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A descriptive study of Bruneian student nurses’ perceptions of stress
Nurse Education Today (2007) 27, 808–818
Nurse Education Today intl.elsevierhealth.com/journals/nedt
A descriptive study of Bruneian student nurses’ perceptions of stress Philip Burnard a,*, Hajah Thaibah Binti PDPD DP Haji Abd Rahim b, Derek Hayes b, Deborah Edwards a a b
School of Nursing and Midwifery Studies, Cardiff University, Wales, UK Penigiran Anak Puteri Rashidah Sa’adatul Bolkiah College of Nursing, Brunei Darussalam
Accepted 22 November 2006
KEYWORDS
Summary While much has been written about stress in nursing in the ‘West’, less research has been done on this issue in many ‘Eastern’ countries. This paper offers the findings of the first study of stress in student nurses in Brunei. The paper describes a study of 20 Brunei nursing students and their views about stress in nursing. A modified grounded theory approach was used in collecting and analysing data (and the ‘modifications’ are described). Findings were organised around the themes: stressors, moderators and outcomes [Carson, J., and Kuipers, E., 1998. Stress management interventions. In: Hardy, S., Carson, J., Thomas, B. (Eds.), Occupational Stress: Personal and Professional Approaches. Stanley Thornes, Cheltenham. pp. 157–174.]. Students often found their status as students caused them stress in the clinical setting: with other nurses, with doctors and even with patients. Academic related stressors included having to complete assignments and having to study in English. Various ways of moderating stress were reported including talking to ‘trusted friends’, engaging in sports or simply being quiet. Positive and negative outcomes of stress were identified: stress could lead to mental illness but, also, it could be motivating. This report concludes with a Weberian ‘ideal type’: a composite word-picture of the findings. c 2006 Elsevier Ltd. All rights reserved.
Stress; Student nurses; Brunei; Nurse education
Literature review Stress, coping are the guiding concepts of this study, reflecting the view of Lazarus and Folkman * Corresponding author. Tel./fax: +44 2920 743738. E-mail address: [email protected] (P. Burnard).
(1984). Although many definitions of stress and coping exist the majority of research conducted with nursing literature utilise this approach. Lazarus and Folkman (1984) define stress as ‘‘a particular relationship between the person and the environment that is appraised by the person as
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.11.002
A descriptive study of Bruneian student nurses’ perceptions of stress taxing or exceeding his or her own resources and endangering his or her well being.’’ It is recognised that nursing is a stressful occupation (Jones and Johnston, 2000; Bennett et al., 2001), and that the problem of stress first becomes evident during nursing training (Rhead, 1995). Stress has been identified as an important psychosocial factor in the educational process because it may influence academic performance and wellbeing. Studies conducted within the UK among Project 2000 students, in USA, Australia and Ireland have identified a wide variety of stressors associated with their course of study and clinical experiences. Clinical stressors Handling emergencies in the clinical area (Clarke and Ruffin, 1992). Initial ward experiences (Mahat, 1998). Clinical experience for those students in the care of children courses (Oermann and Standfest, 1997). Death of a patient (Clarke and Ruffin, 1992; Rhead, 1995; Timmins and Kaliszer, 2002). Lack of practical skills, negative attitudes of ward staff and misunderstanding of supernumerary status (Hamill, 1995). Relationships with clinical staff (Hamill, 1995; Thyer and Bazeley, 1993; Lo, 2002; Timmins and Kaliszer, 2002; Evans and Kelly, 2004). Academic stressors Pressure of grades or fear of failing (Beck et al., 1997; Sheu et al., 2002; Jones and Johnston, 2000). Intense amount of work (Beck and Srivastava, 1991; Clarke and Ruffin, 1992). Evans and Kelly (2004). Study associated with the programme (Clarke and Ruffin, 1992; Thyer and Bazeley, 1993; Jones and Johnston, 2000; Evans and Kelly, 2004). Lack of free time (Beck and Srivastava, 1991; Jones and Johnston, 2000). Finding academic work difficult including examinations (Beck and Srivastava, 1991; Clarke and Ruffin, 1992; Beck et al., 1997; Evans and Kelly, 2004). Long hours of study long hours of study (Beck and Srivastava, 1991; Jones and Johnston, 2000). Relationships with academic staff (Hamill, 1995; Thyer and Bazeley, 1993; Lo, 2002; Timmins and Kaliszer, 2002; Evans and Kelly, 2004).
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Finances (Beck and Srivastava, 1991; Clarke and Ruffin, 1992; Thyer and Bazeley, 1993; Brown and Edelmann, 2000; Timmins and Kaliszer, 2002). Female students experienced higher levels of stress than male students (Tully, 2004). Not being treated as an adult learner, confusing assignment guidelines and the amount of selfdirected learning (Hamill, 1995). First year of academic study (Wang, 1991). Higher stress levels for those enrolled in a part time evening programme. (O’Connor and Bevil, 1996) Showed a relationship between stress and academic performance (Maville and Huerta, 1997). Various studies have been conducted in a variety of other countries (South Africa: Basson and Van der Merwe, 1994; Nepal: Mahat, 1996; Jordan: Abu Tariah and Al-Sharaya, 1997; Israel: Admi, 1997; South Africa: Kirkland, 1998; South Africa: Gwele and Llys, 1998; India: Saxena, 2001; Taiwan: Sheu et al., 2002) and have reported similar findings. Lindop (1989) suggests that many of the stress reactions in nursing students go unnoticed with the consequence that stress levels increase until a person responds by leaving the profession. Stress does not always have negative effects only but also positive ones. The effect of stress on health depends on the adequacy of coping behaviours. Coping behaviour is described as the ‘‘continuous effort to overcome the unbalanced condition caused by internal and external demands.’’ (Lazarus and Folkman, 1984, page 141) When effective coping strategies are used, the emotions can be adjusted and the stressful situation can be resolved. Coping efforts may be directed toward changing the environment (problemfocused) or inward toward changing the meaning of the event (emotion-focused or palliative). Much is still unexplored about the coping processes of nursing students and only eight studies have investigated this (Jones and Johnston, 1997; Kirkland, 1998; Brown and Edelmann, 2000; Mahat, 1998; Lo, 2002; Sheu et al., 2002; Tully, 2004; Evans and Kelly, 2004). As this literature review shows much has been written about stress in nursing in the ‘West’, and less research has been done on this issue in many ‘Eastern’ countries. All of the research with a few exceptions where open ended questions have been used has been of a quantitative nature. This review has also identified that further work is also needed
810 to explore coping within the student nursing population. The aim of this study was therefore to identify aspects of stress and coping as described by nursing students in Brunei Darussalam using a qualitative approach. Brunei is a small Islamic sultanate in northwest Borneo. In cultural terms, Brunei is a collectivist (as opposed to an individualist) culture, with a strong emphasis on the centrality of the family and on the ‘group’ rather than on the ‘individual’ (Hofstede, 1994). The country’s current College of Nursing opened in 1986, and offers nurse education up to diploma level and a range of post-registration courses. The nursing curriculum is broadly based on a British model, although includes many specific cultural references including the teaching of the philosophy of Melayu Islam Berja (MIB). This blends Malay traditions and culture with the religious teachings of Islam and calls for loyalty to the state and mutual respect between ruler and subjects.
P. Burnard et al. close their names and by ascribing a number to each of the transcripts. It was explained to students that the researchers were interested in those students’ views about stress and nursing, that their names would not be recorded and that they were under no pressure to take part in the research and that, if they chose to, they could withdraw at any time.
Sample A purposive and convenience sample (Coyne, 1997), comprising 20 Bruneian nursing students undertaking the Diploma in Nursing course, took part in the study. Seventeen respondents were female and 3 were male, all within the age range of 21–26 years. One female respondent was married and the rest of the sample was single. The students were drawn from all 4 years of the Diploma course.
Data collection Research approach This was a descriptive, qualitative study using a grounded theory strategy (Strauss and Corbin, 1998; Glaser, 1998). However, the ‘modifications’ of the grounded theory approach included the use of thematic content analysis and the reporting of a considerable number of direct, verbatim quotes from the data, within a framework suggested by Carson and Kuipers (1998) (described below). The study also draws together the findings into an ‘ideal type’ (after Weber, discussed below), as an alternative approach to the generation of a theory. Describing grounded theory procedures, Strauss and Corbin (1998) suggest: . . .these procedures were designed not to be followed dogmatically but rather to be used creatively and flexibly by researchers as they deem appropriate. The study also contains ethnographic features, in that it reports cultural issues that may be specific to the location of the study (Bodley, 2000).
Ethical issues A full research proposal was submitted for ethical approval and approval obtained. All respondents took part in the study because they freely agreed to do so and all data were anonymised. Anonymity was achieved by not asking the students to dis-
All respondents were interviewed, using a semistructured approach. All interviews were conducted in Brunei and in the medium of English. Most Bruneians’ first language is Malay but English is taught in all schools in line with the official government bilingual policy (Jones et al., 1991). Nursing students are taught and examined in English. In keeping with the grounded theory approach being used, interviews were modified to clarify, expand on or reject concepts and ideas that arose during previous interviews. Interviews were conducted until ‘saturation’ had occurred. This was achieved by interview 18 and reasonably confirmed by interview 20. All interviews were recorded and analysis was carried out on the verbatim accounts of the respondents.
Data analysis A constant comparative method was used, in which each new transcript was compared and contrasted with previous ones. This helped in both the framing of new questions and also in helping to identify categories of data. Transcriptions of the interviews were also analysed via thematic content analysis (Burnard, 1991), involving organisation of the data into categories and sub-categories, through the search for emerging themes. The aim of this process was to account for most of the data under this category system. The category system was also checked and validated by an independent adjudicator.
A descriptive study of Bruneian student nurses’ perceptions of stress
Findings Carson et al. (1997) reports that studies, which attempt to investigate specific stressors, should add to the robustness of the study by locating the research into an empirically derived, field tested model of the stress process. The categories that were derived from the content analysis were therefore located within Carson and Kuipers (1998) model of stress which identifies three components: stressors, moderators and stress outcomes. Stressors are seen as arising from three main sources: those relating to one’s occupation, major life events and hassles, and uplifts. The focus of stressors in this study was on occupational and academic stress. The critical factor in the model is the mediating or buffering factors which the students can call upon to help them. Moderators are those processes that students can call on to help them cope with the external stressors that are impinging on them. The focus of moderators in this study was on coping skills. Stress outcomes are then determined by the nature of the occupational and academic stress and by the coping strategies that are used manage such experiences.
Stressors The themes that emerged within this category were nursing as a stressful activity, clinical stressors: ‘wearing pink’, academic stress and ‘paperwork’, and language.
Nursing as a stressful activity A number of respondents were able to define, in general terms, what they meant by the term ‘stress’ and how both clinical and academic aspects of nursing contributed to it: Stress is very common in nursing. My definition is that it is a mental disorder because it affects our mental state and it involves us emotionally. As a student, I have been going to the clinical placement and I have found stress in the hospital. Some of the pressure is peer pressure and sometimes it is from other staff and lack of facilities in the hospital – poor management sometimes. At the end of the day I feel very stressed. (R1) Well, what is stressful in nursing is the way it is managed. The system, the nursing schedule, sometimes the people and the environment: both in the college and in the clinical setting are stressful. (R6)
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These responses point to the emotional aspects of stress and, broadly, their causes in both clinical and academic settings, with emphasis placed on both people and on environmental considerations (themes that were developed in more detail in these and other interviews).
Clinical stressors: ‘wearing pink’ A pink uniform denotes the grade of (and, for some respondents, seems to symbolise the status of) student nurse. Indeed, uniform colour appears to inform other staff of how students should be treated and viewed. Brunei is a hierarchical society and, within the nursing profession, it would appear that those who wear pink occupy the lower rungs of that hierarchy. This is a source of stress for some of the students. We are wearing a pink uniform and the staff nurses wear a different colour and this creates a barrier and we cannot object to anything. When we are criticised; we can’t answer back. This can be stressful. (R9) Because we are still students and attached to clinical areas, sometimes we have to adapt very quickly to the environment, get to know the other staff, the doctors (what they like and what they don’t like) and most of our opinions may not be acceptable. We are still students so we cannot say very much – we are wearing the pink uniform! (R10) Status in the nursing hierarchy was a theme for many of the respondents, perceiving a sense of tension at being a student in a clinical setting. On the one hand, their lowly status may make it difficult to receive help from others; on the other, senior staff may expect them to have certain knowledge and skills that they, the students, felt they did not possess. However, the degree to which this was stressful varied: It is the staff there [in the clinical setting]. Because sometimes I don’t feel very good in doing the skills and I feel they criticise me. Clinical practice isn’t always stressful: sometimes it is. (R17) Lack of communication between the staff, in the clinical setting is very stressful – there is a distance between students and trained staff. (R1) Sometimes, too, the volume of work expected of students was seen as a stressor. The uncertainty of what might be expected of them also lead students to doubt their own abilities: In clinical it is stressful because of workload and sometimes the nurses tend to ask students to do all
812 the simple things, like taking temperatures, taking patients to X-rays and so on – they are more likely to ask students to do that – we have to do so much! I like the clinical work but I find it very stressful and more stressful than working in the college. We are new and we do not have much experience and this gives me a very stressful feeling when I do not have the skills I feel I should have. (R8) A constant theme throughout the study was relationships between students and trained nursing staff. Where trained staff were prepared to help, support and teach students, stress seemed less evident. However, it often appeared that senior staff would not adopt teaching/supportive roles, but expected students to still be able to demonstrate nursing skills and knowledge: Somehow, in the clinical area, if we are very close to one person, they tend to show you how that area works, but if you do not get close to a person, you may be just told to get on with it. . .If communication is not very good, in the clinical setting, sometimes staff talk about you behind your back. (10) There is only one thing that is stressful in clinical practice and that is mingling with the seniors who look down on us and who do not want to teach us. (R18) It sometimes appeared to be a case of the degree to which students could ‘manage’ other people. One student suggested the difference between the clinical setting and the academic setting in terms of this type of management: It is more stressful in the clinical area because in the college we can deal with the teachers and they know how we feel. (R10) [emphasis added] Caring for patients and staff shortages were other sources of stress. Due to the human element of nursing and the need to deal with physical, psychological and social issues, many students perceived nursing as more stressful than other occupations: For me, nursing is more stressful than other jobs because we are dealing with human beings, not only to cure them but we deal with their physical, psychological and psychosocial [problems]. (R1) Nursing is stressful, it is a very stressful job because when I did my occupational health option, I visited a website and it showed nursing to be one of the most stressful occupations. I think it is, because in clinical nursing, we have to care for people in a ward and there are too many patients and too big a workload. There is conflict with colleagues, doctors, relatives and even the patients themselves. (R3)
P. Burnard et al.
Academic stress and ‘paperwork’ College life and the nursing education system were significant stressors for some respondents. Various themes were frequently mentioned: having to complete assignments and dissertations, the organisation and changing nature of the college and the college environment itself. Often, the written work was referred to as ‘paperwork’, perhaps to be contrasted with the more ‘practical’ or ‘hands on’ approach taken in the clinical setting. I guess working in the college is more stressful than clinical – you tend to have to do more paperwork. It is the time management that is difficult. (R4) It is more stressful in the college because I love to work in the clinical area. When I am in the college I have to think about my paperwork, the dissertation, the exams, the people around me, the study schedule. . . (R6) For some, academic ‘paperwork’ was extremely stressful. The following respondent notes that the dissertation, in particular, was the most stressful activity she had taken part in to date: In the college we are stressed because we have to learn a lot of theory and every year we have our assignments to do and these are very stressful. We didn’t have much guidance for the dissertations. The dissertation was the most stressful thing I have done in my life. Sometimes we have to do lectures in front of peers and that is very stressful and particularly when the lecturer gives you the title very late.
Language As we have noted, in Brunei, nursing is taught in English but practiced in Malay, reflecting another source of stress for some students. We have presentations in front of our colleagues, our English is not good and we tend to feel down and have negative thinking. I feel my English is not good, due to teachers cannot understand, and explain: they cannot understand, and it causes us to fail English tests. (R13) In the college, studying in English is the main problem for most of the students in Brunei. I like to learn in English but I have difficulty in understanding sometimes: that’s why I feel stressed. (R11) Discussions with the college’s educational staff also indicated that students better English writing skills tend to be more successful in their examinations, assignments and dissertations.
A descriptive study of Bruneian student nurses’ perceptions of stress
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Moderators
Trusted friends
Moderators are the processes that are used to either relieve stress or modify it into a form that makes it acceptable, and students used a range of techniques to manage stress. The themes that emerged within this category were interpersonal issues, trusted friends, sports and hobbies, prayer and nature, organisational and institutional moderators and other ways of coping with stress.
A number of the respondents said that they could talk about their stress to ‘trusted friends’. These trusted friends could be described and compared and contrasted with more general friends; or ‘friends you hang out with’.
Interpersonal issues Stress was often moderated through other people. Students spoke to friends, to their tutors and sometimes – but by no means always – to their parents. Some felt that they would only burden their parents by talking to them about stress. I talk with my friends, sometimes they joke with me and they take me window shopping or we go to the cinema and also I call my parents. (R7) I watch TV or go out with friends. Also we eat. I can talk to my friends about things that stress me but if they are personal I keep them to myself. I can also talk to my sisters – one of my sisters is also a nurse. I can talk to my mum but mostly I keep things from her. (R5) The social and ‘joking’ function of friends was often referred to: it would appear that rather than having ‘deep’ discussions about stress, the function of friends was often to joke and help relieve the tension. Sometimes, friends were chatted to after the initial feelings of stress had passed. The following respondent did not appear to need friends while acutely stressed and preferred not to worry her parents about her stress: I don’t talk to my friends until I have calmed down – after a few days. I do need friends to talk to but not immediately when I feel stressed. I do not share with my parents when I am stressed – I do not want to make them more stressed about my studies because they are paying for my studies – I do not want to make them feel anxious. (R10) Similarly, another student preferred to attempt to calm herself first, before talking to friends. If this failed, friends or tutors could help: If I am stressed I feel I don’t want to talk to anyone: I want to think about my problem on my own. If I cannot, I will find someone I really trust and who can help me, like my husband. If he cannot help I can talk to a best friend or a tutor. (R11)
Trusted friends are ones who understand me at the same level, depth. Trusted friends are ones you can share your feelings with – but not, normally, your depression. Trusted friends are normally my age. (R18) A trusted friend is someone you can trust, someone you are really close to, someone who knows your background, someone who understands your feelings and who is much the same as myself. Other sorts of friends are just ones you hang out with. (R20) For one respondent, having trusted friends was a vital asset. Other sorts of friends might not be reliable or they may even be potentially threatening: It is not easy to find a trusted friend, some friends are back-stabbers. When you face difficulties they just drift away from you and back stab. A trusted friend will help you in difficulties and help you out. Sometimes there is bullying: I was one! I nearly quit: they were not good. A ‘trusted friend’ [is] someone you can confide in. Other friends are just ones to hang out with and have fun with. (R19)
Sports and hobbies A number of students referred to sporting and other hobby activities as means of moderating stress: I also play sports, so I think that I give out all of my stress in my sports – I play netball and badminton – this is organised by the college. (R2) I prefer to go bowling and do some outdoor activities – go to the beach. I talk to my friends – they are very supportive and my family are also supportive. (R4)
Prayer and nature For some, a form of communion with nature was a means of relieving stress. This was sometimes linked to a religious theme: Above all, I go to lonely places, lakes, appreciate God’s creation. (R14) When I am stressed I go to the sea and shout at the sea. (R6)
814 The latter response seemed to be a form of both catharsis and social isolation; it seemed important to be able to get away from others but also to have some form of ‘safe’ emotional release.
Organisational and institutional moderators Many students articulate examples of what they felt could be done to lessen stress within the nursing profession. These ideas might be thought of as ‘organisational moderators.’ In the first example, the student felt that ‘someone’ should be made responsible for the issue of stress and also noted staff and equipment shortages: Nursing should provide a consultant who can solve the problem. Also, I think that nursing officers should be able to work alongside doctors without bias. The stressed person should be able to talk to someone who they can trust. Shortage of staff is also a cause of stress and the lack of appropriate equipment – sometimes we only have one thermometer for example. (R11) Another student identified the human and caring features that needed to be attended to in order to reduce stress; perhaps identifying a ‘core’ aspect of the health care professional/patient relationship: It goes back to patient care, doctors need to respect patients, and give a feeling of really being cared for, as well as nurses, for the patient and family. Not all do at the moment. New doctors are better and there are signs of change. Latest things on internet, research on patient centered on bedside care – this will help all. (R14)
Other ways of coping with stress Individual students identified particular, sometimes idiosyncratic, ways of dealing with stress. One, for example, suggested: Sometimes when I get home from work I like to put the music on very loud and drive so fast! (R8) Another student identified a range of strategies that she used to moderate the effects of work and study related stress: We have counsellors who can help, in the hospital for all the working people, if they have stress. Some people feel guilty about seeing a counsellor and say ‘talk to your friends and family’. I like to talk to my mother, my family and my friends and share with them what makes me feel stressed and seek their help. With humour, I deal with it also and I also like to relax by listening to music, doing
P. Burnard et al. tai chi. Sometimes if I cannot cope, I cry and this helps to release tensions. (R3) This student notes the availability of a counsellor, but also alludes to a certain stigma attached to going to see such a person. In collectivist cultures, it is frequently the case that people will talk about their problems most readily to their family and friends, rather than to a disinterested outsider (Hofstede, 1994). This student also summarises a range of methods discussed by many of her colleagues in the study: crying, using humour, relaxing by listening to music and talking to friends and family.
Stress outcomes The themes that emerged within this category were being motivated, somatic symptoms and psychological symptoms.
Positive outcomes: being motivated For some students, stress could be a motivator, forcing the individual to reconsider his or her position and to be challenged to do something: Yes, I guess everyone has stress. Everyone has to deal with it. Sometimes stress can make us selfmotivated. It makes you think further and further. (R1) We can learn to cope with it; we learn how to cope with difficult situations. (R2) I think, it a way, it is important for one to have stress: it is a signal to say ‘Hello! This is too much!’ This is one of the best things about stress. With proper management of stress, it is a healthy to have some stress. Everyone has stress! Even if your pockets are filled with money, you still have stress! (R4) The last student, quoted above, notes both the ‘warning call’ of stress but also a way of rationalising stress by appreciating that ‘everyone has stress’. However, one student felt unable to find anything positive in stress and suggested: I don’t think there are good effects of stress! (R5)
Negative outcomes: somatic symptoms Students described their experiences of stress. Stress sometimes produced somatic as well as psychological symptoms, and even changed appetites:
A descriptive study of Bruneian student nurses’ perceptions of stress I feel a headache and sometimes not really mental block but I cannot do things when I am stressed, it distracts me and stops me from doing things. It makes me a little upset but I do not cry. (R2) I get a migraine, I just want to bang my head against the wall and shout. (R6) Its kind of like rough: I feel like shouting and I become angry- even towards the person closes to me. In my stressed mood I get a high pitched voice. (R8) When I am stressed I eat a lot. Stress really, really affects my mood and my relationships with friends. (R7) I don’t know how to deal with the stress. Sometimes I don’t eat. (R1)
Negative outcomes: psychological symptoms Negative effects – particularly long term effects – were noted by the students, including the ideas that stress could cause depression and other mental illness, and might even lead students to leaving their training. However, one student also seemed particularly aware of the immediate effects. She noted that one may lose friends in the processes of becoming or being stressed: I find stress is always negative and it can give you mental problems and you will be like in stress all of the time and ignored by people and you let it out to people and you will loose people – they will just go! If you are not stressed, people will come to you. If you are stressed, people will leave you! (R19) For some others, negative views of stress were almost the mirror image of positive ones: I think stress can demotivate you. You feel not comfortable and you do not accept what people say to you and you feel unlikable. You work with less confidence and you feel lost in the ward. You become lonely and don’t want to talk to people and you say to yourself: ‘I am not that good’. (R10) Again, the suggestion, here, is that stress can make you unpopular. This may go some way to explaining some students’ reluctance to talk to the friends and family about stress. Again, in collectivist cultures, a sense of inclusion and a sense of oneness with friends and family is very important (Hofstede, 1994). In stressful times, some wanted to be with friends but others wanted to hide themselves away until the stress feelings had passed. Students often
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described psychological symptoms of stress, such as feelings of depression, anger, tension and anxiety: Well I feel long and short term, my mood and behaviour changing, negative thinking, long term I feel just, lonely, don’t want to speak to anyone – my self-esteem is low, confidence low. (R13) I just keep myself in the room and get rest: I do not want to think any more until the stress has gone. I also loose my temper sometimes. I don’t want to talk to anyone. (R9) I feel I can’t really do anything. I feel like crying and normally I would look for my friends to have a laugh or something. I try not to be angry with people but sometimes I am without realising. (R16) The use of moderators seemed, in most cases, to relieve stress (if only temporarily). A number of students noted, also, that there were both positive and negative effects of stress; particularly unmoderated stress.
Ideal type Finally, the findings were used to produce an ‘ideal type’: an idealised word-picture of an ‘aggregated’ Bruneian student and her/his relationship with stress. Originally developed by the sociologist, Max Weber (Coser, 1977), the concept of an ideal type is a model, and perhaps a set of exaggerated characteristics defining the essence of certain types of behaviour observable in the real world. The ideal type, then, is formed from characteristics and elements of a given phenomenon (in this case students experiencing stress), and is intended to illustrate certain elements common to most cases of that phenomenon. It is not, however, meant to correspond to all of the characteristics of any one particular case, or to reflect statistical averages. The ideal type as defined by the current data is as follows: The Bruneian nursing student comes from a close family background. She is usually Muslim. She has a circle of friends, some of whom are trusted friends – people she can talk to about problems and to whom she will turn before she talks to her parents. Others are simply friends to have fun with – and ‘having fun’ or joking is an important feature of friendship. In clinical nursing, she finds herself having low status and may or may not be helped to learn by more senior staff. In the nursing college, she finds the physical environment not always conducive to study and finds learning resources sparse. She sometimes feels overwhelmed by the
816 diet of assignments and by completing the dissertation – the ‘paperwork’. Having to learn and write in English, rather than her native language (Malay) causes problems. Out of all this she experiences stress. This manifests itself in various ways: sometimes she feels like crying and sometimes she wants to shut herself away in her room. To alleviate the stress, she may engage in sporting activities, listen to music or talk to her trusted friends. She may not, immediately, talk to her parents, for fear of worrying them unnecessarily. She feels that both the nursing college and the clinical settings could be better organised and resourced and realises that shortage of clinical staff contributes to work-related stress.
Limitations A limitation of this study is, perhaps, the less than detailed reference to Islam and its effects on the students’ perceptions of stress in their work and study. Furthermore it should also be noted that culture does much to define both how we conceptualise psychological problems and stress and the degree to which we are prepared to discuss it with a third party (in this case, with a ‘local’ researcher and a ‘foreign’ one). This would explain why the students did not discuss any of the more negative coping strategies i.e. smoking, comfort eating, medication, hostility, taking it out on others The literature, in other cultural contexts, clearly highlights this behaviour across a number of other studies (Jones and Johnston, 1997; Kirkland, 1998; Mahat, 1998; Lo, 2002; Tully, 2004). It should also be noted that the terms mental health and stress mean different things to people across different studies and therefore only tentative comparisons should be made with other studies. Helman (2001) summarises the relationship of culture to psychological and mental health issues in that it influences the clinical presentation and distribution of mental illness and that it determines the ways that mental illness is recognised, labelled, explained and treated by other members of that society.
Discussion This paper reports a qualitative, descriptive study, using a modified grounded theory approach to researching stress in Bruneian students. Through interviews, students expressed their views about stressors (both academic and clinical), moderators
P. Burnard et al. and outcomes of stress (Carson and Kuipers, 1998). Students often found their status as students caused them stress in the clinical setting: with other nurses, with doctors and even with patients. Academic related stressors included having to complete assignments and dissertations which has been identified internationally has an area of concern for nursing students (Beck and Srivastava, 1991; Clarke and Ruffin, 1992; Thyer and Bazeley, 1993; Beck et al., 1997; Jones and Johnston, 2000; Sheu et al., 2002; Evans and Kelly, 2004). It is recognised that students possess language difficulties that affect their academic achievement in nursing programs where English is their second language (Petro-Nustas et al., 2001; Pardue and Haas, 2003). A key stressor identified by this study was having to study in the medium of English. Studies conducted where nursing is taught in English in other countries have noted that English language skills are important skills as they can facilitate the acquisition of up-to-date scientific information and promote life long learning (Abriam-Yago et al., 1999). We note, in our findings, that the relationship between nursing staff (students and trained) on the clinical area was an important issue. This is also evident in the previous literature as demonstrated by Hamill (1995), Thyer and Bazeley (1993), Lo (2002), Timmins and Kaliszer (2002) and Evans and Kelly (2004). Previous research has indicated that students reporting low levels of stress/distress use a number of coping methods to manage their stress for example problem solving (Jones and Johnston, 1997; Mahat, 1998; Lo, 2002; Tully, 2004; Sheu et al., 2002), talking to others – relatives, friends and peers (Evans and Kelly, 2004; Tully, 2004), recreation and sport (Lo, 2002), social support – family, spouse, partners workmates, classmates, lecturers and tutors (Kirkland, 1998; Lo, 2002) Other coping strategies reported included having outside interests, using mentors, and having friends outside nursing (Brown and Edelmann, 2000), staying optimistic (Sheu et al., 2002), the desire to obtain a qualification, the need to finish something I started and determination (Evans and Kelly, 2004) and better studying techniques and time management skills (Lo, 2002). In the present study various ways of moderating stress were reported including social support talking to friends and family, talking to ‘trusted friends’, engaging in sports or simply being quiet. There is a lot of similarity with previous work but this paper reveals that talking to ‘‘trusted friends’’ which was identified separately to that of talking to everyday friends and family is important for students from this culture.
A descriptive study of Bruneian student nurses’ perceptions of stress Potential stressors will only lead to negative stress outcomes if the individual has insufficient resources (coping strategies) to manage them. Nursing students in the study by Evans and Kelly (2004) reported being exhausted, under pressure, upset, worrying about what might happen, rundown, frustrated and worried. This study demonstrated that nursing students experienced range of somatic symptoms and that if not resolved then stress could lead to depression and mental illness as well as and. This is in keeping with the work of Deary et al. (2003) who demonstrated that students who experienced increasing levels of stress and who used more negative coping mechanisms as the programme progressed were more likely to report a psychological symptoms. Shipton (2002) found that the emotions generated by stress in the clinical experience has been reported to lead to nervousness, depression, anxiety, fear, frustration, anger, hopelessness, loneliness and inferiority (Shipton, 2002). Whereas, Pagana (1990) found that the stressful nature of the clinical experience was seen to be more of a challenge i.e. potential for mastery, growth or gain than a threat i.e. the potential for harm in keeping with our finding that stress can act as a motivating factor challenging the student to do something about their situation.
Conclusions From these views and drawing on the cultural literature that identifies Brunei as a collectivist culture, an ‘ideal type’ is suggested, which can be compared with types drawn from other cultures in future research. Given that Brunei was, until the 1970s a British protectorate, it is still possible to detect the possibility of a misfit between ‘British’ forms of nursing education and ‘Islamic’ forms of education and practice. We note, above, the rather anomalous situation of Brunei students being taught in English but ‘practicing’ in Malay. As nursing education in Brunei moves into the university sector, we may find this changing. It may be useful to replicate this study once integration within Brunei University has been fully achieved. Finally, although mostly beyond the scope of this study, it must be kept in mind that the Islamic code of Brunei affects all aspects of the nurses’ and patients’ life in that country. Writing in a nursing context, ElGindy (2006) notes: ‘‘Adherence to Islamic teachings governs every aspect of Muslim life and must be practiced every day, regardless of the physical setting in which Muslims may find themselves.’’
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References Abriam-Yago, K., Yoder, M., Kataoka-Yahiro, M., 1999. The cummins model: a framework for teaching nursing students for whom English is a second language. Journal of Transcultural Nursing 10, 143–149. Abu Tariah, H., Al-Sharaya, H., 1997. Stresses reported by second year nursing students. Nurse Educator 22, 33. Admi, H., 1997. Nursing students’ stress during the initial clinical experience. Journal of Nursing Education 36, 323– 327. Basson, C., Van der Merwe, T., 1994. Occupational stress and coping in a sample of student nurses. Curationis 17, 35–43. Beck, D., Srivastava, R., 1991. Perceived level and sources of stress in baccalaureate nursing students. The Journal of Nursing Education 30, 127–133. Beck, D., Hackett, M., Srivastava, R., McKim, E., Rockwell, B., 1997. Perceived level and sources of stress in university professional schools. Journal of Nursing Education 36, 180– 186. Bennett, P., Lowe, R., Matthews, V., Dourali, M., Tattersall, A., 2001. Stress in nurses: coping, managerial support and work demand. Stress and Health 17, 55–63. Bodley, J.H., 2000. Cultural Anthropology: Tribes, States, and the Global System, third ed. Mountain View, Mayfield, California. Brown, H., Edelmann, R., 2000. Project 2000: a study of expected and experienced stressors and support reported by students and qualified nurses. Journal of Advanced Nursing 31, 857–864. Burnard, P., 1991. A method of analysis interview transcripts in qualitative research. Nurse Education Today 11, 461–466. Carson, J., Kuipers, E., 1998. Stress management interventions. In: Hardy, S., Carson, J., Thomas, B. (Eds.), Occupational Stress: Personal and Professional Approaches. Stanley Thornes, Cheltenham, pp. 157–174. Carson, J., Wood, M., White, H., Thomas, B., 1997. Stress in mental health nursing: findings from the mental health care survey. Mental Health Care 1, 11–14. Clarke, V., Ruffin, C., 1992. Perceived sources of stress among student nurses. Contemporary Nurse: A Journal for the Australian Nursing Profession 1, 35–40. Coser, L., 1977. Masters of Sociological Thought: Ideas in Historical and Social Context, second ed. Harcourt Brace Jovanovich, New York. Coyne, I., 1997. Sampling in qualitative research. Purposeful and theoretical sampling; merging or clear boundaries? Journal of Advanced Nursing 26 (3), 623–630. Deary, I., Watson, R., Hogston, R., 2003. A longitudinal cohort study of burnout and attrition in nursing students. Journal of Advanced Nursing 43, 71–81. ElGindy, G. (2006) Cultural Competence: Treating Muslims with Cultural Sensitivity in a Post-9/11 World. http://www.minoritynurse.com/features/health/02-16-04a.html. Evans, W., Kelly, B., 2004. Pre-registration diploma student nurse stress and coping measures. Nurse Education Today 24, 473–482. Glaser, B., 1998. Doing Grounded Theory: Issues and Discussions. Sociology Press, Mill Valley. Gwele, N., Llys, L., 1998. Levels of stress and academic performance in baccalaureate nursing students. Journal of Nursing Education 37, 404–407. Hamill, C., 1995. The phenomenon of stress as perceived by Project 2000 student nurses: a case study. Journal of Advanced Nursing 21, 528–536.
818 Helman, C.G., 2001. Culture, Health and Illness, fourth ed. Arnold, London. Hofstede, G., 1994. Culture and Organisations: Software of the Mind. McGraw Hill, London. Jones, M., Johnston, D., 1997. Distress, stress and coping in firstyear student nurses. Journal of Advanced Nursing 26, 475–482. Jones, M., Johnston, D., 2000. Reducing distress in first level and student nurses: a review of the applied stress management literature. Journal of Advanced Nursing 32, 66–74. Jones, G., Md. Gary Abdullah, Martin, P.W., Ozog, C., 1991. Multilingualism and bilingual education in Brunei Darussalam. In: English Department Universiti Brunei Darussalam, 1993. English department’s collection of research papers, vol. 2, Universiti Brunei Darussalam, Brunei Darussalam. Kirkland, M., 1998. Stressors and coping strategies among successful female African American baccalaureate nursing students. Journal of Nursing Education 37, 5–12. Lazarus, R., Folkman, S., 1984. Stress, Appraisal and Coping. Springer, New York. Lindop, E., 1989. Individual stress and its relationship to termination of nurse training. Nurse Education Today 9, 172–179. Lo, R., 2002. A longitudinal study of perceived level of stress, coping and self-esteem of undergraduate nursing students: an Australian case study. Journal of Advanced Nursing 39, 119–126. Mahat, G., 1996. Stress and coping: first-year Nepalese nursing students in clinical settings. Journal of Nursing Education 35, 163–169. Mahat, G., 1998. Stress and coping: junior baccalaureate nursing students in clinical settings. Nursing Forum 33, 9–11. Maville, J., Huerta, C., 1997. Stress and social support among Hispanic student nurses: implications for academic achievement. Journal of Cultural Diversity 4, 18–25. O’Connor, P., Bevil, C., 1996. Academic outcomes and stress in full-time day and part-time evening baccalaureate nursing students. Journal of Nursing Education 35, 245–251. Oermann, M., Standfest, K., 1997. Differences in stress and challenge in clinical practice among ADN and BSN students in
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Nurse Education Today intl.elsevierhealth.com/journals/nedt
A descriptive study of Bruneian student nurses’ perceptions of stress Philip Burnard a,*, Hajah Thaibah Binti PDPD DP Haji Abd Rahim b, Derek Hayes b, Deborah Edwards a a b
School of Nursing and Midwifery Studies, Cardiff University, Wales, UK Penigiran Anak Puteri Rashidah Sa’adatul Bolkiah College of Nursing, Brunei Darussalam
Accepted 22 November 2006
KEYWORDS
Summary While much has been written about stress in nursing in the ‘West’, less research has been done on this issue in many ‘Eastern’ countries. This paper offers the findings of the first study of stress in student nurses in Brunei. The paper describes a study of 20 Brunei nursing students and their views about stress in nursing. A modified grounded theory approach was used in collecting and analysing data (and the ‘modifications’ are described). Findings were organised around the themes: stressors, moderators and outcomes [Carson, J., and Kuipers, E., 1998. Stress management interventions. In: Hardy, S., Carson, J., Thomas, B. (Eds.), Occupational Stress: Personal and Professional Approaches. Stanley Thornes, Cheltenham. pp. 157–174.]. Students often found their status as students caused them stress in the clinical setting: with other nurses, with doctors and even with patients. Academic related stressors included having to complete assignments and having to study in English. Various ways of moderating stress were reported including talking to ‘trusted friends’, engaging in sports or simply being quiet. Positive and negative outcomes of stress were identified: stress could lead to mental illness but, also, it could be motivating. This report concludes with a Weberian ‘ideal type’: a composite word-picture of the findings. c 2006 Elsevier Ltd. All rights reserved.
Stress; Student nurses; Brunei; Nurse education
Literature review Stress, coping are the guiding concepts of this study, reflecting the view of Lazarus and Folkman * Corresponding author. Tel./fax: +44 2920 743738. E-mail address: [email protected] (P. Burnard).
(1984). Although many definitions of stress and coping exist the majority of research conducted with nursing literature utilise this approach. Lazarus and Folkman (1984) define stress as ‘‘a particular relationship between the person and the environment that is appraised by the person as
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.11.002
A descriptive study of Bruneian student nurses’ perceptions of stress taxing or exceeding his or her own resources and endangering his or her well being.’’ It is recognised that nursing is a stressful occupation (Jones and Johnston, 2000; Bennett et al., 2001), and that the problem of stress first becomes evident during nursing training (Rhead, 1995). Stress has been identified as an important psychosocial factor in the educational process because it may influence academic performance and wellbeing. Studies conducted within the UK among Project 2000 students, in USA, Australia and Ireland have identified a wide variety of stressors associated with their course of study and clinical experiences. Clinical stressors Handling emergencies in the clinical area (Clarke and Ruffin, 1992). Initial ward experiences (Mahat, 1998). Clinical experience for those students in the care of children courses (Oermann and Standfest, 1997). Death of a patient (Clarke and Ruffin, 1992; Rhead, 1995; Timmins and Kaliszer, 2002). Lack of practical skills, negative attitudes of ward staff and misunderstanding of supernumerary status (Hamill, 1995). Relationships with clinical staff (Hamill, 1995; Thyer and Bazeley, 1993; Lo, 2002; Timmins and Kaliszer, 2002; Evans and Kelly, 2004). Academic stressors Pressure of grades or fear of failing (Beck et al., 1997; Sheu et al., 2002; Jones and Johnston, 2000). Intense amount of work (Beck and Srivastava, 1991; Clarke and Ruffin, 1992). Evans and Kelly (2004). Study associated with the programme (Clarke and Ruffin, 1992; Thyer and Bazeley, 1993; Jones and Johnston, 2000; Evans and Kelly, 2004). Lack of free time (Beck and Srivastava, 1991; Jones and Johnston, 2000). Finding academic work difficult including examinations (Beck and Srivastava, 1991; Clarke and Ruffin, 1992; Beck et al., 1997; Evans and Kelly, 2004). Long hours of study long hours of study (Beck and Srivastava, 1991; Jones and Johnston, 2000). Relationships with academic staff (Hamill, 1995; Thyer and Bazeley, 1993; Lo, 2002; Timmins and Kaliszer, 2002; Evans and Kelly, 2004).
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Finances (Beck and Srivastava, 1991; Clarke and Ruffin, 1992; Thyer and Bazeley, 1993; Brown and Edelmann, 2000; Timmins and Kaliszer, 2002). Female students experienced higher levels of stress than male students (Tully, 2004). Not being treated as an adult learner, confusing assignment guidelines and the amount of selfdirected learning (Hamill, 1995). First year of academic study (Wang, 1991). Higher stress levels for those enrolled in a part time evening programme. (O’Connor and Bevil, 1996) Showed a relationship between stress and academic performance (Maville and Huerta, 1997). Various studies have been conducted in a variety of other countries (South Africa: Basson and Van der Merwe, 1994; Nepal: Mahat, 1996; Jordan: Abu Tariah and Al-Sharaya, 1997; Israel: Admi, 1997; South Africa: Kirkland, 1998; South Africa: Gwele and Llys, 1998; India: Saxena, 2001; Taiwan: Sheu et al., 2002) and have reported similar findings. Lindop (1989) suggests that many of the stress reactions in nursing students go unnoticed with the consequence that stress levels increase until a person responds by leaving the profession. Stress does not always have negative effects only but also positive ones. The effect of stress on health depends on the adequacy of coping behaviours. Coping behaviour is described as the ‘‘continuous effort to overcome the unbalanced condition caused by internal and external demands.’’ (Lazarus and Folkman, 1984, page 141) When effective coping strategies are used, the emotions can be adjusted and the stressful situation can be resolved. Coping efforts may be directed toward changing the environment (problemfocused) or inward toward changing the meaning of the event (emotion-focused or palliative). Much is still unexplored about the coping processes of nursing students and only eight studies have investigated this (Jones and Johnston, 1997; Kirkland, 1998; Brown and Edelmann, 2000; Mahat, 1998; Lo, 2002; Sheu et al., 2002; Tully, 2004; Evans and Kelly, 2004). As this literature review shows much has been written about stress in nursing in the ‘West’, and less research has been done on this issue in many ‘Eastern’ countries. All of the research with a few exceptions where open ended questions have been used has been of a quantitative nature. This review has also identified that further work is also needed
810 to explore coping within the student nursing population. The aim of this study was therefore to identify aspects of stress and coping as described by nursing students in Brunei Darussalam using a qualitative approach. Brunei is a small Islamic sultanate in northwest Borneo. In cultural terms, Brunei is a collectivist (as opposed to an individualist) culture, with a strong emphasis on the centrality of the family and on the ‘group’ rather than on the ‘individual’ (Hofstede, 1994). The country’s current College of Nursing opened in 1986, and offers nurse education up to diploma level and a range of post-registration courses. The nursing curriculum is broadly based on a British model, although includes many specific cultural references including the teaching of the philosophy of Melayu Islam Berja (MIB). This blends Malay traditions and culture with the religious teachings of Islam and calls for loyalty to the state and mutual respect between ruler and subjects.
P. Burnard et al. close their names and by ascribing a number to each of the transcripts. It was explained to students that the researchers were interested in those students’ views about stress and nursing, that their names would not be recorded and that they were under no pressure to take part in the research and that, if they chose to, they could withdraw at any time.
Sample A purposive and convenience sample (Coyne, 1997), comprising 20 Bruneian nursing students undertaking the Diploma in Nursing course, took part in the study. Seventeen respondents were female and 3 were male, all within the age range of 21–26 years. One female respondent was married and the rest of the sample was single. The students were drawn from all 4 years of the Diploma course.
Data collection Research approach This was a descriptive, qualitative study using a grounded theory strategy (Strauss and Corbin, 1998; Glaser, 1998). However, the ‘modifications’ of the grounded theory approach included the use of thematic content analysis and the reporting of a considerable number of direct, verbatim quotes from the data, within a framework suggested by Carson and Kuipers (1998) (described below). The study also draws together the findings into an ‘ideal type’ (after Weber, discussed below), as an alternative approach to the generation of a theory. Describing grounded theory procedures, Strauss and Corbin (1998) suggest: . . .these procedures were designed not to be followed dogmatically but rather to be used creatively and flexibly by researchers as they deem appropriate. The study also contains ethnographic features, in that it reports cultural issues that may be specific to the location of the study (Bodley, 2000).
Ethical issues A full research proposal was submitted for ethical approval and approval obtained. All respondents took part in the study because they freely agreed to do so and all data were anonymised. Anonymity was achieved by not asking the students to dis-
All respondents were interviewed, using a semistructured approach. All interviews were conducted in Brunei and in the medium of English. Most Bruneians’ first language is Malay but English is taught in all schools in line with the official government bilingual policy (Jones et al., 1991). Nursing students are taught and examined in English. In keeping with the grounded theory approach being used, interviews were modified to clarify, expand on or reject concepts and ideas that arose during previous interviews. Interviews were conducted until ‘saturation’ had occurred. This was achieved by interview 18 and reasonably confirmed by interview 20. All interviews were recorded and analysis was carried out on the verbatim accounts of the respondents.
Data analysis A constant comparative method was used, in which each new transcript was compared and contrasted with previous ones. This helped in both the framing of new questions and also in helping to identify categories of data. Transcriptions of the interviews were also analysed via thematic content analysis (Burnard, 1991), involving organisation of the data into categories and sub-categories, through the search for emerging themes. The aim of this process was to account for most of the data under this category system. The category system was also checked and validated by an independent adjudicator.
A descriptive study of Bruneian student nurses’ perceptions of stress
Findings Carson et al. (1997) reports that studies, which attempt to investigate specific stressors, should add to the robustness of the study by locating the research into an empirically derived, field tested model of the stress process. The categories that were derived from the content analysis were therefore located within Carson and Kuipers (1998) model of stress which identifies three components: stressors, moderators and stress outcomes. Stressors are seen as arising from three main sources: those relating to one’s occupation, major life events and hassles, and uplifts. The focus of stressors in this study was on occupational and academic stress. The critical factor in the model is the mediating or buffering factors which the students can call upon to help them. Moderators are those processes that students can call on to help them cope with the external stressors that are impinging on them. The focus of moderators in this study was on coping skills. Stress outcomes are then determined by the nature of the occupational and academic stress and by the coping strategies that are used manage such experiences.
Stressors The themes that emerged within this category were nursing as a stressful activity, clinical stressors: ‘wearing pink’, academic stress and ‘paperwork’, and language.
Nursing as a stressful activity A number of respondents were able to define, in general terms, what they meant by the term ‘stress’ and how both clinical and academic aspects of nursing contributed to it: Stress is very common in nursing. My definition is that it is a mental disorder because it affects our mental state and it involves us emotionally. As a student, I have been going to the clinical placement and I have found stress in the hospital. Some of the pressure is peer pressure and sometimes it is from other staff and lack of facilities in the hospital – poor management sometimes. At the end of the day I feel very stressed. (R1) Well, what is stressful in nursing is the way it is managed. The system, the nursing schedule, sometimes the people and the environment: both in the college and in the clinical setting are stressful. (R6)
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These responses point to the emotional aspects of stress and, broadly, their causes in both clinical and academic settings, with emphasis placed on both people and on environmental considerations (themes that were developed in more detail in these and other interviews).
Clinical stressors: ‘wearing pink’ A pink uniform denotes the grade of (and, for some respondents, seems to symbolise the status of) student nurse. Indeed, uniform colour appears to inform other staff of how students should be treated and viewed. Brunei is a hierarchical society and, within the nursing profession, it would appear that those who wear pink occupy the lower rungs of that hierarchy. This is a source of stress for some of the students. We are wearing a pink uniform and the staff nurses wear a different colour and this creates a barrier and we cannot object to anything. When we are criticised; we can’t answer back. This can be stressful. (R9) Because we are still students and attached to clinical areas, sometimes we have to adapt very quickly to the environment, get to know the other staff, the doctors (what they like and what they don’t like) and most of our opinions may not be acceptable. We are still students so we cannot say very much – we are wearing the pink uniform! (R10) Status in the nursing hierarchy was a theme for many of the respondents, perceiving a sense of tension at being a student in a clinical setting. On the one hand, their lowly status may make it difficult to receive help from others; on the other, senior staff may expect them to have certain knowledge and skills that they, the students, felt they did not possess. However, the degree to which this was stressful varied: It is the staff there [in the clinical setting]. Because sometimes I don’t feel very good in doing the skills and I feel they criticise me. Clinical practice isn’t always stressful: sometimes it is. (R17) Lack of communication between the staff, in the clinical setting is very stressful – there is a distance between students and trained staff. (R1) Sometimes, too, the volume of work expected of students was seen as a stressor. The uncertainty of what might be expected of them also lead students to doubt their own abilities: In clinical it is stressful because of workload and sometimes the nurses tend to ask students to do all
812 the simple things, like taking temperatures, taking patients to X-rays and so on – they are more likely to ask students to do that – we have to do so much! I like the clinical work but I find it very stressful and more stressful than working in the college. We are new and we do not have much experience and this gives me a very stressful feeling when I do not have the skills I feel I should have. (R8) A constant theme throughout the study was relationships between students and trained nursing staff. Where trained staff were prepared to help, support and teach students, stress seemed less evident. However, it often appeared that senior staff would not adopt teaching/supportive roles, but expected students to still be able to demonstrate nursing skills and knowledge: Somehow, in the clinical area, if we are very close to one person, they tend to show you how that area works, but if you do not get close to a person, you may be just told to get on with it. . .If communication is not very good, in the clinical setting, sometimes staff talk about you behind your back. (10) There is only one thing that is stressful in clinical practice and that is mingling with the seniors who look down on us and who do not want to teach us. (R18) It sometimes appeared to be a case of the degree to which students could ‘manage’ other people. One student suggested the difference between the clinical setting and the academic setting in terms of this type of management: It is more stressful in the clinical area because in the college we can deal with the teachers and they know how we feel. (R10) [emphasis added] Caring for patients and staff shortages were other sources of stress. Due to the human element of nursing and the need to deal with physical, psychological and social issues, many students perceived nursing as more stressful than other occupations: For me, nursing is more stressful than other jobs because we are dealing with human beings, not only to cure them but we deal with their physical, psychological and psychosocial [problems]. (R1) Nursing is stressful, it is a very stressful job because when I did my occupational health option, I visited a website and it showed nursing to be one of the most stressful occupations. I think it is, because in clinical nursing, we have to care for people in a ward and there are too many patients and too big a workload. There is conflict with colleagues, doctors, relatives and even the patients themselves. (R3)
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Academic stress and ‘paperwork’ College life and the nursing education system were significant stressors for some respondents. Various themes were frequently mentioned: having to complete assignments and dissertations, the organisation and changing nature of the college and the college environment itself. Often, the written work was referred to as ‘paperwork’, perhaps to be contrasted with the more ‘practical’ or ‘hands on’ approach taken in the clinical setting. I guess working in the college is more stressful than clinical – you tend to have to do more paperwork. It is the time management that is difficult. (R4) It is more stressful in the college because I love to work in the clinical area. When I am in the college I have to think about my paperwork, the dissertation, the exams, the people around me, the study schedule. . . (R6) For some, academic ‘paperwork’ was extremely stressful. The following respondent notes that the dissertation, in particular, was the most stressful activity she had taken part in to date: In the college we are stressed because we have to learn a lot of theory and every year we have our assignments to do and these are very stressful. We didn’t have much guidance for the dissertations. The dissertation was the most stressful thing I have done in my life. Sometimes we have to do lectures in front of peers and that is very stressful and particularly when the lecturer gives you the title very late.
Language As we have noted, in Brunei, nursing is taught in English but practiced in Malay, reflecting another source of stress for some students. We have presentations in front of our colleagues, our English is not good and we tend to feel down and have negative thinking. I feel my English is not good, due to teachers cannot understand, and explain: they cannot understand, and it causes us to fail English tests. (R13) In the college, studying in English is the main problem for most of the students in Brunei. I like to learn in English but I have difficulty in understanding sometimes: that’s why I feel stressed. (R11) Discussions with the college’s educational staff also indicated that students better English writing skills tend to be more successful in their examinations, assignments and dissertations.
A descriptive study of Bruneian student nurses’ perceptions of stress
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Moderators
Trusted friends
Moderators are the processes that are used to either relieve stress or modify it into a form that makes it acceptable, and students used a range of techniques to manage stress. The themes that emerged within this category were interpersonal issues, trusted friends, sports and hobbies, prayer and nature, organisational and institutional moderators and other ways of coping with stress.
A number of the respondents said that they could talk about their stress to ‘trusted friends’. These trusted friends could be described and compared and contrasted with more general friends; or ‘friends you hang out with’.
Interpersonal issues Stress was often moderated through other people. Students spoke to friends, to their tutors and sometimes – but by no means always – to their parents. Some felt that they would only burden their parents by talking to them about stress. I talk with my friends, sometimes they joke with me and they take me window shopping or we go to the cinema and also I call my parents. (R7) I watch TV or go out with friends. Also we eat. I can talk to my friends about things that stress me but if they are personal I keep them to myself. I can also talk to my sisters – one of my sisters is also a nurse. I can talk to my mum but mostly I keep things from her. (R5) The social and ‘joking’ function of friends was often referred to: it would appear that rather than having ‘deep’ discussions about stress, the function of friends was often to joke and help relieve the tension. Sometimes, friends were chatted to after the initial feelings of stress had passed. The following respondent did not appear to need friends while acutely stressed and preferred not to worry her parents about her stress: I don’t talk to my friends until I have calmed down – after a few days. I do need friends to talk to but not immediately when I feel stressed. I do not share with my parents when I am stressed – I do not want to make them more stressed about my studies because they are paying for my studies – I do not want to make them feel anxious. (R10) Similarly, another student preferred to attempt to calm herself first, before talking to friends. If this failed, friends or tutors could help: If I am stressed I feel I don’t want to talk to anyone: I want to think about my problem on my own. If I cannot, I will find someone I really trust and who can help me, like my husband. If he cannot help I can talk to a best friend or a tutor. (R11)
Trusted friends are ones who understand me at the same level, depth. Trusted friends are ones you can share your feelings with – but not, normally, your depression. Trusted friends are normally my age. (R18) A trusted friend is someone you can trust, someone you are really close to, someone who knows your background, someone who understands your feelings and who is much the same as myself. Other sorts of friends are just ones you hang out with. (R20) For one respondent, having trusted friends was a vital asset. Other sorts of friends might not be reliable or they may even be potentially threatening: It is not easy to find a trusted friend, some friends are back-stabbers. When you face difficulties they just drift away from you and back stab. A trusted friend will help you in difficulties and help you out. Sometimes there is bullying: I was one! I nearly quit: they were not good. A ‘trusted friend’ [is] someone you can confide in. Other friends are just ones to hang out with and have fun with. (R19)
Sports and hobbies A number of students referred to sporting and other hobby activities as means of moderating stress: I also play sports, so I think that I give out all of my stress in my sports – I play netball and badminton – this is organised by the college. (R2) I prefer to go bowling and do some outdoor activities – go to the beach. I talk to my friends – they are very supportive and my family are also supportive. (R4)
Prayer and nature For some, a form of communion with nature was a means of relieving stress. This was sometimes linked to a religious theme: Above all, I go to lonely places, lakes, appreciate God’s creation. (R14) When I am stressed I go to the sea and shout at the sea. (R6)
814 The latter response seemed to be a form of both catharsis and social isolation; it seemed important to be able to get away from others but also to have some form of ‘safe’ emotional release.
Organisational and institutional moderators Many students articulate examples of what they felt could be done to lessen stress within the nursing profession. These ideas might be thought of as ‘organisational moderators.’ In the first example, the student felt that ‘someone’ should be made responsible for the issue of stress and also noted staff and equipment shortages: Nursing should provide a consultant who can solve the problem. Also, I think that nursing officers should be able to work alongside doctors without bias. The stressed person should be able to talk to someone who they can trust. Shortage of staff is also a cause of stress and the lack of appropriate equipment – sometimes we only have one thermometer for example. (R11) Another student identified the human and caring features that needed to be attended to in order to reduce stress; perhaps identifying a ‘core’ aspect of the health care professional/patient relationship: It goes back to patient care, doctors need to respect patients, and give a feeling of really being cared for, as well as nurses, for the patient and family. Not all do at the moment. New doctors are better and there are signs of change. Latest things on internet, research on patient centered on bedside care – this will help all. (R14)
Other ways of coping with stress Individual students identified particular, sometimes idiosyncratic, ways of dealing with stress. One, for example, suggested: Sometimes when I get home from work I like to put the music on very loud and drive so fast! (R8) Another student identified a range of strategies that she used to moderate the effects of work and study related stress: We have counsellors who can help, in the hospital for all the working people, if they have stress. Some people feel guilty about seeing a counsellor and say ‘talk to your friends and family’. I like to talk to my mother, my family and my friends and share with them what makes me feel stressed and seek their help. With humour, I deal with it also and I also like to relax by listening to music, doing
P. Burnard et al. tai chi. Sometimes if I cannot cope, I cry and this helps to release tensions. (R3) This student notes the availability of a counsellor, but also alludes to a certain stigma attached to going to see such a person. In collectivist cultures, it is frequently the case that people will talk about their problems most readily to their family and friends, rather than to a disinterested outsider (Hofstede, 1994). This student also summarises a range of methods discussed by many of her colleagues in the study: crying, using humour, relaxing by listening to music and talking to friends and family.
Stress outcomes The themes that emerged within this category were being motivated, somatic symptoms and psychological symptoms.
Positive outcomes: being motivated For some students, stress could be a motivator, forcing the individual to reconsider his or her position and to be challenged to do something: Yes, I guess everyone has stress. Everyone has to deal with it. Sometimes stress can make us selfmotivated. It makes you think further and further. (R1) We can learn to cope with it; we learn how to cope with difficult situations. (R2) I think, it a way, it is important for one to have stress: it is a signal to say ‘Hello! This is too much!’ This is one of the best things about stress. With proper management of stress, it is a healthy to have some stress. Everyone has stress! Even if your pockets are filled with money, you still have stress! (R4) The last student, quoted above, notes both the ‘warning call’ of stress but also a way of rationalising stress by appreciating that ‘everyone has stress’. However, one student felt unable to find anything positive in stress and suggested: I don’t think there are good effects of stress! (R5)
Negative outcomes: somatic symptoms Students described their experiences of stress. Stress sometimes produced somatic as well as psychological symptoms, and even changed appetites:
A descriptive study of Bruneian student nurses’ perceptions of stress I feel a headache and sometimes not really mental block but I cannot do things when I am stressed, it distracts me and stops me from doing things. It makes me a little upset but I do not cry. (R2) I get a migraine, I just want to bang my head against the wall and shout. (R6) Its kind of like rough: I feel like shouting and I become angry- even towards the person closes to me. In my stressed mood I get a high pitched voice. (R8) When I am stressed I eat a lot. Stress really, really affects my mood and my relationships with friends. (R7) I don’t know how to deal with the stress. Sometimes I don’t eat. (R1)
Negative outcomes: psychological symptoms Negative effects – particularly long term effects – were noted by the students, including the ideas that stress could cause depression and other mental illness, and might even lead students to leaving their training. However, one student also seemed particularly aware of the immediate effects. She noted that one may lose friends in the processes of becoming or being stressed: I find stress is always negative and it can give you mental problems and you will be like in stress all of the time and ignored by people and you let it out to people and you will loose people – they will just go! If you are not stressed, people will come to you. If you are stressed, people will leave you! (R19) For some others, negative views of stress were almost the mirror image of positive ones: I think stress can demotivate you. You feel not comfortable and you do not accept what people say to you and you feel unlikable. You work with less confidence and you feel lost in the ward. You become lonely and don’t want to talk to people and you say to yourself: ‘I am not that good’. (R10) Again, the suggestion, here, is that stress can make you unpopular. This may go some way to explaining some students’ reluctance to talk to the friends and family about stress. Again, in collectivist cultures, a sense of inclusion and a sense of oneness with friends and family is very important (Hofstede, 1994). In stressful times, some wanted to be with friends but others wanted to hide themselves away until the stress feelings had passed. Students often
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described psychological symptoms of stress, such as feelings of depression, anger, tension and anxiety: Well I feel long and short term, my mood and behaviour changing, negative thinking, long term I feel just, lonely, don’t want to speak to anyone – my self-esteem is low, confidence low. (R13) I just keep myself in the room and get rest: I do not want to think any more until the stress has gone. I also loose my temper sometimes. I don’t want to talk to anyone. (R9) I feel I can’t really do anything. I feel like crying and normally I would look for my friends to have a laugh or something. I try not to be angry with people but sometimes I am without realising. (R16) The use of moderators seemed, in most cases, to relieve stress (if only temporarily). A number of students noted, also, that there were both positive and negative effects of stress; particularly unmoderated stress.
Ideal type Finally, the findings were used to produce an ‘ideal type’: an idealised word-picture of an ‘aggregated’ Bruneian student and her/his relationship with stress. Originally developed by the sociologist, Max Weber (Coser, 1977), the concept of an ideal type is a model, and perhaps a set of exaggerated characteristics defining the essence of certain types of behaviour observable in the real world. The ideal type, then, is formed from characteristics and elements of a given phenomenon (in this case students experiencing stress), and is intended to illustrate certain elements common to most cases of that phenomenon. It is not, however, meant to correspond to all of the characteristics of any one particular case, or to reflect statistical averages. The ideal type as defined by the current data is as follows: The Bruneian nursing student comes from a close family background. She is usually Muslim. She has a circle of friends, some of whom are trusted friends – people she can talk to about problems and to whom she will turn before she talks to her parents. Others are simply friends to have fun with – and ‘having fun’ or joking is an important feature of friendship. In clinical nursing, she finds herself having low status and may or may not be helped to learn by more senior staff. In the nursing college, she finds the physical environment not always conducive to study and finds learning resources sparse. She sometimes feels overwhelmed by the
816 diet of assignments and by completing the dissertation – the ‘paperwork’. Having to learn and write in English, rather than her native language (Malay) causes problems. Out of all this she experiences stress. This manifests itself in various ways: sometimes she feels like crying and sometimes she wants to shut herself away in her room. To alleviate the stress, she may engage in sporting activities, listen to music or talk to her trusted friends. She may not, immediately, talk to her parents, for fear of worrying them unnecessarily. She feels that both the nursing college and the clinical settings could be better organised and resourced and realises that shortage of clinical staff contributes to work-related stress.
Limitations A limitation of this study is, perhaps, the less than detailed reference to Islam and its effects on the students’ perceptions of stress in their work and study. Furthermore it should also be noted that culture does much to define both how we conceptualise psychological problems and stress and the degree to which we are prepared to discuss it with a third party (in this case, with a ‘local’ researcher and a ‘foreign’ one). This would explain why the students did not discuss any of the more negative coping strategies i.e. smoking, comfort eating, medication, hostility, taking it out on others The literature, in other cultural contexts, clearly highlights this behaviour across a number of other studies (Jones and Johnston, 1997; Kirkland, 1998; Mahat, 1998; Lo, 2002; Tully, 2004). It should also be noted that the terms mental health and stress mean different things to people across different studies and therefore only tentative comparisons should be made with other studies. Helman (2001) summarises the relationship of culture to psychological and mental health issues in that it influences the clinical presentation and distribution of mental illness and that it determines the ways that mental illness is recognised, labelled, explained and treated by other members of that society.
Discussion This paper reports a qualitative, descriptive study, using a modified grounded theory approach to researching stress in Bruneian students. Through interviews, students expressed their views about stressors (both academic and clinical), moderators
P. Burnard et al. and outcomes of stress (Carson and Kuipers, 1998). Students often found their status as students caused them stress in the clinical setting: with other nurses, with doctors and even with patients. Academic related stressors included having to complete assignments and dissertations which has been identified internationally has an area of concern for nursing students (Beck and Srivastava, 1991; Clarke and Ruffin, 1992; Thyer and Bazeley, 1993; Beck et al., 1997; Jones and Johnston, 2000; Sheu et al., 2002; Evans and Kelly, 2004). It is recognised that students possess language difficulties that affect their academic achievement in nursing programs where English is their second language (Petro-Nustas et al., 2001; Pardue and Haas, 2003). A key stressor identified by this study was having to study in the medium of English. Studies conducted where nursing is taught in English in other countries have noted that English language skills are important skills as they can facilitate the acquisition of up-to-date scientific information and promote life long learning (Abriam-Yago et al., 1999). We note, in our findings, that the relationship between nursing staff (students and trained) on the clinical area was an important issue. This is also evident in the previous literature as demonstrated by Hamill (1995), Thyer and Bazeley (1993), Lo (2002), Timmins and Kaliszer (2002) and Evans and Kelly (2004). Previous research has indicated that students reporting low levels of stress/distress use a number of coping methods to manage their stress for example problem solving (Jones and Johnston, 1997; Mahat, 1998; Lo, 2002; Tully, 2004; Sheu et al., 2002), talking to others – relatives, friends and peers (Evans and Kelly, 2004; Tully, 2004), recreation and sport (Lo, 2002), social support – family, spouse, partners workmates, classmates, lecturers and tutors (Kirkland, 1998; Lo, 2002) Other coping strategies reported included having outside interests, using mentors, and having friends outside nursing (Brown and Edelmann, 2000), staying optimistic (Sheu et al., 2002), the desire to obtain a qualification, the need to finish something I started and determination (Evans and Kelly, 2004) and better studying techniques and time management skills (Lo, 2002). In the present study various ways of moderating stress were reported including social support talking to friends and family, talking to ‘trusted friends’, engaging in sports or simply being quiet. There is a lot of similarity with previous work but this paper reveals that talking to ‘‘trusted friends’’ which was identified separately to that of talking to everyday friends and family is important for students from this culture.
A descriptive study of Bruneian student nurses’ perceptions of stress Potential stressors will only lead to negative stress outcomes if the individual has insufficient resources (coping strategies) to manage them. Nursing students in the study by Evans and Kelly (2004) reported being exhausted, under pressure, upset, worrying about what might happen, rundown, frustrated and worried. This study demonstrated that nursing students experienced range of somatic symptoms and that if not resolved then stress could lead to depression and mental illness as well as and. This is in keeping with the work of Deary et al. (2003) who demonstrated that students who experienced increasing levels of stress and who used more negative coping mechanisms as the programme progressed were more likely to report a psychological symptoms. Shipton (2002) found that the emotions generated by stress in the clinical experience has been reported to lead to nervousness, depression, anxiety, fear, frustration, anger, hopelessness, loneliness and inferiority (Shipton, 2002). Whereas, Pagana (1990) found that the stressful nature of the clinical experience was seen to be more of a challenge i.e. potential for mastery, growth or gain than a threat i.e. the potential for harm in keeping with our finding that stress can act as a motivating factor challenging the student to do something about their situation.
Conclusions From these views and drawing on the cultural literature that identifies Brunei as a collectivist culture, an ‘ideal type’ is suggested, which can be compared with types drawn from other cultures in future research. Given that Brunei was, until the 1970s a British protectorate, it is still possible to detect the possibility of a misfit between ‘British’ forms of nursing education and ‘Islamic’ forms of education and practice. We note, above, the rather anomalous situation of Brunei students being taught in English but ‘practicing’ in Malay. As nursing education in Brunei moves into the university sector, we may find this changing. It may be useful to replicate this study once integration within Brunei University has been fully achieved. Finally, although mostly beyond the scope of this study, it must be kept in mind that the Islamic code of Brunei affects all aspects of the nurses’ and patients’ life in that country. Writing in a nursing context, ElGindy (2006) notes: ‘‘Adherence to Islamic teachings governs every aspect of Muslim life and must be practiced every day, regardless of the physical setting in which Muslims may find themselves.’’
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