are still in their early stages of training to evaluate how they might improve their situations. Nursing school senior students have recommended the stress management methods listed above, and they are helpful to junior students as well as prospective students. Practical stress management approaches are crucial for the nursing career in general.

Study

There is a direct necessity for receiving immediate feedback on the employed teaching techniques to achieve learning objectives. In this regard, evaluation of the effectiveness of the training mechanisms will take place through administering a questionnaire to all nursing students in St Andrews Healthcare Hospital and Berrywood Hospital who have already begun their clinical placement on their approaches to stress management.

Besides, another questionnaire will be necessary to record their approaches after completing clinical placement to determine if they can manage stress. A comparison between the two sets of information will be undertaken.  According to NICE guidelines, a questionnaire is an effective strategy of examining the knowledge and attitudes of a group of healthcare professionals that are geographically dispersed (NICE, 2014).

Act

The findings of the study stage will dictate the activities to be employed at this stage. Therefore, after examining the outcomes from the questionnaire, more recommendations on the PDSA cycle will be made conditional to the outcomes, whether negative or positive, from the previous cycle.

If the students who took part in the training exercise can cope with stress and feel more supported, then the stress management training program will continue. On the other hand, if the results turn to be negative, then further changes would be incorporated in the plan, especially new strategies that would result in positive outcomes.

According to Hallinan et al. (2016), constant reviewing of the implemented changes to acclimatize to the modifications and also to the feedback and involvement for the efficient functioning of the strategies employed.

Methods

This submission plans to use peer-reviewed journals (quantitative, qualitative, and mixed methods) as well as questionnaires for data collection among novice and experienced nursing students.

Qualitative Research Approach

A qualitative research technique for this research will be employed since qualitative methods are useful in finding out the meaning that individuals give to events that they experience (Schratz & Michael, 2019).  The phenomenological techniques will be employed to understand how the participants perceive the topic being studied. The phenomenological model is appropriate for a small sample, such as 15 participants to ascertain the fundamentals of their experiences with the phenomenon (Creswell & John, 2011). Besides, this model will generate outlines and create connections of meaning that will build new knowledge (Clark et al., 2008). The grounded theory will be used to analyze the data collected and learn stress management among novice and experienced nursing students. The qualitative research techniques to be used in this study are further discussed below, which include a questionnaire and systematic collection of data from peer-reviewed works of literature.

Literature search

This study will employ a qualitative systematic review method through online sources such as EMBASE, Google scholar, as well as the school’s online library.  Christmals et al. (2017) describe a literature search as a systematic procedure of searching pieces of evidence associated with the subject under study. Therefore, this process will be organized as recommended by McGowan & Jessie et al., (2016) to enable an active listing and selection of related studies to the subject under research.

It is vital to conduct a search strategy in efforts to begin a systematic review of a given subject. According to the Nursing and Midwifery Council (2015), nurses should practice with the aid of the best evidence available; the role of the nurse needs an individual to progress and develop in a dynamic setting to offer the best services.

Search Strategy

The search strategy will use the university’s library search to identify works of literature from databases such as EMBASE and CINAHL to select the most recent primary journals. These databases will be selected as they form part sources of fundamental research; they will be ranked based on their originality and efficiency.

Several subject titles related to the subject heading will be identified and used in the search process. For instance, the keywords will include; stress management, nursing students, nursing students in placement. It will also be essential to employ Boolean operators such as (and, in) to consolidate the keywords to enable the selection of relevant literature (Coughlan et al., 2013).  Peer journals will be identified in the search process. According to Aveyard & Helen (2010), the most recent evidence can be found in journal articles.

Besides, the nursing and midwifery council requires that all nurses should have competence in appreciating the worth of evidence in practice, can understand and evaluate research, relate to appropriate models and results to their work, and ascertain areas that need further investigation (NMC, 2015).

Inclusion and exclusion criteria

The inclusion gauges for this submission include peer-reviewed articles in all forms, i.e., qualitative, quantitative, and mixed methods related to Stress Management among Nursing Students and those in Placement. The second criterion will be sourcing for all articles between the years 2010 to 2020, published in English. Newer sources will ensure that the evidence sourced is relevant and valid with the current times. On the other hand, the exclusion criteria will include abstracts and other pieces of literature that are not connected with the topic under research. This strategy will ensure that the study has logical precision, and also only vital evidence is used. This inclusion and exclusion criteria will be employed, as identified by Burns (2005), to reduce bias.

The following tables show the inclusive and exclusive criteria to be employed in this submission.

Main themes

The primary themes in this chapter will be stress in nursing students and stress management in novice and experienced nursing students.

In the results, section terms associated with occupational and school settings, including job stress, workloads, among others, will be used. These terminologies are put in the perspective of students’ clinical practice, discerning that nursing students maintain a working relationship with the center.

Limitations of the search

It might not be possible to review all identified, valid literature connected to the topic under study, and this might limit the validity of the research. Besides, because UK research on this topic is limited, therefore various journal articles from other countries will be used, primarily Australian and Spanish, since their healthcare is transferable to the UK’s (Webb and Roe, 2007).

Critiquing tool

Holland and Rees’ (2010) structured critical model for articles will be used in the study. Besides, systematic analysis of meta-analysis studies will also be utilized to conclude the subject matter. According to Holland and Rees, the structured critical framework enables the researcher to identify the strength and weaknesses of a research article. Besides, this model suggests that the approach to appraising a research article for quality is to evaluate its research question as well as its aims and see whether they are stated clearly and also whether their research design is appropriate (Holland & Rees, 2010).

Research Design

This section describes the procedures of collecting data to be used in this study. Data relating to how nursing students manage stress before and after undergoing the training will be collected for comparison.

Participants Demographics

The study will collect data from nursing students in all years (both novice and experienced) and those the placement duration at St Andrews Healthcare Hospital and Berrywood Hospital. This group will be appropriate because they are ‘knowledgeable informants’ (Creswell & John, 2011). Besides, since the study’s objective is to increase understanding of the stress management among nursing students, it will be crucial to include participants who are at least a semester old in the nursing college. The perceptions that these students have in their first semester at college offer them a basis to compare their experiences in stress management to other students who have fewer responsibilities that could increase anxiety, which is a potential stressor. The researcher will send letters to the facilities to ask permission to undertake the research. Upon approval, they will visit each of the facilities and inform every stakeholder who will be affected by the process of what they will expect.

The lead nurse at each of the hospital facility will be enlisted to assist in sample selection. These administrators are well conversant with the nursing students seeking placement at the institution or are already in deployment. The nursing students will be recruited voluntarily

To increase the number of participants, the researcher will also ask the selected participants to recruit other potential participants as well. Upon invitation, the participants who will agree to participate will be contacted directly by the researcher. All participants agreeing to participate in the questionnaire will be briefed on details regarding the research’s objectives, the needs of the researcher, and the confidentiality clause. For instance, the recruits will be informed that the information they would present will only be used for research purposes. They will again be reminded of the data collection procedure, the purpose of the research, and the anticipated advantages, their rights on withdrawing from the process at any moment. All these procedures are recommended by Creswell & John (2011) since they create a good rapport with the participants and show understanding of the subject under study.

The recruited will be given a questionnaire protocol three days before answering the questionnaire; this approach will provide them with time to reflect on the answers they will provide to the questions. Besides, providing the survey protocol ahead of time allows the participants to view the questionnaire and seek any clarification in parts where they seem ambiguous to them.  The survey will begin with ‘please describe your experience as a nursing student or as a nursing student in placement’; this structure will offer the participant the flexibility they need to give their experiences with stress and how they manage it. Most of the questions will be open-ended to allow the respondents to answer freely and openly (Krosnick, Jon, 2018).

The questionnaire will be administered in several ways; for instance, for the first lot of recruits identified by the lead nurse, the researchers will deliver the questionnaire in paper form. This approach will increase engagement between the researchers and participants, including asking questions and receiving immediate feedback about the questionnaire (Choi et al., 2005). For individuals who will be fronted by the participants, the questionnaires will be administered by mail.

A questionnaire will be ideal because the participants will state their perceptions and feelings privately without being perturbed about the reaction from the researcher, even though some participants might still be inclined to provide socially acceptable responses, Choi et al., (2005). Nevertheless, the participants will be encouraged to answer as honestly as possible to increase the drawing of valid conclusions from the study.

The respondent’s answers will be examined in depth to improve the credibility of the research findings. The answers will be carefully read, and the conclusions tabled for logical analysis and interpretation of the information.

Pilot study

A pilot study will be done as an approach to developing relevant lines of questions for the research. Besides, the pilot study would help in the procedure of refining data collection procedures (Gentles & Stephen, 2015). According to Baskarada & Sasa (2014), one of the significant attributes of undertaking surveys and other data collection procedures is to ensure efficiency. Money time and efforts must be utilized in the most efficient way to attain success in data collection, especially those that entail a considerable sample. Therefore, conducting a pilot study promotes efficiency by offering an opportunity to identify possible undermining factors and dealing away with them. Specifically, a pilot survey tests the correctness of the instructions available in the document and whether the participants can follow the directions as specified. This process also offers improved information on if the employed type of survey is active in meeting the study’s objectives.

The objective of the study was to determine stress management levels among nursing students in school and placement. The pilot study will recruit five participants for this study through convenience sampling. Convenience sampling is crucial since it is easy to use, and it allows the researcher to obtain necessary information without undergoing the difficulties of conducting a randomized sample. This technique is also essential in documenting the relationship between various phenomena (Sedgwick & Philip, 2013).

The participants to be recruited in this process will be both novice and experienced nursing students. Other characteristics also include; already in placement or not yet placed. This procedure makes sure that the results obtained for the process apply to the entire population that will participate in the actual study.

The process will be divided into two processes participatory and undeclared studies.

The process will opt for a participatory pilot survey first and then an undeclared pilot study later (Bjorner et al., 2010). A participatory study involves informing the participants that they are in a pre-test phase; on the other hand, an undeclared study consists of undertaking a full-scale survey as if it was a real one. Two of the participants will take a participatory survey while the other three will take the undeclared pilot study process. In the participatory process, the participants will be asked what they perceive of the questionnaire; then, the researcher will document their comments, suggestions. For instance, One of the major questions will be: Do you think the questions are clear to you? They might also be asked to identify what among the questions are hard to answer. After undertaking a participatory process, then the remaining three participants will conduct the undeclared survey. The two operations will use paper questionnaires rather than online questionnaires because it is simple to administer and control the activities involved for actual results.

After obtaining the results of the two surveys, the researcher will then solve the logistical, technical, and other concerns that will be identified after the process. For instance, the questionnaire format could be revised, or the form of the interview can be transformed into an appropriate one. If the errors were minor, then the researcher could execute the extensive scale survey. However, if the errors will be significant, then the researcher will conduct another pilot study to determine whether the errors have been effectively solved.

Notably, if the participants would be more difficult to recruit because of the several formal request procedures involved, then the pilot studies would not be conducted at all. Instead, some of the questions might be improved during the actual period of administering the questionnaires. For instance, the researcher would ask the participants to seek clarification in whichever questions they might feel are not clear to them

Review of the survey protocol

Revision of the survey protocol will affect all the items of the questionnaire, such as the purpose of the study, the people who will have access to the information provided by the participants, the respondents’ rights and risks, and the period taken to discard the data. Generally, whatever the respondents will perceive as vague and inconsistent with them will be subject to revision.

Data analysis

After the completion of the questionnaires, all questionnaires that were presented physically to the participants will be collected and analyzed in paper form. Online questionnaires will also be received and put ready for analysis. Answers submitted through online spreadsheets will be entered in a summary sheet, and scores will be computed and submitted electronically.

For the questionnaires in paper form, the following steps will follow in the data analysis process.

Preparation of a simple grid to collect and organize data delivered in the questionnaires.

A simple coding system will be developed for questions and the model that answers take. This action will simplify the data analysis process greatly (Stuckey & Heather, 2014). Coding for closed questions will be easy since the answers will be ranked numerically, and the code will use the same scale. However, evaluating open-ended questions will require organizing them into a set of general classes, which can then be coded. In this regard, data will be entered on a grid; the percentage of the participants answering each category of every question will be calculated.

Preparation of a grid

Since there will be quite a large number of questionnaires, it will be easier to interpret the results of the survey when they are transferred into a single grid (Check table 1).

Table one shows a typical grid that will be used in interpreting results from the paper questionnaires.

Coding data

All closed questions will contain answers on a scale of 1 to 5, and these are the numbers that will be entered directly into the grid. For the open-ended questions, they will need to be translated into a numerical scale, after which they can be entered into the grid as well. For instance, the first question will ask the students to note whether they are male or female. Value 1 will be ascribed to every male response and 0 for every female response. Ascribing values for every response helps in computing summary statistics and essential when trying to establish the relationship between variables (St. Pierre et al., 2014). Besides, making an entry for all questions data analysis will be easy, and the results will be accurate. All the answers will be read and will be grouped into meaningful categories. There will be a category known as ‘other’ for responses that the author cannot categorize implicitly.

Data evaluation

The proportion of respondents in every category will be calculated; the group for didn’t know or didn’t answer will be identified because it offers crucial information on the strength of feeling over a specific question. The results will then be used to compute mean scores for group questions. The mean score will then be used as the overall stress levels and management levels of students. This might not be a legitimate approach since it assumes that the author will be working on an evenly spaced scale; for instance, ‘very poor’ means twice as bad as ‘poor’ (Stuckey & Heather, 2015).

Scores will be added for related questions to derive the index of stress management levels among nursing students. Caution will be taken in designing the questionnaires; otherwise this approach will be inappropriate. In this regard, every question will be considered as relevant and of equal importance.

Establishing Trustworthiness

Any qualitative research is often criticized for its reliability; therefore, such studies should always be open for criticism and also further research. Generally, reliability refers to the level in which the research findings of a study can be replicated in other settings (Noble et al., 2015). According to Sarantakos & Sotirios (2012), two significant questions should be addressed in social research, and the first one is; is data valid? And the second, Are the research methods reliable? These are the fundamental questions that determine whether research is credible and reliable.

In efforts to increase the trustworthiness of this study, the researcher will employ approaches as recommended by Williams et al. (2009). In this regard, the researcher will reduce threats to credibility by triangulating data. Triangulation, in this case, means using a cross-verification of two or more sources of data in a study (Noble et al., 2015). The main objective of this drive is to facilitate data validation. Therefore this study will use mixed research methods such as surveys and systematic reviews of peer-reviewed articles to collect data on the same topic.

Another aspect that increases the study’s trustworthiness is dependability (also known as reliability). Dependability refers to the consistency of the research procedures and findings. Therefore, to improve the study’s credibility, the researcher will provide an audit trail by outlining how data will be collected, how groupings will be done, and the procedure to be followed to arrive at conclusions (Williams et al., 2009). The research procedures will be properly documented to enable an outsider to develop an audit and critique the processes involved.

There will be the usage of excellent, rich, and thick descriptions of findings to enable other researchers to make quick decisions regarding the transferability of this research. This aspect is referred to as external validity, whereby the research findings on the sample population can be applied to a population at large (Roberts et al., 2006). The researcher will try to reduce control for bias during the study to ensure objectivity. In this regard, constant comparison of data will be undertaken both through surveys and secondary sources, searching for works of literature for samples of the topic under discussion to get several viewpoints on the issue. Lastly, the researcher will be open to both negative and positive instances of the subject under discussion to reduce bias in the study. There will be continuous checking and rechecking of data collected, and this will ensure the conformability aspect of an investigation, as highlighted by Sarantakos & Sotirios, (2012).

Data triangulation is of critical significance in ensuring the trustworthiness of a qualitative study. As the research unfolds and specific pieces of information become identified, appropriate steps will be taken to validate every piece of information against at least one other source — for instance, survey results (first source) and systematic review findings (second source). Employing a second source will guarantee a more precise, accurate, and wide-ranging and objective results (Noble et al., 2015). Therefore, for this research, a survey and review of secondary sources will be compared to ensure trustworthiness.

Ethics

Voluntary Participation and Consent

All participants should be willing to participate in a study voluntarily. Therefore, any need for persuasion or deception in efforts to achieve individual trust on the side of the researcher will not be acceptable. Recruitment for the participant will begin by asking the lead nurses to assist in enlisting potential participants for the study. Every invitation made will be accompanied by a consent form that will act as an agreement of trust between the researcher and the participants.

Sampling

This is the first step in the research design of a study. The researcher will explain why they have selected a specific group to participate in the study. Besides, they will also tell why they will leave out a specific group. In this case, all participants would be presumed to be adults (18 years and above), and so there will be no need for parental permission. However, in case of a participant who has special needs, permission from the guardian will be necessary along with consent from them.

Risk of Harm

The researcher will do everything in their power to protect the participants. Therefore, they will focus on the risk to benefit ratio before undertaking the study. If the conceived risks outweigh the benefits, then the study will be abandoned or redesigned. However, an evaluation of the risks will happen right from the start of the study until the end. Some of the possible risks of harm could include psychological, legal, and economical, among others.

Respect for anonymity and confidentiality

The aspect of privacy is one of the crucial elements of research. If a researcher cannot ensure confidentiality, then they can at least guarantee anonymity.

Confidentiality refers to the management of private information by the researcher to protect the participant’s identity.  Besides, the participants have the freedom of withholding or providing as much information they wish to decide on (Kaiser & Karen, 2009). Therefore the researcher is supposed to maintain the confidentiality that exceeds loyalty. However, Wiles, Rose, et al. (2008) identifies an ethical dilemma where confidentiality could be broken to satisfy the moral obligation of protecting society. In this regard, the utilitarian theory focuses on the best interest of all stakeholders involved and the greater good of the society. The approach emphasizes that confidentiality could be broken when the happiness of society is of greater importance.

Conversely, the deontological model argues that the moral obligation of ensuring confidentiality matters more than the happiness of society. However, when a researcher acts in line with the deontological arguments, then they have not protected society’s interests.

Another concern is when a researcher reports confidential information to courts, causing a moral dilemma. In this case, it is safe to assume that moral obligation and personal ethos supersede the legal requirement of the researcher.

A researcher faces several challenges when it comes to maintaining confidentiality while researching because conduct is personal. In cases where the sample is small, and reports identify direct quotations of the participants, Kaiser & Karen, (2009) argue that it is wise for the researcher to use pseudonyms and distort categorizing of details participants in case of interviews during transcription of the tapes.

However, Kaiser & Karen (2009) perceive that in cases where information is complex or extremely confidential, the researcher should seek a certificate from relevant authorities to ensure the privacy of the respondents, especially in researches where the researchers are compelled to disclose the information by legal jurisdiction.

One of the Economic and Social Research Council’s ethics principles during research is that the confidentiality of information provided by the respondents should be protected whatsoever (Fielding et al., 2008). Nevertheless, the principle highlights that sometimes confidentiality can be restricted. For instance, in situations where the participant is exposed to a risk of harm, then information can be disclosed to protect them.

Therefore in this study, the researcher will always bear in mind all social and psychological implications that accrue to a breach of confidentiality might have on participants. The researcher will have to inform the participants of their rights and employ all possible coding mechanisms that could be appropriate to ensure confidentiality is maintained.

Skills of the researcher

According to Noble et al. (2015), there are three most fundamental aspects of research, which include the proficiency of the researcher, meticulous research design, and sensible findings. Therefore, the researcher will ensure that they possess the necessary skills and knowledge for a particular study. They will also make sure they are aware of the limits of individual competence in the study process. Any gap in knowledge will be clearly stated. In case the researcher meets an area where they don’t understand, they will work under qualified personnel and later to be reviewed by the ethics committee.

In the systematic review, the following ethical considerations will be implemented.

Plagiarism- plagiarism is regarded as stealing and is unethical; it includes knowingly using a person’s content without giving them credit. Therefore, the researcher will ensure that every material and ideas used in this study are cited and referenced accordingly.

Fabrication- There will be no duplicate submissions nor even fabrication of content. For instance, the author will report results as they will be. This action aims at showing a representation of the original findings. The author will also make sure that past research is not suppressed to open a concept that they deem fit. Both negative and positive references will be used to ensure no bias.

Unbiased pieces of literature- the author will ensure that they remain unbiased to gender, previous researches, among other factors. Any conflict of interest while undertaking the study will be addressed.

Despite all these ethical concerns, what is superior is a careful selection of the method of data collection that ensures validity and dependability. These are the significant necessities that are needed in any type of research. The choice is contingent on the objective of the study. Besides, the research will involve humans, and all the above ethical considerations will be taken into account.

Dissemination

Dingli & Sandra (2013) describe the dissemination of research findings as a planned procedure of conveying the research findings to a target audience and even where appropriate communicating and engaging in a broader policy to facilitate research approval and implementation. In simple terms, this concept involves meticulously planning, thoughtful deliberation of the target audience, and interacting with the audiences.

Before sharing the research, the author will ensure that the work has undergone review by experts to meet the standards and outlooks in the professional field. This action will seek to assess the work and ensure that the conclusions presented follow a logical deduction from the data presented. This process also identifies the threats to validity and determines whether the analysis of literature is realistic and systematic.

Key audiences

Successfully disseminating research findings needs identifying who are the right audiences, where the audience is located, and how to reach them (Titler & Marita, 2007). In considering the right audience, it is crucial to think about who might be interested in the research work. Also, the audience might include those who might not express enthusiastic interest but may still benefit from the information present in the research (Dingli & Sandra, 2013).

Therefore, the research findings of this study are likely to benefit a lot of people, and they include.’

The respondents and nursing students in schools and clinical practice – it will be essential to share the research findings to the participants and also other people who share similar characteristics or interests in the subject under research, including nursing teachers. The information will assist them in noting the changes they have made after undergoing an improvement plan. They will also identify areas that need improvement to ensure they manage stress effectively.

Scholars and experts- other researchers studying similar topics would be another perfect audience for the research findings. By disseminating information to these audiences, it will assist them in developing their research works and also offering criticism that is healthy to research work.

Organizations and policymakers- institutions that work in the nursing field, including hospitals where the nursing students are placed, nursing schools, and all engaged members of society, could represent a potential audience for the research findings.

The general public- whereas there are several informal audiences for research findings, the general public is also a crucial audience for research findings. According to Dingli & Sandra (2013), research is an item under social work, and it involves working in capacities in the social world that the public might not wish to see. Part of the researcher’s work is to shine a light on aspects that raise the consciousness of society as a whole.

All the stakeholders mentioned above represent an audience that has an interest in the research work. However, it is essential to look outside the discipline and share it with everyone so that they can also use it in their fields where necessary (Titler & Marita, 2007).

Methods of Dissemination

The method of disseminating the research findings will depend on the audience. Therefore, the process will vary the means of spreading the information with keen consideration on the effectiveness of the method. According to Huberman & Michael (2012), the dissemination strategy should be in line with the norms and attitudes of the audience. For instance, in a scholarly journal, the author outlines submission guidelines that define the conditions for disseminating their work via a specified journal. Therefore, this research will employ various strategies to reach particular audiences. They include.

Submission in an online journal database- this method will primarily target the scholars, experts, and all other audiences that might need the information for specific purposes. Providing the results both in print and electronically would meet the various demands of these audiences. It will also be crucial to subscribe to the websites to stay current on the literature on the subject topic. The research findings will be rephrased, such as ‘Journal of Stress Management among Nursing Students and those in Placement’ this way, the work will be shared widely among other scholars who might be interested in studying the topic.

Formal presentations- another method to disseminate research findings will be formal presentations. This is a strategy aimed at creating an engaging, understandable interaction with the audience. In this regard, this approach seeks to inform people about information that is relevant to their lives and practice, which is why it is rigorous and follows a strict format. Therefore, the researcher will ensure the research findings are relevant to the practice, especially to the lives of the audience. And so, a formal presentation will be a perfect strategy to disseminate research findings to participants, nursing students, and those who are in placement. Since these audiences have an interest in the results, their most significant concern will be how they apply the information in their daily life and practice. The audience is also knowledgeable about the subject and so presenting conclusions with modesty needed by a social scientist will be essential.

Disseminating to the public

The author will disseminate information to the public using several mediums; however, the major ones include popular media outlets to reach a wider audience.

The researcher will be cautious about overstating the extent of certainty they have in the conclusions. This approach aims at avoiding misleading the public audience on the result. Also, the author will review the journalistic standards of the media outlet by evaluating their previous work to determine the extent of control over the final product.  Secondly, the author will inform the general public about the research findings using reports. However, the reports to be consumed by the public differ widely as compared with reports for scholarly consumption. Therefore, the author will tailor the information to suit the needs of the society, for instance, the public will want to hear about how the research findings will affect them rather than how it will affect other groups. Lastly, newspaper editorials will also be an excellent platform to share information with the general public.