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Clinical placement anxiety in undergraduate nursing students: A concept analysis
Journal Pre-proof Clinical placement anxiety in undergraduate nursing students: A concept analysis
Marie-Claude G. Simpson, Jo-Ann V. Sawatzky PII:
S0260-6917(19)30928-1
DOI:
https://doi.org/10.1016/j.nedt.2019.104329
Reference:
YNEDT 104329
To appear in:
Nurse Education Today
Received date:
17 June 2019
Revised date:
13 October 2019
Accepted date:
29 December 2019
Please cite this article as: M.-C.G. Simpson and J.-A.V. Sawatzky, Clinical placement anxiety in undergraduate nursing students: A concept analysis, Nurse Education Today(2020), https://doi.org/10.1016/j.nedt.2019.104329
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© 2020 Published by Elsevier.
Journal Pre-proof
CLINICAL PLACEMENT ANXIETY IN UNDERGRADUATE NURSING STUDENTS: A CONCEPT ANALYSIS
Marie-Claude G. Simpson RN, BN, MN (student) Université de Saint-Boniface,
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200 de la Cathédrale Avenue
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Winnipeg, Manitoba, CANADA R2H 0H7 (204) 792-1287
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[email protected]
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&
Jo-Ann V. Sawatzky RN, PhD
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College of Nursing, University of Manitoba Winnipeg, Manitoba, CANADA R3T 2N2
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(204) 474-9317
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[email protected]
Funding Source This review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest None declared Ethical Approval Not applicable
Journal Pre-proof ABSTRACT Objective: The primary aim of this review was to complete an in-depth analysis of clinical placement anxiety in undergraduate nursing students. Our overall goal was to establish a strong foundation for clinical education strategies and future research on clinical placement anxiety in nursing education. Design & Methods: We utilized Walker and Avant‟s systematic 8-step approach to concept analysis as a framework to develop a comprehensive understanding of clinical placement anxiety in undergraduate students. Data sources: A review of existing literature on clinical placement anxiety was
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conducted using the electronic databases of PubMed, CINAHL, and PsychInfo, as well as
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a grey literature and snowball search. Search terms included clinical placement, clinical experience, nursing students, undergraduate nursing students, and anxiety. Results: The
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literature search resulted in 81 articles that met the inclusion criteria. Five defining attributes were identified: a vague or unknown threat, psychological-emotional responses,
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psychological-cognitive responses, physiological responses, and unfamiliar environments
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or situations. Antecedents, consequences, and empirical referents of the concept were also highlighted. Conclusions: Insights gleaned from this concept analysis may enhance
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the ability of clinical nursing educators to effectively prevent and manage student anxiety in the clinical setting. By contextualizing anxiety, we have also validated the importance of further exploration of the anxiety
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experienced by undergraduate nursing students during their clinical experiences. Thus,
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this concept analysis establishes the foundation for educational strategies, as well as future research in nursing education. Note: 231 words/max 300 Keywords Clinical placements, clinical experience, anxiety, undergraduate nursing student
Journal Pre-proof INTRODUCTION It is well-known that anxiety has a negative impact on one‟s health and well-being (American Psychiatric Association, 2013). Nursing students experience an enormous amount of stress and anxiety during their academic studies (Benner, 1983; Benner, Tanner, & Chelsa, 2009; Macauley et al., 2018). Students affected by anxiety are at increased risk for poor academic and clinical performance outcomes, as well as decreased
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well-being (Benner, 1983; Benner et al., 2009; Chernomas & Shapiro, 2013; Macauley,
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2018). Moreover, several researchers have found that most anxiety experienced by
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nursing students is attributed to their clinical placement experiences (Chernomas &
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Shapiro, 2013; Kleehammer, Hart, & Keck, 1990; Nolan, 1998). For example, in the preliminary findings of an interventional study to reduce anxiety in nursing students (N =
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100), Sharif and Armitage (2004) found that most participants experienced clinical
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anxiety.
Benner et al. (2009) identified several challenges that students face when exposed
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to new or unfamiliar clinical settings. For example, a student‟s focus may shift from
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gaining clinical experience to concerns about personal insufficiencies. Feeling incompetent or overwhelmed by the clinical placement may result in incapacitating anxiety (Benner et al., 2009). Therefore, it is essential to understand the factors that influence clinical placement anxiety and to develop strategies to reduce these factors so that students can successfully integrate into the nursing profession and become proficient novice nurses. The purpose of this paper is to provide an in-depth analysis of the concept of clinical placement anxiety in undergraduate nursing students. Our primary goal is to
Journal Pre-proof provide insights for nurse educators to effectively prevent and manage undergraduate student anxiety in the clinical setting. In addition, our objective is to establish a solid foundation for future research in this critical area of nursing education. Walker and Avant‟s (2011) systematic 8-step approach was the framework utilized to guide the review of the existing literature. This paper defines the concept by analyzing the terms utilized, as well as identifying and defining the key attributes, cases, antecedents, and
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consequences, and empirical referents.
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METHOD
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Walker and Avant‟s (2011) approach to concept analysis is a commonly used
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framework in the published literature (McEwen & Wills, 2014). According to Walker and Avant (2011), the framework's purpose is to guide the development of comprehensive
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concepts to further the nursing profession by clarifying vague ideas and ill-defined
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concepts. Walker and Avant‟s (2011) framework uses an eight steps approach: 1) select the concept; 2) determine the purpose of the analysis; 3) discover all uses of the concept;
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4) determine the defining attributes; 5) identify a model case; 6) identify borderline,
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related, and contrary cases; 7) identify antecedents and consequences; and 8) define empirical referents.
A literature search was conducted using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and PsychInfo. Grey literature and snowball searches were also completed. The following keywords were used: clinical placement, clinical experience, undergraduate nursing students, anxiety. Only English articles referring to undergraduate nursing students, clinical, and anxiety were examined; articles that referred to graduate nursing students or simulations were
Journal Pre-proof excluded. To accomplish a comprehensive understanding of the literature, no date restrictions were applied. The results yielded a total of 81 articles that met the inclusion criteria. RESULTS Defining Anxiety In lay terms, while Merriam-Webster's dictionary (2019) defines anxiety
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generically as: “apprehensive, uneasiness or nervousness usually over an impending or
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anticipated ill” (para. 1), the Oxford University Press (2019) uses the terms of worry,
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nervousness, and unease, as well as the notion of uncertain outcome to define anxiety. In
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medical terms, Stedman‟s Medical Dictionary (2005) defines anxiety as “Apprehension of danger and dread accompanied by restlessness, tension, tachycardia, and dyspnea
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unattached to a clearly identifiable stimulus” (p.97). However, the disciplines of
anxiety.
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psychiatry, psychology, and nursing each have their own unique ways of defining
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As a term, anxiety has been used in psychiatric medicine literature for centuries.
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Documents dating back to ancient Greece (i.e., Hippocrates c460 to c370 AD) attempted to describe and even classify anxiety as an illness (Crocq, 2015). Much more recently, anxiety was first introduced in the American Psychiatric Association‟s (APA) Diagnostic and Statistical Manuel of Mental Disorders DSM-I as the primary characteristic for psychoneurotic disorders in 1952 (Crocq, 2015), and as a disorder in psychiatry in 1980. The APA‟s (2013) DSM-V defines anxiety as a normal human experience of fear in the face of a future or imminent threat. Similarly, the Mayo Clinic (Mayo Clinic, 2019)
Journal Pre-proof describes the occasional experience of anxiety as normal, which differs from the notion of anxiety as a disorder, which is excessive or pathological in nature (APA, 2013). The discipline of psychology views anxiety as behavioral or cognitive, as opposed to pathological. For example, Rachman (2004) defines anxiety as “the tense, unsettling anticipation of a threatening but vague event; a feeling of uneasy suspense” (p. 3). Similarly, Lazarus and Folkman (1984) define anxiety as a vague and uncomfortable
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feeling; however, they emphasize that it is "exacerbated by prolonged stress and the
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presence of multiple stressors" (p. 4). Additionally, Eysenck et al. (2007) identify anxiety
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as the inability to modify behavior when one's goal is threatened. According to Rachman
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(2004), the experience of anxiety includes intense, constricting, and pre-occupying sensations, which can be explained as changes in attention (e.g., self-attention),
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perception (e.g., objective or subjective distortion), emotional processes (e.g., intense
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feelings), affect, cognition, and memory, as well as physical reactions (e.g., increased heart rate, image distortion). Roeckelein (2006) describes anxiety as a subjective
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emotional state due to perceived angst that manifests into physical symptoms, such as
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tremors, pain, muscle tension, and headaches. In the nursing literature, the definition of anxiety aligns closely with the disciplines of psychiatry and psychology as a normal subjective response to a vague or unknown threat. Hildegard Peplau (1989), a psychiatric nurse theorist, well-known for her theoretical framework on interpersonal relations, describes anxiety as a clinical construct. According to Peplau (1989), everyone experiences anxiety to varying degrees throughout their life, and it is a cognitively prompted, subjective (i.e., affective) experience. The negative consequences of experiencing anxiety are physiological
Journal Pre-proof reactions to the perceived threat (e.g., sweating, trembling) and behavioral responses, such as escape or avoidance (Peplau, 1989). Similarly, Meisenhelder (1987) defines anxiety as “a psychological and physical response to a threat to self-concept” (p. 27). This threat is subjective and elicits emotions, such as apprehension and tension. Similar to the fight or flight response to fear, Meisenhelder (1987) also describes this same response within the context of anxiety. Importantly, Meisenhelder describes anxiety as “a
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serious obstacle to clinical functioning in the student nurse” (p.27).
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In summary, within the discipline of nursing, anxiety is defined as a cognitive
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perception of a potential vague or ambiguous, subjective threat, which triggers
changes.
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Defining Clinical Placement Anxiety
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psychological responses, and consequent, physiological reactions and behavioural
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For this concept analysis, clinical placement is defined as undergraduate nursing student experiences in the clinical setting for the purposes of learning the practical skills,
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applying the nursing knowledge, and experiencing the professional behaviors required to
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achieve the essential competencies of novice nurses. Any type of actual clinical learning experiences, including clinical practicums or clinical preceptorship experiences, are included in this definition; however, clinical simulation, which is used to prepare students for clinical placement by pretending or role-playing, is distinct from the experience of learning and practicing in real-world situations. Therefore, clinical placement anxiety is defined as a vague perceived threat to a student‟s goals or expectations in clinical practice, due to the presence of stressors, including unfamiliar environments or situations,
Journal Pre-proof resulting in psychological, physiological, and behavioral responses, and which, in turn may have a negative impact on the student‟s clinical outcomes. Defining Attributes of Clinical Placement Anxiety Defining attributes are the fundamental elements of a concept. These attributes are characteristics of the concept that repeatedly appear during the researching process. By identifying these attributes, the phenomenon is understood within the context of
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similarities and differences related to other concepts (Walker & Avant, 2011).
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Based on the reviewed literature, five defining attributes for clinical placement
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anxiety were identified: vague perceived threat, psychological-emotional responses and
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psychological-cognitive responses, as well as, physiological responses, and the presence of an unfamiliar environment or situation.
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The vagueness quality of clinical student anxiety may be related to the generally
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overwhelming sense of responsibility in the clinical setting, especially for the novice student. Several studies identified that students experience anxiety related to first
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interactions with patients, making mistakes, patient harm, patient care, and feelings of
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incompetence (Alshahrani et al., 2018; Beck, 1993; Melincavage, 2011; Sharif & Armitage, 2004; Sun et al., 2016). Kim (2003) noted that talking to physicians, being late, and being observed by instructors produced high anxiety among senior nursing students. Although Melo et al. (2010) noted similar themes, they also observed themes such as lack of confidence regarding skills and competencies, and lack of clinical preparation. The attribute of a vague perceived threat differentiates clinical placement anxiety from the concepts of fear and stress. Meisenhelder (1987) differentiates anxiety from fear by considering the subjective versus objective nature of the threat and degree of danger.
Journal Pre-proof While the presence of specific stressors may produce anxiety (Lazarus & Folkman, 1984), students in the clinical setting may not be able to identify the specific causes of their sense of anxiety; whereas fear is characterized by the ability to recognize a threat and consequential imminent danger (Whitley, 1992). Stress, on the other hand, is the result of a transactional relationship with the environment that exceeds the ability to cope (Lazarus & Folkman, 1986). Therefore, while anxiety is caused by a perceived vague
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threat, fear is a recognised threat, and stress is caused by overwhelming environmental
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pressures.
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Psychological-emotional responses to clinical placement anxiety are subjective, and
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as such, are identified only when described by the individual (e.g., worry, uneasiness, insecurity, dread, apprehension, uncertainty). Psychological-cognitive responses are the
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cognitive processes that influence the perceived reality and subsequent behaviors, such as
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perceptual disturbances, object distortion, memory bias, selective attention, misinterpretations (Ray, Gulati, & Rai, 2017), avoidance and escape (Rachman, 2004),
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and decreased performance and efficiency (Eysenck et al. 2007). Psychological responses
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to clinical placement anxiety are less acute and intense than fear responses, such as feeling terrified and running away from the threat. The physiological responses to clinical placement anxiety are objective and measurable. Although the physical manifestations may include increased pulse and respiratory rate, perspiration, facial flushing, restlessness, jaw clenching, and insomnia (Folk & Folk, 2018; Meisenhelder, 1987), these responses are generally less intense than those manifested in fear.
Journal Pre-proof Finally, the perceived threat experienced in clinical placement anxiety is more likely to occur in new or unfamiliar environments or situations (Beck, 1993; Benner et al., 2009; Chernomas & Shapiro, 2013; Kim, 2003; Melo et al., 2010; Nolan 1998). Several studies have also revealed that the presence of anxiety is in anticipation of the clinical experience (Chernomas & Shapiro, 2013; Kim, 2003; Melo et al., 2010; Nolan 1998). Several studies identified that initial clinical experiences produced high levels of
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anxiety (Beck, 1993; Kim, 2003; Kleehammer et al., 1990; Nolan, 1998; Sharif &
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Masoumi, 2005). In a recent mixed methods study of first-year undergraduate nursing
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students in their first clinical placements (N = 58), Alshahrani et al. (2018) noted that
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most students (91%) were moderately anxious (46%), anxious (31%), or extremely anxious (14%). Thus, new situations or environments are the catalysts for the perceived
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threat in the students‟ clinical learning experiences and the consequent psychological,
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behavioural, and physiological responses that ensue. It follows that novice clinical
placement anxiety.
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students and those entering new clinical settings may be at particular risk for clinical
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Antecedents and Consequences Antecedents and consequences are important in refining and supporting the defining attributes. While antecedents are the factors that must precede the concept, consequences are outcomes or events resulting from the occurrence of the concept (Walker & Avant, 2011). The key antecedents for clinical placement anxiety include the capacity to perceive one‟s own emotions or feelings, the individual‟s cognitive ability, as well as perceived self-efficacy. Clinical placement anxiety will only occur if the student has the
Journal Pre-proof ability to feel psychological/ emotive processes or emotions. Furthermore, clinical placement anxiety tends to occur when there are perceived changes in the environment or future situations, and the student feels threatened or vulnerable (Rachman, 2004). Cognitive ability is an essential component in a person's ability to learn and perform; however, it is also this ability that stimulates the physiological and affective reactions that influence the perceived expected outcome (Bandura, 1986). Likewise, the student‟s
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perceived self-efficacy directly affects the student‟s sense of vulnerability or confidence,
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making them either more resilient or more susceptible to emotional arousal and clinical
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placement anxiety. According to Bandura (1986), an inverse relationship exists between
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self-efficacy and stress reactions, such as anxiety. Bandura (1997) also posits that high levels of inefficacy contribute to the inability to cope and perform. (Bandura 1997).
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Therefore, according to this theory, students with low self-efficacy are more likely to
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have higher clinical placement anxiety. An interpretive descriptive study by White (2003) on clinical decision making in fourth-year nursing students (N = 17) lends support for this
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theory, with the finding that self-confidence was inversely related with anxiety in the
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clinical decision making.
Within the context of a concept analysis, consequences can be negative or positive. The key negative consequence is the presence of relief behaviors, such as avoidance and escape (Peplau 1989, Rachman, 2004). These behaviors create a brief sense of relief (Rachman, 2004), which in turn encourages or reinforces individuals to continue the negative behaviors (Peplau, 1989; Rachman, 2004), and places them at higher risk for the development of an anxiety disorder (APA, 2013). High attrition rates and poor academic outcomes, as well as risks to physical and mental well-being, have been associated with
Journal Pre-proof experiencing anxiety in clinical placements (Macauley et al., 2018; Ruz et al., 2018; Sun et al., 2016). Additionally, Ruz et al. (2018) found that nursing students (N=170) who experienced persistent anxiety were more likely to have poor academic achievement and higher absenteeism rates. Conversely, the positive consequences of clinical placement anxiety are effective coping and resiliency, which in turn motivate behavioural change and result in personal
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growth. A positive behavioral change results in an increased sense of self-worth,
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achievement (James et al., 2016; Rachman, 2004), and self-efficacy (Bandura, 1997).
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Identifying Case Examples
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According to Walker and Avant (2011), cases should be used as examples to better understand the full extent of the concept being defined. Walker and Avant (2011)
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recommend utilizing model, borderline, related, and contrary cases. The following cases
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are fictional examples.
Model case. A model case validates the concept and exemplifies the ideal
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circumstances in which all the defining attributes are present (Walker & Avant, 2011).
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Amanda is a 1st year nursing student who is starting her first clinical placement. She has not slept all night due to vague feelings of unease and apprehension, feels her heart racing, and her chest feels heavy whenever she thinks about the upcoming clinical experience. On arrival to the clinical unit, Amanda meets her clinical instructor, who is frowning and looks unfriendly. She spends the morning avoiding the instructor and attempts to stand in the back of the group to avoid attracting attention to herself. Later in the day, Amanda is forced to seek guidance from the instructor regarding a new skill. Amanda feels unwell; she is perspiring and trembling. The instructor is patient and kind,
Journal Pre-proof which allays Amanda’s anxiety. After performing the skill well, she feels more selfconfident and realizes she has misjudged her instructor because of her anxiety. In this model case, Amanda is experiencing all of the defining attributes of clinical placement anxiety. These attributes include a vague threat to self, physiological, psychological-emotional, and psychological-cognitive responses (i.e., misperception of the instructor, behavioral changes, avoidance), as well as the catalyst of the unfamiliarity
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of the situation/environment. The key positive consequences of the clinical placement
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anxiety are Amanda‟s increased sense of self-confidence and self-awareness.
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Borderline case. The borderline case is an example that includes most of the
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elements of the model case; however, it differs by at least one of the elements and thus demonstrates how the concept changes when there are inconsistencies (Walker & Avant,
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2011).
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Aaron is a second-year nursing student who is shadowing a nurse in the emergency department for the day. Aaron has never been in an emergency department before and
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worries about what the day will be like. His hands are moist with perspiration; he has
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retreated to the bathroom several times this morning to avoid the scary environment. Aaron and his preceptor walk into the waiting room where a patient is yelling and making physically aggressive movements. The patient makes eye contact with Aaron and makes a threatening movement towards him. Aaron’s heart rate quickens, he starts to sweat profusely, and he perceives this patient as an imminent threat. Aaron turns and leaves the waiting room. This borderline case includes many of the defining attributes of clinical placement anxiety. However, the sudden, intense, and identifiable threat perceived by Aaron, as well
Journal Pre-proof as his intense physiological response are more typical of fear than anxiety. Aaron‟s response of escape is consistent with responses to anxiety and fear. Related case. A related case does not include all the defining attributes of the concept being analyzed (Walker & Avant, 2011). Frank is repeating his fourth-year clinical placement. His father passed away the previous term, which was devastating for him. Frank also recently lost his part-time job
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as a waiter at a local restaurant. While he is doing patient research, he notices many
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skills and treatments that he will need to perform on the following clinical day. He feels
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worried about failing again, and he is concerned about being able to complete all the
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necessary tasks successfully. He feels a heaviness in his chest and butterflies in his stomach; he begins to cry.
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This case represents the related concept of stress. Frank has recently experienced
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several significant personal life stressors which have disrupted his state of equilibrium. This stress is compounded by his return to the clinical area and the fear of failure.
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Although Frank exhibits the psychological and physiological responses of anxiety, the
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stressors in this situation are significant to Frank‟s well-being and have exceeded his ability to cope, which is consistent with stress. Contrary case. A contrary case is easily understood and identified as completely different from the concept being analyzed (Walker & Avant, 2011). Cassie is completing her last clinical practicum course; she is familiar with the staff and the expectations of her preceptor. Her patient requires a nasogastric tube insertion, which she has done several times before. Cassie is enthusiastic to perform this
Journal Pre-proof procedure again; she feels calm and confident. She successfully completes the procedure independently. She feels accomplished and validated. This case does not depict any of the defining attributes of clinical placement anxiety. Cassie is familiar with the environment and does not perceive any threat. Consequently, she does not exhibit physiological, psychological, or behavioural signs of anxiety. This is a positive learning experience resulting in personal and professional
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growth.
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Empirical referents
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According to Walker and Avant (2011), empirical referents establish a means to
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measure the occurrence of the concept of interest. Table 1 is a compilation of empirical referents for clinical placement anxiety, based on a review of the related literature.
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Although, this is not an exhaustive list, it serves as a reference for the indicators of
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clinical placement anxiety, within the
context of the defining attributes. This list may also be useful to nursing students and
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instructors in the clinical setting.
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In the research literature, anxiety has been measured using a variety of valid and reliable tools, including the Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond, 1995), Hamilton Anxiety Rating Scale (HARS; Hamilton, 1959), Overall Anxiety Security and Impairment Scale (OASIS; Norman et al., 2006), PENN State Worry Questionnaire (PSWQ; Meyer et al., 1990), State-Trait Anxiety Inventory (STAI; Spielberger, 1983), and Westside Test-Anxiety Scale (WTAS; Driscoll, 2007). Although only a few of these tools have been used to measure clinical placement anxiety, several authors have utilized the STAI in studies related to undergraduate nursing students and
Journal Pre-proof anxiety in clinical settings (Melo et al., 2010; Patton & Goldenberg, 1999; Shahsavari et al., 2017; Villeneuve et al., 2018). As well, in a descriptive study (N = 61), Kim (2003) utilized the Trait Anxiety (T-Anxiety) Scale component of the STAI and the Clinical Experience Assessment form (CEAF; Kleehammer et al. 1990) to identify anxietyprovoking experiences in nursing students. Additionally, grounded in Bandura‟s (1986) social-cognitive theory, White (2014) developed the Nursing Anxiety and Self
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Confidence with Clinical Decision Making (NASC-CDM) tool. This reliable and valid
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27-item tool is a self-reported, 6-point Likert scale instrument with two subscales
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measuring levels of self-confidence and anxiety in undergraduate nursing students
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(White, 2014). White, Fetter, and Ruth-Sahd (2018) utilized the NASC-CDM scale in a recent quasi-experimental study to measure the impact of a summer externships on
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promoting self-confidence and reducing anxiety related to clinical decision-making in
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nursing students (N = 134). Importantly, the results of this study support an inverse
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relationship between self-confidence and anxiety in the clinical setting. Discussion
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This concept analysis of clinical placement anxiety provides insights for educators and researchers. The research-based evidence related to each of the defining attributes, and the antecedents and consequences, as well as the case examples may guide educators to effectively prevent and address anxiety in their clinical students. For researchers, the identified gaps in the current literature provide a sound rationale for further research in this important area of nursing education. Educators should consider implementing any or all of the reportedly effective strategies to prevent or decrease clinical placement anxiety in their students. For example,
Journal Pre-proof incorporating pre-clinical knowledge and skill development sessions, such as pre-clinical workshops, orientations, and simulations have been found to be effective in decreasing anxiety in the clinical setting (Baksi et al., 2017; Park, 2018; Ratanasiripong et al., 2015; Shahsavari et al., 2017; Watt et al., 2016; White et al., 2018).). Research evidence also supports the strategies of mindfulness (Ratanasiripong et al., 2015) and peer support (Kim et al., 2013; Walker & Verklan, 2016; Zentz, Kurts, & Alverson, 2014) to decrease
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clinical placement anxiety. While anxiety influences clinical performance and effective
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clinical learning, self-reflection and self-efficacy have been identified as a positive
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influence on clinical performance (Pai, 2016; Pai et al., 2017). Sharif and Armitage
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(2004) found that student GPA scores increased, and clinical placement anxiety decreased after a 12-week program that consisted of a weekly session on anxiety control
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and coping strategies.
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Educators also need to be aware of potential harms associated with clinical placement anxiety and the need for support and mental health resources for students who
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are experiencing persistent or incapacitating anxiety. Despite faculty members being
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optimally positioned to identify and support students, Reeve et al. (2013) observed that few students seek help and support from faculty. Therefore, a healthy clinical learning environment, with empathetic, supportive, and approachable faculty and staff is pivotal to the prevention and management of clinical placement anxiety (Melincavage, 2011). Nurse educators would benefit from professional development workshops that focus on strategies to better support and advocate for students‟ well-being in the clinical setting (Chernomas & Shapiro, 2013; Yearwood & Riley, 2010).
Journal Pre-proof Clinical placement anxiety in undergraduate nursing students is an emerging area of nursing research. However, few studies have explicitly focused on nursing student anxiety in the clinical setting. Qualitative inquiry, which focuses on a phenomenological or „lived experience‟ approach, as well as interventional research, which focuses on strategies to reduce clinical placement anxiety, is needed. Finally, although several anxiety tools have been used in studies related to nursing student anxiety, further research
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is needed to develop reliable and valid tools to measure clinical placement anxiety as
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defined by this concept analysis.
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CONCLUSION
The concept of clinical placement anxiety in undergraduate nursing students was
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explored using Walker and Avant‟s (2011) 8-step approach to concept analysis. A
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comprehensive understanding of the concept was established by defining clinical
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placement anxiety as a vague perceived threat to a student‟s goals or expectations in clinical practice, due to the presence of stressors, including unfamiliar environments or
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situations, resulting in psychological, physiological, and behavioral responses, and which,
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in turn may have a negative impact on the student‟s clinical outcomes. In addition, the core attributes, antecedents and consequences, as well as empirical referents, were identified. The case examples provided context and clarity for the concept. Insights gleaned from this concept analysis established a foundation for strategies to effectively prevent and manage student anxiety in the clinical setting. Gaps in the current evidence surrounding clinical placement anxiety have also been highlighted. As well, conceptualizing clinical placement anxiety validates the importance of further exploration of the anxiety experienced by undergraduate nursing students during their clinical
Journal Pre-proof experiences. Thus, this concept analysis establishes the foundation for educational strategies in nursing education, as well as future research. REFERENCES Alshahrani, Y., Cusack, L., & Rasmussen, P. (2018). Undergraduate nursing students‟ strategies for coping with their first clinical placement: Descriptive survey study. Nurse Education Today, 69, 104-108.
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Beck, C. T. (1993). Nursing students‟ initial clinical experience: a phenomenological study. International Journal of Nursing Studies, 30(6), 489–497. https://doi.org/10.1016/0020-7489(93)90020-U Benner, P. (1983). Uncovering the knowledge embedded in clinical practice. Image: The Journal of Nursing Scholarship, 15(2), 36–41. https://doi.org/10.1111/j.15475069.1983.tb01353.x Benner, P., Tanner, C., & Chelsa, C. (2009). Expertise in nursing practice: caring, clinical judgment, and ethics (2nd ed.). Philadelphia, PA: Springer publishing.
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Table 1. Empirical Referents of Clinical Placement Anxiety Psycho-cognitive responses
Psycho-emotional responses
-Decreased sexual function -Facial flushing -SOB/heaviness in chest -Increased heart rate/ palpitations -Increased blood pressure -Increased respiration rate -Insomnia -Jaw clenching -Silent/gaze avoidance -Stuttering -Sweating or increased perspiration -Abdominal pain/cramps -Diarrhea -Dizziness -Leg weakness -Nausea -Pulsing in the ear -Restlessness -Urinary urgency and/or frequency -Tremors
-Avoidance -Confusion -Decreased information retention/ learning ability -Decreased productivity -Difficulty problem solving -Difficulty concentrating -Hypervigilance -Impaired attention -Memory bias/loss -Misinterpretations -Perceptual distortions -Selective attention -Thought blocking
-Apprehension, unease -Dread of negative evaluation -Feelings of insufficiency -Feeling incompetent -Helplessness -Focus on self /selfattention -Sense of vulnerability -Uncertainty -Worry/concern
Unfamiliar environment or situation -New clinical site -New skills/tasks -New encounters
Vague perceived threat -non-specific perceived threat -perceived potential or future danger -feeling a sense of vulnerability
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Physiological responses
Note: Compilation of empirical referents from the literature (Folk & Folk, 2018; Berry & Wagner, 2015; Rachman 2004; Rachman et al., 1987; Roeckelein, 2006; Spielberger, 1983)
Marie-Claude G. Simpson, Jo-Ann V. Sawatzky PII:
S0260-6917(19)30928-1
DOI:
https://doi.org/10.1016/j.nedt.2019.104329
Reference:
YNEDT 104329
To appear in:
Nurse Education Today
Received date:
17 June 2019
Revised date:
13 October 2019
Accepted date:
29 December 2019
Please cite this article as: M.-C.G. Simpson and J.-A.V. Sawatzky, Clinical placement anxiety in undergraduate nursing students: A concept analysis, Nurse Education Today(2020), https://doi.org/10.1016/j.nedt.2019.104329
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© 2020 Published by Elsevier.
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CLINICAL PLACEMENT ANXIETY IN UNDERGRADUATE NURSING STUDENTS: A CONCEPT ANALYSIS
Marie-Claude G. Simpson RN, BN, MN (student) Université de Saint-Boniface,
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200 de la Cathédrale Avenue
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Winnipeg, Manitoba, CANADA R2H 0H7 (204) 792-1287
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[email protected]
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&
Jo-Ann V. Sawatzky RN, PhD
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College of Nursing, University of Manitoba Winnipeg, Manitoba, CANADA R3T 2N2
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(204) 474-9317
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[email protected]
Funding Source This review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest None declared Ethical Approval Not applicable
Journal Pre-proof ABSTRACT Objective: The primary aim of this review was to complete an in-depth analysis of clinical placement anxiety in undergraduate nursing students. Our overall goal was to establish a strong foundation for clinical education strategies and future research on clinical placement anxiety in nursing education. Design & Methods: We utilized Walker and Avant‟s systematic 8-step approach to concept analysis as a framework to develop a comprehensive understanding of clinical placement anxiety in undergraduate students. Data sources: A review of existing literature on clinical placement anxiety was
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conducted using the electronic databases of PubMed, CINAHL, and PsychInfo, as well as
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a grey literature and snowball search. Search terms included clinical placement, clinical experience, nursing students, undergraduate nursing students, and anxiety. Results: The
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literature search resulted in 81 articles that met the inclusion criteria. Five defining attributes were identified: a vague or unknown threat, psychological-emotional responses,
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psychological-cognitive responses, physiological responses, and unfamiliar environments
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or situations. Antecedents, consequences, and empirical referents of the concept were also highlighted. Conclusions: Insights gleaned from this concept analysis may enhance
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the ability of clinical nursing educators to effectively prevent and manage student anxiety in the clinical setting. By contextualizing anxiety, we have also validated the importance of further exploration of the anxiety
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experienced by undergraduate nursing students during their clinical experiences. Thus,
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this concept analysis establishes the foundation for educational strategies, as well as future research in nursing education. Note: 231 words/max 300 Keywords Clinical placements, clinical experience, anxiety, undergraduate nursing student
Journal Pre-proof INTRODUCTION It is well-known that anxiety has a negative impact on one‟s health and well-being (American Psychiatric Association, 2013). Nursing students experience an enormous amount of stress and anxiety during their academic studies (Benner, 1983; Benner, Tanner, & Chelsa, 2009; Macauley et al., 2018). Students affected by anxiety are at increased risk for poor academic and clinical performance outcomes, as well as decreased
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well-being (Benner, 1983; Benner et al., 2009; Chernomas & Shapiro, 2013; Macauley,
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2018). Moreover, several researchers have found that most anxiety experienced by
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nursing students is attributed to their clinical placement experiences (Chernomas &
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Shapiro, 2013; Kleehammer, Hart, & Keck, 1990; Nolan, 1998). For example, in the preliminary findings of an interventional study to reduce anxiety in nursing students (N =
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100), Sharif and Armitage (2004) found that most participants experienced clinical
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anxiety.
Benner et al. (2009) identified several challenges that students face when exposed
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to new or unfamiliar clinical settings. For example, a student‟s focus may shift from
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gaining clinical experience to concerns about personal insufficiencies. Feeling incompetent or overwhelmed by the clinical placement may result in incapacitating anxiety (Benner et al., 2009). Therefore, it is essential to understand the factors that influence clinical placement anxiety and to develop strategies to reduce these factors so that students can successfully integrate into the nursing profession and become proficient novice nurses. The purpose of this paper is to provide an in-depth analysis of the concept of clinical placement anxiety in undergraduate nursing students. Our primary goal is to
Journal Pre-proof provide insights for nurse educators to effectively prevent and manage undergraduate student anxiety in the clinical setting. In addition, our objective is to establish a solid foundation for future research in this critical area of nursing education. Walker and Avant‟s (2011) systematic 8-step approach was the framework utilized to guide the review of the existing literature. This paper defines the concept by analyzing the terms utilized, as well as identifying and defining the key attributes, cases, antecedents, and
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consequences, and empirical referents.
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METHOD
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Walker and Avant‟s (2011) approach to concept analysis is a commonly used
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framework in the published literature (McEwen & Wills, 2014). According to Walker and Avant (2011), the framework's purpose is to guide the development of comprehensive
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concepts to further the nursing profession by clarifying vague ideas and ill-defined
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concepts. Walker and Avant‟s (2011) framework uses an eight steps approach: 1) select the concept; 2) determine the purpose of the analysis; 3) discover all uses of the concept;
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4) determine the defining attributes; 5) identify a model case; 6) identify borderline,
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related, and contrary cases; 7) identify antecedents and consequences; and 8) define empirical referents.
A literature search was conducted using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and PsychInfo. Grey literature and snowball searches were also completed. The following keywords were used: clinical placement, clinical experience, undergraduate nursing students, anxiety. Only English articles referring to undergraduate nursing students, clinical, and anxiety were examined; articles that referred to graduate nursing students or simulations were
Journal Pre-proof excluded. To accomplish a comprehensive understanding of the literature, no date restrictions were applied. The results yielded a total of 81 articles that met the inclusion criteria. RESULTS Defining Anxiety In lay terms, while Merriam-Webster's dictionary (2019) defines anxiety
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generically as: “apprehensive, uneasiness or nervousness usually over an impending or
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anticipated ill” (para. 1), the Oxford University Press (2019) uses the terms of worry,
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nervousness, and unease, as well as the notion of uncertain outcome to define anxiety. In
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medical terms, Stedman‟s Medical Dictionary (2005) defines anxiety as “Apprehension of danger and dread accompanied by restlessness, tension, tachycardia, and dyspnea
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unattached to a clearly identifiable stimulus” (p.97). However, the disciplines of
anxiety.
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psychiatry, psychology, and nursing each have their own unique ways of defining
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As a term, anxiety has been used in psychiatric medicine literature for centuries.
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Documents dating back to ancient Greece (i.e., Hippocrates c460 to c370 AD) attempted to describe and even classify anxiety as an illness (Crocq, 2015). Much more recently, anxiety was first introduced in the American Psychiatric Association‟s (APA) Diagnostic and Statistical Manuel of Mental Disorders DSM-I as the primary characteristic for psychoneurotic disorders in 1952 (Crocq, 2015), and as a disorder in psychiatry in 1980. The APA‟s (2013) DSM-V defines anxiety as a normal human experience of fear in the face of a future or imminent threat. Similarly, the Mayo Clinic (Mayo Clinic, 2019)
Journal Pre-proof describes the occasional experience of anxiety as normal, which differs from the notion of anxiety as a disorder, which is excessive or pathological in nature (APA, 2013). The discipline of psychology views anxiety as behavioral or cognitive, as opposed to pathological. For example, Rachman (2004) defines anxiety as “the tense, unsettling anticipation of a threatening but vague event; a feeling of uneasy suspense” (p. 3). Similarly, Lazarus and Folkman (1984) define anxiety as a vague and uncomfortable
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feeling; however, they emphasize that it is "exacerbated by prolonged stress and the
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presence of multiple stressors" (p. 4). Additionally, Eysenck et al. (2007) identify anxiety
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as the inability to modify behavior when one's goal is threatened. According to Rachman
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(2004), the experience of anxiety includes intense, constricting, and pre-occupying sensations, which can be explained as changes in attention (e.g., self-attention),
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perception (e.g., objective or subjective distortion), emotional processes (e.g., intense
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feelings), affect, cognition, and memory, as well as physical reactions (e.g., increased heart rate, image distortion). Roeckelein (2006) describes anxiety as a subjective
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emotional state due to perceived angst that manifests into physical symptoms, such as
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tremors, pain, muscle tension, and headaches. In the nursing literature, the definition of anxiety aligns closely with the disciplines of psychiatry and psychology as a normal subjective response to a vague or unknown threat. Hildegard Peplau (1989), a psychiatric nurse theorist, well-known for her theoretical framework on interpersonal relations, describes anxiety as a clinical construct. According to Peplau (1989), everyone experiences anxiety to varying degrees throughout their life, and it is a cognitively prompted, subjective (i.e., affective) experience. The negative consequences of experiencing anxiety are physiological
Journal Pre-proof reactions to the perceived threat (e.g., sweating, trembling) and behavioral responses, such as escape or avoidance (Peplau, 1989). Similarly, Meisenhelder (1987) defines anxiety as “a psychological and physical response to a threat to self-concept” (p. 27). This threat is subjective and elicits emotions, such as apprehension and tension. Similar to the fight or flight response to fear, Meisenhelder (1987) also describes this same response within the context of anxiety. Importantly, Meisenhelder describes anxiety as “a
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serious obstacle to clinical functioning in the student nurse” (p.27).
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In summary, within the discipline of nursing, anxiety is defined as a cognitive
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perception of a potential vague or ambiguous, subjective threat, which triggers
changes.
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Defining Clinical Placement Anxiety
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psychological responses, and consequent, physiological reactions and behavioural
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For this concept analysis, clinical placement is defined as undergraduate nursing student experiences in the clinical setting for the purposes of learning the practical skills,
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applying the nursing knowledge, and experiencing the professional behaviors required to
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achieve the essential competencies of novice nurses. Any type of actual clinical learning experiences, including clinical practicums or clinical preceptorship experiences, are included in this definition; however, clinical simulation, which is used to prepare students for clinical placement by pretending or role-playing, is distinct from the experience of learning and practicing in real-world situations. Therefore, clinical placement anxiety is defined as a vague perceived threat to a student‟s goals or expectations in clinical practice, due to the presence of stressors, including unfamiliar environments or situations,
Journal Pre-proof resulting in psychological, physiological, and behavioral responses, and which, in turn may have a negative impact on the student‟s clinical outcomes. Defining Attributes of Clinical Placement Anxiety Defining attributes are the fundamental elements of a concept. These attributes are characteristics of the concept that repeatedly appear during the researching process. By identifying these attributes, the phenomenon is understood within the context of
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similarities and differences related to other concepts (Walker & Avant, 2011).
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Based on the reviewed literature, five defining attributes for clinical placement
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anxiety were identified: vague perceived threat, psychological-emotional responses and
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psychological-cognitive responses, as well as, physiological responses, and the presence of an unfamiliar environment or situation.
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The vagueness quality of clinical student anxiety may be related to the generally
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overwhelming sense of responsibility in the clinical setting, especially for the novice student. Several studies identified that students experience anxiety related to first
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interactions with patients, making mistakes, patient harm, patient care, and feelings of
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incompetence (Alshahrani et al., 2018; Beck, 1993; Melincavage, 2011; Sharif & Armitage, 2004; Sun et al., 2016). Kim (2003) noted that talking to physicians, being late, and being observed by instructors produced high anxiety among senior nursing students. Although Melo et al. (2010) noted similar themes, they also observed themes such as lack of confidence regarding skills and competencies, and lack of clinical preparation. The attribute of a vague perceived threat differentiates clinical placement anxiety from the concepts of fear and stress. Meisenhelder (1987) differentiates anxiety from fear by considering the subjective versus objective nature of the threat and degree of danger.
Journal Pre-proof While the presence of specific stressors may produce anxiety (Lazarus & Folkman, 1984), students in the clinical setting may not be able to identify the specific causes of their sense of anxiety; whereas fear is characterized by the ability to recognize a threat and consequential imminent danger (Whitley, 1992). Stress, on the other hand, is the result of a transactional relationship with the environment that exceeds the ability to cope (Lazarus & Folkman, 1986). Therefore, while anxiety is caused by a perceived vague
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threat, fear is a recognised threat, and stress is caused by overwhelming environmental
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pressures.
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Psychological-emotional responses to clinical placement anxiety are subjective, and
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as such, are identified only when described by the individual (e.g., worry, uneasiness, insecurity, dread, apprehension, uncertainty). Psychological-cognitive responses are the
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cognitive processes that influence the perceived reality and subsequent behaviors, such as
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perceptual disturbances, object distortion, memory bias, selective attention, misinterpretations (Ray, Gulati, & Rai, 2017), avoidance and escape (Rachman, 2004),
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and decreased performance and efficiency (Eysenck et al. 2007). Psychological responses
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to clinical placement anxiety are less acute and intense than fear responses, such as feeling terrified and running away from the threat. The physiological responses to clinical placement anxiety are objective and measurable. Although the physical manifestations may include increased pulse and respiratory rate, perspiration, facial flushing, restlessness, jaw clenching, and insomnia (Folk & Folk, 2018; Meisenhelder, 1987), these responses are generally less intense than those manifested in fear.
Journal Pre-proof Finally, the perceived threat experienced in clinical placement anxiety is more likely to occur in new or unfamiliar environments or situations (Beck, 1993; Benner et al., 2009; Chernomas & Shapiro, 2013; Kim, 2003; Melo et al., 2010; Nolan 1998). Several studies have also revealed that the presence of anxiety is in anticipation of the clinical experience (Chernomas & Shapiro, 2013; Kim, 2003; Melo et al., 2010; Nolan 1998). Several studies identified that initial clinical experiences produced high levels of
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anxiety (Beck, 1993; Kim, 2003; Kleehammer et al., 1990; Nolan, 1998; Sharif &
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Masoumi, 2005). In a recent mixed methods study of first-year undergraduate nursing
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students in their first clinical placements (N = 58), Alshahrani et al. (2018) noted that
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most students (91%) were moderately anxious (46%), anxious (31%), or extremely anxious (14%). Thus, new situations or environments are the catalysts for the perceived
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threat in the students‟ clinical learning experiences and the consequent psychological,
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behavioural, and physiological responses that ensue. It follows that novice clinical
placement anxiety.
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students and those entering new clinical settings may be at particular risk for clinical
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Antecedents and Consequences Antecedents and consequences are important in refining and supporting the defining attributes. While antecedents are the factors that must precede the concept, consequences are outcomes or events resulting from the occurrence of the concept (Walker & Avant, 2011). The key antecedents for clinical placement anxiety include the capacity to perceive one‟s own emotions or feelings, the individual‟s cognitive ability, as well as perceived self-efficacy. Clinical placement anxiety will only occur if the student has the
Journal Pre-proof ability to feel psychological/ emotive processes or emotions. Furthermore, clinical placement anxiety tends to occur when there are perceived changes in the environment or future situations, and the student feels threatened or vulnerable (Rachman, 2004). Cognitive ability is an essential component in a person's ability to learn and perform; however, it is also this ability that stimulates the physiological and affective reactions that influence the perceived expected outcome (Bandura, 1986). Likewise, the student‟s
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perceived self-efficacy directly affects the student‟s sense of vulnerability or confidence,
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making them either more resilient or more susceptible to emotional arousal and clinical
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placement anxiety. According to Bandura (1986), an inverse relationship exists between
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self-efficacy and stress reactions, such as anxiety. Bandura (1997) also posits that high levels of inefficacy contribute to the inability to cope and perform. (Bandura 1997).
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Therefore, according to this theory, students with low self-efficacy are more likely to
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have higher clinical placement anxiety. An interpretive descriptive study by White (2003) on clinical decision making in fourth-year nursing students (N = 17) lends support for this
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theory, with the finding that self-confidence was inversely related with anxiety in the
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clinical decision making.
Within the context of a concept analysis, consequences can be negative or positive. The key negative consequence is the presence of relief behaviors, such as avoidance and escape (Peplau 1989, Rachman, 2004). These behaviors create a brief sense of relief (Rachman, 2004), which in turn encourages or reinforces individuals to continue the negative behaviors (Peplau, 1989; Rachman, 2004), and places them at higher risk for the development of an anxiety disorder (APA, 2013). High attrition rates and poor academic outcomes, as well as risks to physical and mental well-being, have been associated with
Journal Pre-proof experiencing anxiety in clinical placements (Macauley et al., 2018; Ruz et al., 2018; Sun et al., 2016). Additionally, Ruz et al. (2018) found that nursing students (N=170) who experienced persistent anxiety were more likely to have poor academic achievement and higher absenteeism rates. Conversely, the positive consequences of clinical placement anxiety are effective coping and resiliency, which in turn motivate behavioural change and result in personal
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growth. A positive behavioral change results in an increased sense of self-worth,
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achievement (James et al., 2016; Rachman, 2004), and self-efficacy (Bandura, 1997).
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Identifying Case Examples
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According to Walker and Avant (2011), cases should be used as examples to better understand the full extent of the concept being defined. Walker and Avant (2011)
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recommend utilizing model, borderline, related, and contrary cases. The following cases
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are fictional examples.
Model case. A model case validates the concept and exemplifies the ideal
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circumstances in which all the defining attributes are present (Walker & Avant, 2011).
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Amanda is a 1st year nursing student who is starting her first clinical placement. She has not slept all night due to vague feelings of unease and apprehension, feels her heart racing, and her chest feels heavy whenever she thinks about the upcoming clinical experience. On arrival to the clinical unit, Amanda meets her clinical instructor, who is frowning and looks unfriendly. She spends the morning avoiding the instructor and attempts to stand in the back of the group to avoid attracting attention to herself. Later in the day, Amanda is forced to seek guidance from the instructor regarding a new skill. Amanda feels unwell; she is perspiring and trembling. The instructor is patient and kind,
Journal Pre-proof which allays Amanda’s anxiety. After performing the skill well, she feels more selfconfident and realizes she has misjudged her instructor because of her anxiety. In this model case, Amanda is experiencing all of the defining attributes of clinical placement anxiety. These attributes include a vague threat to self, physiological, psychological-emotional, and psychological-cognitive responses (i.e., misperception of the instructor, behavioral changes, avoidance), as well as the catalyst of the unfamiliarity
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of the situation/environment. The key positive consequences of the clinical placement
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anxiety are Amanda‟s increased sense of self-confidence and self-awareness.
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Borderline case. The borderline case is an example that includes most of the
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elements of the model case; however, it differs by at least one of the elements and thus demonstrates how the concept changes when there are inconsistencies (Walker & Avant,
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2011).
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Aaron is a second-year nursing student who is shadowing a nurse in the emergency department for the day. Aaron has never been in an emergency department before and
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worries about what the day will be like. His hands are moist with perspiration; he has
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retreated to the bathroom several times this morning to avoid the scary environment. Aaron and his preceptor walk into the waiting room where a patient is yelling and making physically aggressive movements. The patient makes eye contact with Aaron and makes a threatening movement towards him. Aaron’s heart rate quickens, he starts to sweat profusely, and he perceives this patient as an imminent threat. Aaron turns and leaves the waiting room. This borderline case includes many of the defining attributes of clinical placement anxiety. However, the sudden, intense, and identifiable threat perceived by Aaron, as well
Journal Pre-proof as his intense physiological response are more typical of fear than anxiety. Aaron‟s response of escape is consistent with responses to anxiety and fear. Related case. A related case does not include all the defining attributes of the concept being analyzed (Walker & Avant, 2011). Frank is repeating his fourth-year clinical placement. His father passed away the previous term, which was devastating for him. Frank also recently lost his part-time job
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as a waiter at a local restaurant. While he is doing patient research, he notices many
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skills and treatments that he will need to perform on the following clinical day. He feels
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worried about failing again, and he is concerned about being able to complete all the
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necessary tasks successfully. He feels a heaviness in his chest and butterflies in his stomach; he begins to cry.
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This case represents the related concept of stress. Frank has recently experienced
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several significant personal life stressors which have disrupted his state of equilibrium. This stress is compounded by his return to the clinical area and the fear of failure.
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Although Frank exhibits the psychological and physiological responses of anxiety, the
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stressors in this situation are significant to Frank‟s well-being and have exceeded his ability to cope, which is consistent with stress. Contrary case. A contrary case is easily understood and identified as completely different from the concept being analyzed (Walker & Avant, 2011). Cassie is completing her last clinical practicum course; she is familiar with the staff and the expectations of her preceptor. Her patient requires a nasogastric tube insertion, which she has done several times before. Cassie is enthusiastic to perform this
Journal Pre-proof procedure again; she feels calm and confident. She successfully completes the procedure independently. She feels accomplished and validated. This case does not depict any of the defining attributes of clinical placement anxiety. Cassie is familiar with the environment and does not perceive any threat. Consequently, she does not exhibit physiological, psychological, or behavioural signs of anxiety. This is a positive learning experience resulting in personal and professional
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growth.
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Empirical referents
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According to Walker and Avant (2011), empirical referents establish a means to
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measure the occurrence of the concept of interest. Table 1 is a compilation of empirical referents for clinical placement anxiety, based on a review of the related literature.
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Although, this is not an exhaustive list, it serves as a reference for the indicators of
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clinical placement anxiety, within the
context of the defining attributes. This list may also be useful to nursing students and
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instructors in the clinical setting.
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In the research literature, anxiety has been measured using a variety of valid and reliable tools, including the Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond, 1995), Hamilton Anxiety Rating Scale (HARS; Hamilton, 1959), Overall Anxiety Security and Impairment Scale (OASIS; Norman et al., 2006), PENN State Worry Questionnaire (PSWQ; Meyer et al., 1990), State-Trait Anxiety Inventory (STAI; Spielberger, 1983), and Westside Test-Anxiety Scale (WTAS; Driscoll, 2007). Although only a few of these tools have been used to measure clinical placement anxiety, several authors have utilized the STAI in studies related to undergraduate nursing students and
Journal Pre-proof anxiety in clinical settings (Melo et al., 2010; Patton & Goldenberg, 1999; Shahsavari et al., 2017; Villeneuve et al., 2018). As well, in a descriptive study (N = 61), Kim (2003) utilized the Trait Anxiety (T-Anxiety) Scale component of the STAI and the Clinical Experience Assessment form (CEAF; Kleehammer et al. 1990) to identify anxietyprovoking experiences in nursing students. Additionally, grounded in Bandura‟s (1986) social-cognitive theory, White (2014) developed the Nursing Anxiety and Self
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Confidence with Clinical Decision Making (NASC-CDM) tool. This reliable and valid
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27-item tool is a self-reported, 6-point Likert scale instrument with two subscales
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measuring levels of self-confidence and anxiety in undergraduate nursing students
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(White, 2014). White, Fetter, and Ruth-Sahd (2018) utilized the NASC-CDM scale in a recent quasi-experimental study to measure the impact of a summer externships on
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promoting self-confidence and reducing anxiety related to clinical decision-making in
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nursing students (N = 134). Importantly, the results of this study support an inverse
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relationship between self-confidence and anxiety in the clinical setting. Discussion
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This concept analysis of clinical placement anxiety provides insights for educators and researchers. The research-based evidence related to each of the defining attributes, and the antecedents and consequences, as well as the case examples may guide educators to effectively prevent and address anxiety in their clinical students. For researchers, the identified gaps in the current literature provide a sound rationale for further research in this important area of nursing education. Educators should consider implementing any or all of the reportedly effective strategies to prevent or decrease clinical placement anxiety in their students. For example,
Journal Pre-proof incorporating pre-clinical knowledge and skill development sessions, such as pre-clinical workshops, orientations, and simulations have been found to be effective in decreasing anxiety in the clinical setting (Baksi et al., 2017; Park, 2018; Ratanasiripong et al., 2015; Shahsavari et al., 2017; Watt et al., 2016; White et al., 2018).). Research evidence also supports the strategies of mindfulness (Ratanasiripong et al., 2015) and peer support (Kim et al., 2013; Walker & Verklan, 2016; Zentz, Kurts, & Alverson, 2014) to decrease
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clinical placement anxiety. While anxiety influences clinical performance and effective
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clinical learning, self-reflection and self-efficacy have been identified as a positive
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influence on clinical performance (Pai, 2016; Pai et al., 2017). Sharif and Armitage
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(2004) found that student GPA scores increased, and clinical placement anxiety decreased after a 12-week program that consisted of a weekly session on anxiety control
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and coping strategies.
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Educators also need to be aware of potential harms associated with clinical placement anxiety and the need for support and mental health resources for students who
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are experiencing persistent or incapacitating anxiety. Despite faculty members being
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optimally positioned to identify and support students, Reeve et al. (2013) observed that few students seek help and support from faculty. Therefore, a healthy clinical learning environment, with empathetic, supportive, and approachable faculty and staff is pivotal to the prevention and management of clinical placement anxiety (Melincavage, 2011). Nurse educators would benefit from professional development workshops that focus on strategies to better support and advocate for students‟ well-being in the clinical setting (Chernomas & Shapiro, 2013; Yearwood & Riley, 2010).
Journal Pre-proof Clinical placement anxiety in undergraduate nursing students is an emerging area of nursing research. However, few studies have explicitly focused on nursing student anxiety in the clinical setting. Qualitative inquiry, which focuses on a phenomenological or „lived experience‟ approach, as well as interventional research, which focuses on strategies to reduce clinical placement anxiety, is needed. Finally, although several anxiety tools have been used in studies related to nursing student anxiety, further research
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is needed to develop reliable and valid tools to measure clinical placement anxiety as
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defined by this concept analysis.
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CONCLUSION
The concept of clinical placement anxiety in undergraduate nursing students was
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explored using Walker and Avant‟s (2011) 8-step approach to concept analysis. A
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comprehensive understanding of the concept was established by defining clinical
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placement anxiety as a vague perceived threat to a student‟s goals or expectations in clinical practice, due to the presence of stressors, including unfamiliar environments or
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situations, resulting in psychological, physiological, and behavioral responses, and which,
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in turn may have a negative impact on the student‟s clinical outcomes. In addition, the core attributes, antecedents and consequences, as well as empirical referents, were identified. The case examples provided context and clarity for the concept. Insights gleaned from this concept analysis established a foundation for strategies to effectively prevent and manage student anxiety in the clinical setting. Gaps in the current evidence surrounding clinical placement anxiety have also been highlighted. As well, conceptualizing clinical placement anxiety validates the importance of further exploration of the anxiety experienced by undergraduate nursing students during their clinical
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Table 1. Empirical Referents of Clinical Placement Anxiety Psycho-cognitive responses
Psycho-emotional responses
-Decreased sexual function -Facial flushing -SOB/heaviness in chest -Increased heart rate/ palpitations -Increased blood pressure -Increased respiration rate -Insomnia -Jaw clenching -Silent/gaze avoidance -Stuttering -Sweating or increased perspiration -Abdominal pain/cramps -Diarrhea -Dizziness -Leg weakness -Nausea -Pulsing in the ear -Restlessness -Urinary urgency and/or frequency -Tremors
-Avoidance -Confusion -Decreased information retention/ learning ability -Decreased productivity -Difficulty problem solving -Difficulty concentrating -Hypervigilance -Impaired attention -Memory bias/loss -Misinterpretations -Perceptual distortions -Selective attention -Thought blocking
-Apprehension, unease -Dread of negative evaluation -Feelings of insufficiency -Feeling incompetent -Helplessness -Focus on self /selfattention -Sense of vulnerability -Uncertainty -Worry/concern
Unfamiliar environment or situation -New clinical site -New skills/tasks -New encounters
Vague perceived threat -non-specific perceived threat -perceived potential or future danger -feeling a sense of vulnerability
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Physiological responses
Note: Compilation of empirical referents from the literature (Folk & Folk, 2018; Berry & Wagner, 2015; Rachman 2004; Rachman et al., 1987; Roeckelein, 2006; Spielberger, 1983)