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Understanding nursing students'stress: a proposed framework
ticle
nderstanding nursing students' ress: a proposed framework ~nn V. Sawatzky A paucity of comprehensive research, as well as inconsistent application of theories/conceptual frameworks, have resulted in a limited knowledge of stress in nursing students. The purpose of this paper is to establish a framework for understanding the stress/coping/adaptation process in the nursing student population. To this end, Pollock's Adaptation Nursing Model (Pollock 1984) is discussed and subsequently recommended as a possible alternative. Utilization of this framework as an organizing construct for the paper facilitates a comprehensive review of recent literature related to stress in undergraduate nursing students. In addition, it is proposed that Pollock's model can provide nurse educators, practitioners, administrators and researchers with a framework for understanding nursing students' stress.
Jo-Ann V. Sawatzky MN, RN, Lecturer, Faculty of Nursing, University of Manitoba, Winnipeg R3T 2N2, Canada (Requests for offprints to JVS)
Manuscript accepted: 12 January 1996
Introduction
Theoretical foundations
Recent literature has been replete with suggested ways in which nursing educators can reduce stress in their students. Whereas many of these recommendations have focused on changes in teaching strategies or in the curriculum, little attention has been directed at the students themselves. There is a paucity of comprehensive research in the area of nursing students' stress. Furthermore, most published studies have merely identified actual stressors: little is known about the impact of the stressor on the individual nursing student. Because all students are exposed to essentially the same academic stress, it may be more important to question why some students seem to thrive despite these stressors, while others leave because of them. For the past several decades, perception, or cognitive appraisal, of stressful events has been recognized as a significant factor in the stress / coping / adaptation process. Additionally, numerous stress-resistance resources have been acknowledged as pivotal in explaining individual differences in perception and coping. Because Pollock's Adaptation Nursing Model (Pollock 1984) encompasses many of these important concepts, this model is proposed as a means to understand (that is, to describe, explain and predict) the stress/adaptation process in nursing students (Figure).
Developed by Susan Pollock in 1984, the Adaptation Nursing Model proposes that the personality characteristic of hardiness buffers or mediates the stress-illness relationship, both directly by the enhancement of successful coping and indirectly through its influence on the perception of the stressor. Pollock's model arrived at its current state of refinement through a sequence of revisions and additions. The purpose of the original conceptual framework was to 'describe the stress phenomenon in more precise and scientific terms and to identify the basic components of the stress concept' (Pollock 1984 p 1). For her definitions of stress and coping Pollock relied on the writings of physiological and psychological stress experts Hans Selye and Richard Lazarus. Pollock credits two other theorists, Roy and Helson, for her concepts relating to adaptation: Sister Callista Roy (1971) utilized much of Helson's (1964) work and adapted the concepts to nursing. The predominant influence of Roy's adaptation model is readily apparent in Pollock's evolving frameworks. Like Roy, Pollock (1984) defined adaptation as a dynamic process between the environment and the individual which is considered effective if it promotes the physiological as well as the psychological and social integrity of the person.
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Understanding nursing students" stress
NURSING STUDENT STRESS (PERCEIVED)
NURSING STUDENT STRESS (ACTUAL)
T
HARDINESS CHARACTERISTIC
LEVEL OF ADAPTATION
1 SUCCESSFUL COPING
[ USE OF SOCIAL RESOURCES
Figure The Adaptation Nursing Model (revised).
Thus Pollock's original Adaptation Nursing Model integrated and synthesized concepts from Selye, Lazarus, Helson, and Roy. Although Kobasa's (1979) hardiness characteristic is mentioned in the initial text, it is not until subsequent publications that it becomes central to the model. Social support as a mediator or stressresistance resource is the latest addendum to the model. Although Pollock's most recent work reflects her interest in chronic illness, the model itself is easily applied to other situations and can be used to facilitate an understanding of stress in nursing students. The organization of the following review of related literature is based on the major concepts of the Adaptation Nursing Model as it applies to the nursing student population.
Stress Description and analysis of biological stress were pioneered by Hans Selye (1956), generally regarded as the father of stress research. His definition of stress is in keeping with
© 1998 Harcourt Brace& Co. Ltd
psychology's tradition of a stimulus-response orientation: '...stress is the nonspecific response of the body to any demand made upon it:' (Selye 1974 p 27). Best known for his explanation of stress in terms of the three stages of the general adaptation syndrome (the alarm reaction, the stage of resistance and the stage of exhaustion) Selye also recognized the significance of both exogenous and endogenous conditioning factors in the response to stressors or increased demands on the body. Furthermore, it was Selye who first distinguished between negative or undesirable (distress) and positive or desirable (eustress) stress responses: '...stress is the spice of life. Without it you would be a vegetable or dead' (Selye 1974 p 27). Although Selye's biological view of stress is oversimplified, it established the foundation for a plethora of subsequent research. The psychological aspect of stress in particular has been the focus of much attention in recent years. Over the past several decades, a frequent observation by stress researchers has been that regardless of the intensity, duration or chronicity
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Understanding nursing students" stress
of the stressor, responses often vary dramatically from one individual to another. Renowned for his work in the area of coping. Lazarus (1966) contends that perception or cognitive appraisal of the stressor is the key to understanding the psychological component of the stress response. To understand w h y people respond differently to comparable situations one must consider the cognitive processes involved in the interaction as well as the factors affecting the mediation. Because 'it is the observed stimulus-response relationship, not stimulus o r response, that defines stress' (Lazarus & Folkman 1984 p 15), Lazarus & Folkman suggest a relational definition: 'Psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being' (Lazarus & Folkman 1984 p 19). Based on a biological and psychological, as well as a sociological perspective, Pollock (1984) defines stress as: the whole set of physiolggic and psychologic phenomena including the objective event or stressor, the person's perception of the stressor, the conditioning factors or contextual stimuli, the various intervening processes or the residual stimuli, and the manifestations of response to the stressor (Pollock 1984 p 3).
Stress in nursing students Regardless of the desired outcome, the process of education can be a very stressful experience. The stressors specific to nursing education have been consistentl~ although sparsely, acknowledged in the literature for almost 50 years. As early as the 1930s, nurses and student nurses were being polled about the problems and difficulties related to training (McKay 1978). Many of the stressors identified in those early years of nursing education parallel the stressors on nursing students today. The conclusion that this population is under constant strain also appears to have been untouched by time. Unfortunately, however, despite suggestions and recommendations, efforts to assist students in coping with the stresses of nursing education are still limited. According to McKay (1978), 'the first step in changing the environment of nursing schools is to
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identify which factors are producing stress among students' (McKay 1978 p 385). Most of the original studies simply categorized the types and the frequency of occurrence of students' stressors. In a classic study, Fox and his colleagues (Fox et al 1963) explored both the stressful and the satisfying experiences of nursing students. Utilizing the Nursing School Experience Sheet (NSES) developed by the same authors in an earlier study, stressors were categorized into the four major areas of personal, social, academic, and clinical experiences. Whereas personal stressors were found to relate most to the student's emotional state and feelings about the nursing profession, academic stressors were associated with school rules and policies, relationships with faculty and coordination of class and clinical schedules. Expectations of instructors ranked as the highest clinical stressor. Utilizing the technique developed by Fox and his associates, Elfert (1976) explored both stressful and satisfying experiences in the first 2 years of a nursing program. As one might expect, major concerns and satisfactions were initially derived from family and friends, as well as from evaluations and course grades. However, with the introduction of clinical practice this focus shifted and remained higher in the clinical than in the personal, social or academic categories. These results coincide with MacMaster's (1979) findings and the similar conclusion that sources of stress for nursing students depend on the phase of the program and of life in general. The themes of personal inadequacy and fear of making mistakes are recurrent throughout the literature, especially in relation to the clinical area. The stress of the initial clinical experience in particular has been the focus of several studies (Pagana 1988, 1990, Bell 1991). A review of related literature by McKay (1978) summarizes the most significant nursing student stressors as being the 'extreme competition for power, grades, and survival, and the resulting feelings of powerlessness, alienation, and personal insecurity' (McKay 1978 p 390). These same negative consequential terms are used by Kobasa to describe the antithesis of hardiness. Lazarus and Folkman (1984) revolutionized stress research in that the introduction of cognitive appraisal effectively changed the focus of subsequent stress investigations. Although this concept has become well recognized in most areas
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Understanding nursing students" stress
of nursing research as the key to understanding stress, few studies have focused on the population of nursing students. Beck and Srivastava (1991) identified not only the sources but also the perceived level of stress in baccalaureate nursing students. The finding of lower stress scores in registered nurses (RN/BNs) than in generic students was attributed to maturity, previous experience, and better problem-solving and stress management skills. Despite the recent trend of advanced educational preparation in entry level nursing students, the authors appear to assume that the generic students represent a younger, and therefore less mature group. Simply clarifying the demographic data obtained from the sample might have been enough to support this conclusion. Furthermore, this study examined only negative perceptions of stress. It would have been of interest to know if the RN/BN students perceived the stressful situations in a more positive or challenging way than did the generic students. Also: based on Lazarus and Folkman's theory of cognitive appraisal of stress, Pagana (1988) developed an instrument to assess the appraisal of stress in the initial clinical experiences of nursing students. Although the findings of her study revealed that most students perceived the experience as being threatening rather than challenging, she did not isolate the threatened and challenged groups to determine why they perceived the situation differently. In a fairly recent study, Lindrop (1991) found that individual stressful experiences were similar for students who left and those who stayed in the training program. His conclusion was that 'people who remain appear to have a strong sense of determination: a need to achieve and to see things through to the end' (Lindrop 1991 p 119). He thus acknowledges the significance of personality in the stress/coping/adaptation process. Lindrop's study also revealed that those who stayed had benefited more from the support of their peers. On the other hand, the reason why most students left was related to the negative attitude of nursing staff towards learners. This reinforces Pollock's appreciation of the significant role of social support in successful coping. It also fortifies the paramount importance of 'care to the caregiver'. Although Carter's (1982) focus is quite different, her findings not only reflect a feminist perspective but also generate support for
© 1998 Harcourt Brace& Co. Ltd
Pollock's model. Most studies assume nursing students' stress to be greater than that of their liberal arts peers. Carter, however, dispels this myth. She found that the stress levels and coping styles of the two groups were quite similar. Changes in women's values and expectations over the past two decades, according to Carter, have effected 'additional sources of stress, specifically role conflict and the need for independence and autonomy in controlling one's life' (Carter 1982 p 248). Resolutions oJ~the conflicts, according to Carter, 'will be dependent on the coping strategies the women have or can develop and the supportive interpersonal networks upon which they can rely' (Carter 1982 p 252).
Coping and adaptation Lazarus and Fo]kman (1984) define coping as 'constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person' (Lazarus & Folkman 1984 p 141): coping is viewed as a process. Based on their writings, Pollock, in her conceptual framework, includes problem- and emotion-focused coping as significant intervening variables. An important difference between these two concepts is that problem-focused coping is directed at managing or changing the situation causing the distress, whereas emotion-focused coping 'is directed at regulating emotional response to the problem' (Lazarus & Folkman 1984 p 150). Although this approach to coping is not directly addressed in the available literature related to students, numerous nursing studies report the effectiveness of problem- and appraisal-oriented strategies (Dewe 1987, Ceslowitz 1989, Rosenthal et a11989). Emotionorientated strategies, on the other hand, appear to be utilized less frequently (Rosenthal et a11989). Although Kelly and Cross (1985) found that nurses primarily used adaptive coping measures such as drawing on past experience, discussing the problem with others and basing their actions on their understanding of the situation, they also reported such maladaptive coping as crying, sleeping less and eating more. Maladaptive measures such as avoidance were reported in a third of respondents in McGrath et al's (1989)
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study of nurses in Northern Ireland. Other maladaptive measures reported in the literature include caffeine, alcohol and nicotine intake (Harris 1984, Robinson & Lewis 1990). Coping in nursing students has, however, not been completely overlooked. In an analysis of coping methods in returning RN/BNs, Lee (1988) found that 'the majority of re-entry students (82%) in the study used direct action as a coping method in dealing with stressful incidents' (Lee 1988 p 312), as opposed to palliation. Preparation against harm and the use of social networking were the predominant methods of direct action coping. Although age and maturity may have been influencing factors in this study, they were not addressed. Others have, however, found coping skills to be related to level of maturity (Mattson 1990) and to age (Sharpley & Scuderi 1990). Not surprisingly, like RN/BNs, generic students also report maladaptive coping measures. For example, Haslam et al (1989) found that examination stress was positively related to abnormal eating habits and dietary restraint in female (n -- 100) undergraduate students. According to the Adaptation Nursing Model, a person's level of adaptation is contingent on successful coping. Recognition of the erosive effects of stress and realization of the significance of successful coping for nursing students have given rise to various stress-reduction strategies. Stress inoculation programs, for example, have been tested and found to effect successful coping in this population (Foley & Stone 1988, Manderino & Yonkman 1985). Facilitating the students' independence and autonomy is also being acknowledged as paramount to coping and adaptation. To this end, teaching strategies are slowly changing. Additionally, courses related to women's studies are being recognised as effecting changes such as 'increased self-esteem, expansion of life options and goals, identification with other women, and identification of one's own experiences as a part of a larger social context' (Boughn 1987 p 31), thus serving to facilitate the coping process for the nursing student.
influenced by factors such as personality characteristics, constitutional predispositions, social supports and health practices. These generalized resistance resources (Antonovsky 1982) or buffers further explain w h y not all of those who experience high degrees of stress become ill and w h y some of these individuals appear to actually thrive on stress. Pollock's model focuses on the influence of two stress buffers: social support and the personality characteristic of hardiness.
Social support Research literature across the social science disciplines is replete with evidence detailing the benefits of social support. Studies involving nursing students are no exception, with documentation and recognition of the significance of social support dating back as far as the late 1930s (McKay 1978). Family and friends are the most common sources of support. However, in the educational setting, peer support and a sense of community (McCarthy et al 1990) are reported to play an important stress-buffering role. Additionally, the support of faculty is of paramount importance to the nursing student. For example, according to Sobol (1978), 'it is difficult for students to develop autonomy, selfrealization, and self-direction when it is not encouraged by the faculty' (Sobo11978 p 243). These attributes are repeatedly referred to in the literature as essential elements of successful coping. In contrast, traditional autocratic, dictatorial approaches to nursing education, which effect a sense of powerlessness in the student, are now being acknowledged as detrimental to the learning process (Griffith & Bakanauskas 1983). This sense of powerlessness, lack of control and support are the antithesis of what Kobasa has identified as characteristic of hardiness. There is thus an apparent close affinity between social support and this personality trait. This is reflected in the Adaptation Nursing Model, which proposes a positive relationship between the two concepts.
G e n e r a l i z e d resistance resources Although there are countless coping strategies available, all do not elicit an adaptive response. The ability to cope with the environment is
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Hardiness Although the concept of hardiness is an integration of various theoretical and empirical
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Understanding nursing students" stress
leads, the existential theory of personality (Kobasa & Maddi 1977) was central in its development (Kobasa 1979). The hardiness concept evolved from anecdotal evidence that not all of those who experience high degrees of stress become ill and that some of these individuals appear to actually thrive on stress (Kobasa et a11979). Research results of a 'merely modest relationship between stressful life events and illness symptoms' (Kobasa et a11982b p 391) added validity to these observations. Although, like Antonovsky, Kobasa is keenly aware of the growing list of variables which may buffer the organism against the debilitating effects of stress, she has focused on this particular aspect of personality. Hardiness is defined by Kobasa and associates (Kobasa et a11982a) as 'a constellation of personality characteristics that function as a resistance resource in the encounter with stressful life events' (Kobasa et al 1982a p 169). The sense of control, or belief that the course of events can be influenced by one's efforts or attributes, is derived from Rotter's et al (1962) concept of locus of control Commitment is essentially defined by Kobasa (1982a) as a belief in the truth, importance, and interest-value of what one is doing. Finally, challenge (Kobasa 1982b) is expressed as the belief that change rather than stability is normal in life and that the anticipation of change is seen as an opportunity for growth rather than as a threat to one's security. Together the three main elements of commitment, control and challenge form a personality style which effects coping by a buffering effect on the stress-illness relationship (Kobasa 1982a). Although most studies utilizing Kobasa's hardiness model have examined its buffering effects, perception of the stressful event has not been adequately addressed. Previous studies have focused primarily on actual stressors rather than on the individual's perception of those events. Pollock not only acknowledges the stressbuffering effect of hardiness vis-a-vis successful coping, but also recognizes the significance of perception of the stressful event on the outcome or level of adaptation. Additionally, she postulates a significant effect of hardiness on the perception of the stressful event, and of perception on successful coping: Hardiness may indirectly affect adaptation to chronic illness by influencing the individual's
© 1998 Harcou~Brace& Co. Ltd
perception of the stressor (chronic iLllness), the coping strategies chosen, or the social resources used. Perception and the use of social resources were also significantly related to the presence of hardiness in the study of healthy adults (Pollock 1989 p 59).
Hardiness in nursing students Given the paucity of hardiness research within the population of nursing students and Carter's (1982) observed similitude between all female undergraduates, the examination of related studies is appropriate. In a mixed-gender sample of undergraduate students Banks & Gannon found that 'those higher in hardiness ~ended to experience less frequent stressors and to perceive the minor events they did experience as less stressful' (Banks & Gannon 1988 p 25). Ganellen & Blaney (1984) discovered a strong correlation between the commitment and challenge dimensions of hardiness and social support in female undergraduate students. However, they found that only the commitment dimension significantly buffered the effects of life stress. In an investigation of the mediating effects of health practices and hardiness in the stress-illness relationship, with a predominantly female undergraduate sample, Wiebe & McCallum concluded that 'hardy individuals may be more healthy because they practice better health behaviors than nonhardy individuals" (Wiebe & McCallum 1986 p 436). Other studies, however, have found the effect of health practices on health to be independent of hardiness (Kobasa et al 1982a, Kobasa et al 1985, Roth et a11989). Similarly, Hannah's (1988) study of 37 male and 59 female undergraduate students revealed no relationship between health behaviour and hardiness. However, the hardiness-health concern interaction was, in fact, significant. Pollock has attempted to dispel this confusion with her Health-Related Hardiness Scale (Pollock & Duffy 1990). This alternative to Kobasa's hardiness instrument was developed in response to unsolved measurement problems and as a means to acquire empirical evidence for the effect of hardiness on adaptation to actual and potential health problems. Pagana (1990) has pioneered the specific application of the hardiness concept to nursing students' appraisal of stress. To date, hers is the
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Understanding nursing students"stress
only published study of hardiness in the nursing student population. Although support for the hardiness hypothesis was found to be weak when applied to Lazarus and Folkman's theory, it did correlate positively with challenge and negatively with threat. Because the report of insignificant correlations between total social support and threat and challenge is contrary to those of numerous other studies, one must question these results. However, this study establishes a premise upon which to apply Pollock's conceptual framework to further stress research with the population of nursing students.
Recommendations Because there has been very little comprehensive research and because the application of theories and conceptual frameworks has been inconsistent, we have limited knowledge of the stress/coping/adaptation process in the nursing student population. The utilization of the Adaptation Nursing Model as an organizing framework for this review of the related literature establishes a logical framework for understanding the stressful nature of nursing students' educational experience. In addition, it provides supportive rationale for the utilization of the Adaptation Nursing Model as a framework for future research in this area. For example, faculty can influence the student's outcome by minimizing the actual stressors and providing social support. It may, however, be more important to examine ways to facilitate changes within the students themselves, as well as in their personal environments. Future research should also focus on ways of increasing students' ability to cope with the stressors of nursing education. For example, Fishman (1987) suggests that hardiness can be taught through techniques such as situational reconstruction, focusing, and compensatory selfimprovement. Encouraging nursing students to broaden their personal social supports and social networks could also go a long way to effect adaptation during their educational experience and throughout their lifetime. Hence, the Adaptation Nursing Model can provide nurse educators, practitioners, administrators and researchers with a framework for understanding nursing students' stress.
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Furthermore, the ease with which Pollock's model was adapted to this population suggests that it may be a useful and versatile framework for the nursing profession as a whole. References Antonovsky A 1982 Health, stress and coping. Jossey Bass, CA Banks J, Gannon L 1988 The influence of hardiness on the relationships between stressors and psychosomatic symptomology. American Journal of Community Psychology 16 (1): 25-37 Beck D, Srivastava R 1991 Perceived level and sources of stress in baccalaureate nursing students. Journal of Nursing Education 30 (3): 127-133 Bell M 1991 Learning a complex nursing skill: student anxiety and the effect of preclinical skill evaluation. Journal of Nursing Education 30 (5): 222-226 Boughn S 1987 A strategy for increasing student autonomy: women's health course. Nurse Educator 12 (6): 31-33 Carter E 1982 Stress in nursing students: dispelling some of the myth. Nursing Outlook 4:248-252 Ceslowitz S 1989 Burnout and coping strategies among hospital staff nurses. Journal of Advanced Nursing 14: 553-557 Dewe P 1987 Identifying strategies nurses use to cope with work stress. Journal of Advanced Nursing 12:489-497 Elfert H 1976 Satisfying and stressful incidents reported by students during the first two years of a new baccalaureate programme in nursing. Nursing Papers 8 (2): 36-43 Fishman J 1987 Getting tough: can people learn to have disease-resistant personalities? Psychology Today 21 (12): 26-28 Foley J, Stone G 1988 Stress inoculation with nursing students. Western Journal of Nursing Research 10 (4): 435-447 Fox D, Diamond L, Walsh R, Knopf L, Hogden J 1963 Correlates of satisfaction and stress with nursing school experience. Nursing Research 12 (2): 83-88 Ganellen R, Blaney P 1984 Hardiness and social support as moderators of the effects of life stress. Journal of Personality and Social Psychology 47 (1): 156-163 Griffith J, Bakanauskas A 1983 Student-instructor relationships in nursing education. Journal of Nursing Education 22 (3): 104-107 Hannah T 1988 Hardiness and health behavior: the role of health concern as a moderator variable. Behavioral Medicine. Summer: 59-63 Haslam C, Stevens R, Haslam R 1989 Eating habits and stress correlates in a female student population. Work and Stress 3 (4): 327-334 Harris J 1984 Stressors and stress in critical care. Critical Care Nurse 1:84-97 Helson H 1964 Adaptation-level theory. Harper & Row, New York Kelly J, Cross D 1985 Stress, coping behaviors, and recommendations for intensive care and medical surgical ward registered nurses. Research in Nursing and Health 8:321-328
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Kobasa S 1979 Stressful life events, personality and health: an inquiry into hardiness. Journal of Personality and Social Psychology 37 (1): 1-11 Kobasa S 1982a Commitment and coping in stress resistance among lawyers. Journal of Personality and Social Psychology 42 (4): 707-717 Kobasa S 1982b The hardy personality: toward a social psychology of stress and health. In: Sanders G, Suls J (eds) Social psychology of health and illness. Lawrence Erlbaum, Hillsdale, NJ Kobasa S, Maddi S 1977 Existential personality theory. In: Corsini R (ed) Current personality theories. Peacock Publishers, I1 Kobasa S, Hilker R, Maddi S 1979 Who stays healthy under stress? Journal of Occupational Medicine 21 (9): 595-598 Kobasa S, Maddi S, Kahn S 1982a Hardiness and health: a prospective study. Journal of Personality and Social Psychology 42 (1): 168-177 Kobasa S, Maddi S, Puccetti M 1982b Personality and exercise as buffers in the stress-illness relationship. Journal of Behavioral Medicine 5 (4): 391-404 Kobasa S, Maddi S, Puccetti M, Zola M 1985 Effectiveness of hardiness, exercise and social support as resources against illness. Journal of Psychosomatic Research 29 (5): 525-533 Lazarus R 1966 Psychological stress and the coping process. McGraw-Hill, New York Lazarus R, Folkman S 1984 Stress, appraisal and coping. Springer, New York Lee E 1988 Analysis of coping methods reported by returning RNs. Journal of Nursing Education 27 (7): 309-313 Lindrop E 1991 Individual stress among nurses in training: why some leave while other stay. Nurse Education Today 11 (2): 172-179 McCarthy M, Pretty G, Catano V 1990 Psychological sense of community and student burnout. Journal of College Student Development 31:211-216 McGrath A, Reid N, Boore J 1989 Occupational stress in nursing. International Journal of Nursing Studies 26 (4): 343-358 McKay S 1978 A review of student stress in nursing education programs. Nursing Forum 17 (4): 376-393 MacMaster E 1979 Sources of stress in university nursing students. Nursing Paper 11 (3): 87-96 Manderino M, Yonkman C 1985 Stress inoculation: a method of helping students cope with anxiety related to
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clinical performance. Journal of Nursing Education 24 (3): 115-118 Mattson S 1990 Coping and developmental maturity of RN baccalaureate students. Western Journal of Nursing Research 12 (4): 514-524 Pagana K 1988 Stresses and threats reported by baccalaureate students in relation to an initial clinical experience. Journal of Nursing Education 27 (9): 418-424 Pagana K 1990 The relationship of hardiness and social support to student appraisal of stress in an initial clinical nursing situation. Journal of Nursing Education 29 (6): 255-261 Pollock S 1984 The stress response. Critical Care Quarterly 3:1-13 Pollock S 1989 The hardiness characteristics: a motivating factor in adaptation. Advances in Nursing Science 11 (2): 53-62 Pollock S, Duffy M 1990 The health-related hardiness scale: Development and psychometric analysis. Nursing Research 39 (4): 218-222 Robinson J, Lewis D 1990 Coping with ICU work-related stressors: a study. Critical Care Nurse 10 (5): 80-88 Rosenthal S, Schmid K, Black M 1989 Stress and coping in a NICU. Research in Nursing and Health 12:257-265 Roth D, Wiebe D, Fillingim R, Shay K 1989 Life events, fitness, hardiness and health: a simultaneoas analysis of proposed stress-resistance effects. Journal of Personality and Social Psychology 57 (1): 136-142 Rotter J, Seeman M, Liverant S 1962 Internal w~ external locus of control of reinforcement: a major variable in behavior theory. In: Washburne N F (ed) Decisions, values and groups. Pergamon Press, New "fork Roy C 1971 Introduction to nursing: an adaptation model. Appleton-Century-Crofts, NJ Selye H 1956 The stress of life. McGraw-HilL New York Selye H 1974 Stress without distress. Lippinco ~t, New York Sharpley C, Scuderi C 1990 The relationship between sex, age, and heart rate reactivity to a psychological stressor: implications for student stress management. Journal of College Student Development 31:262-269 Sobol E 1978 Self-actualization and the baccalaureate nursing student's response to stress. Nursing Research 27 (4): 238-244 Wiebe D, McCallum D 1986 Health practices and hardiness as mediators in the stress-illness relationslq@. Health Psychology 5 (5): 425-438
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nderstanding nursing students' ress: a proposed framework ~nn V. Sawatzky A paucity of comprehensive research, as well as inconsistent application of theories/conceptual frameworks, have resulted in a limited knowledge of stress in nursing students. The purpose of this paper is to establish a framework for understanding the stress/coping/adaptation process in the nursing student population. To this end, Pollock's Adaptation Nursing Model (Pollock 1984) is discussed and subsequently recommended as a possible alternative. Utilization of this framework as an organizing construct for the paper facilitates a comprehensive review of recent literature related to stress in undergraduate nursing students. In addition, it is proposed that Pollock's model can provide nurse educators, practitioners, administrators and researchers with a framework for understanding nursing students' stress.
Jo-Ann V. Sawatzky MN, RN, Lecturer, Faculty of Nursing, University of Manitoba, Winnipeg R3T 2N2, Canada (Requests for offprints to JVS)
Manuscript accepted: 12 January 1996
Introduction
Theoretical foundations
Recent literature has been replete with suggested ways in which nursing educators can reduce stress in their students. Whereas many of these recommendations have focused on changes in teaching strategies or in the curriculum, little attention has been directed at the students themselves. There is a paucity of comprehensive research in the area of nursing students' stress. Furthermore, most published studies have merely identified actual stressors: little is known about the impact of the stressor on the individual nursing student. Because all students are exposed to essentially the same academic stress, it may be more important to question why some students seem to thrive despite these stressors, while others leave because of them. For the past several decades, perception, or cognitive appraisal, of stressful events has been recognized as a significant factor in the stress / coping / adaptation process. Additionally, numerous stress-resistance resources have been acknowledged as pivotal in explaining individual differences in perception and coping. Because Pollock's Adaptation Nursing Model (Pollock 1984) encompasses many of these important concepts, this model is proposed as a means to understand (that is, to describe, explain and predict) the stress/adaptation process in nursing students (Figure).
Developed by Susan Pollock in 1984, the Adaptation Nursing Model proposes that the personality characteristic of hardiness buffers or mediates the stress-illness relationship, both directly by the enhancement of successful coping and indirectly through its influence on the perception of the stressor. Pollock's model arrived at its current state of refinement through a sequence of revisions and additions. The purpose of the original conceptual framework was to 'describe the stress phenomenon in more precise and scientific terms and to identify the basic components of the stress concept' (Pollock 1984 p 1). For her definitions of stress and coping Pollock relied on the writings of physiological and psychological stress experts Hans Selye and Richard Lazarus. Pollock credits two other theorists, Roy and Helson, for her concepts relating to adaptation: Sister Callista Roy (1971) utilized much of Helson's (1964) work and adapted the concepts to nursing. The predominant influence of Roy's adaptation model is readily apparent in Pollock's evolving frameworks. Like Roy, Pollock (1984) defined adaptation as a dynamic process between the environment and the individual which is considered effective if it promotes the physiological as well as the psychological and social integrity of the person.
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Understanding nursing students" stress
NURSING STUDENT STRESS (PERCEIVED)
NURSING STUDENT STRESS (ACTUAL)
T
HARDINESS CHARACTERISTIC
LEVEL OF ADAPTATION
1 SUCCESSFUL COPING
[ USE OF SOCIAL RESOURCES
Figure The Adaptation Nursing Model (revised).
Thus Pollock's original Adaptation Nursing Model integrated and synthesized concepts from Selye, Lazarus, Helson, and Roy. Although Kobasa's (1979) hardiness characteristic is mentioned in the initial text, it is not until subsequent publications that it becomes central to the model. Social support as a mediator or stressresistance resource is the latest addendum to the model. Although Pollock's most recent work reflects her interest in chronic illness, the model itself is easily applied to other situations and can be used to facilitate an understanding of stress in nursing students. The organization of the following review of related literature is based on the major concepts of the Adaptation Nursing Model as it applies to the nursing student population.
Stress Description and analysis of biological stress were pioneered by Hans Selye (1956), generally regarded as the father of stress research. His definition of stress is in keeping with
© 1998 Harcourt Brace& Co. Ltd
psychology's tradition of a stimulus-response orientation: '...stress is the nonspecific response of the body to any demand made upon it:' (Selye 1974 p 27). Best known for his explanation of stress in terms of the three stages of the general adaptation syndrome (the alarm reaction, the stage of resistance and the stage of exhaustion) Selye also recognized the significance of both exogenous and endogenous conditioning factors in the response to stressors or increased demands on the body. Furthermore, it was Selye who first distinguished between negative or undesirable (distress) and positive or desirable (eustress) stress responses: '...stress is the spice of life. Without it you would be a vegetable or dead' (Selye 1974 p 27). Although Selye's biological view of stress is oversimplified, it established the foundation for a plethora of subsequent research. The psychological aspect of stress in particular has been the focus of much attention in recent years. Over the past several decades, a frequent observation by stress researchers has been that regardless of the intensity, duration or chronicity
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of the stressor, responses often vary dramatically from one individual to another. Renowned for his work in the area of coping. Lazarus (1966) contends that perception or cognitive appraisal of the stressor is the key to understanding the psychological component of the stress response. To understand w h y people respond differently to comparable situations one must consider the cognitive processes involved in the interaction as well as the factors affecting the mediation. Because 'it is the observed stimulus-response relationship, not stimulus o r response, that defines stress' (Lazarus & Folkman 1984 p 15), Lazarus & Folkman suggest a relational definition: 'Psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being' (Lazarus & Folkman 1984 p 19). Based on a biological and psychological, as well as a sociological perspective, Pollock (1984) defines stress as: the whole set of physiolggic and psychologic phenomena including the objective event or stressor, the person's perception of the stressor, the conditioning factors or contextual stimuli, the various intervening processes or the residual stimuli, and the manifestations of response to the stressor (Pollock 1984 p 3).
Stress in nursing students Regardless of the desired outcome, the process of education can be a very stressful experience. The stressors specific to nursing education have been consistentl~ although sparsely, acknowledged in the literature for almost 50 years. As early as the 1930s, nurses and student nurses were being polled about the problems and difficulties related to training (McKay 1978). Many of the stressors identified in those early years of nursing education parallel the stressors on nursing students today. The conclusion that this population is under constant strain also appears to have been untouched by time. Unfortunately, however, despite suggestions and recommendations, efforts to assist students in coping with the stresses of nursing education are still limited. According to McKay (1978), 'the first step in changing the environment of nursing schools is to
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identify which factors are producing stress among students' (McKay 1978 p 385). Most of the original studies simply categorized the types and the frequency of occurrence of students' stressors. In a classic study, Fox and his colleagues (Fox et al 1963) explored both the stressful and the satisfying experiences of nursing students. Utilizing the Nursing School Experience Sheet (NSES) developed by the same authors in an earlier study, stressors were categorized into the four major areas of personal, social, academic, and clinical experiences. Whereas personal stressors were found to relate most to the student's emotional state and feelings about the nursing profession, academic stressors were associated with school rules and policies, relationships with faculty and coordination of class and clinical schedules. Expectations of instructors ranked as the highest clinical stressor. Utilizing the technique developed by Fox and his associates, Elfert (1976) explored both stressful and satisfying experiences in the first 2 years of a nursing program. As one might expect, major concerns and satisfactions were initially derived from family and friends, as well as from evaluations and course grades. However, with the introduction of clinical practice this focus shifted and remained higher in the clinical than in the personal, social or academic categories. These results coincide with MacMaster's (1979) findings and the similar conclusion that sources of stress for nursing students depend on the phase of the program and of life in general. The themes of personal inadequacy and fear of making mistakes are recurrent throughout the literature, especially in relation to the clinical area. The stress of the initial clinical experience in particular has been the focus of several studies (Pagana 1988, 1990, Bell 1991). A review of related literature by McKay (1978) summarizes the most significant nursing student stressors as being the 'extreme competition for power, grades, and survival, and the resulting feelings of powerlessness, alienation, and personal insecurity' (McKay 1978 p 390). These same negative consequential terms are used by Kobasa to describe the antithesis of hardiness. Lazarus and Folkman (1984) revolutionized stress research in that the introduction of cognitive appraisal effectively changed the focus of subsequent stress investigations. Although this concept has become well recognized in most areas
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of nursing research as the key to understanding stress, few studies have focused on the population of nursing students. Beck and Srivastava (1991) identified not only the sources but also the perceived level of stress in baccalaureate nursing students. The finding of lower stress scores in registered nurses (RN/BNs) than in generic students was attributed to maturity, previous experience, and better problem-solving and stress management skills. Despite the recent trend of advanced educational preparation in entry level nursing students, the authors appear to assume that the generic students represent a younger, and therefore less mature group. Simply clarifying the demographic data obtained from the sample might have been enough to support this conclusion. Furthermore, this study examined only negative perceptions of stress. It would have been of interest to know if the RN/BN students perceived the stressful situations in a more positive or challenging way than did the generic students. Also: based on Lazarus and Folkman's theory of cognitive appraisal of stress, Pagana (1988) developed an instrument to assess the appraisal of stress in the initial clinical experiences of nursing students. Although the findings of her study revealed that most students perceived the experience as being threatening rather than challenging, she did not isolate the threatened and challenged groups to determine why they perceived the situation differently. In a fairly recent study, Lindrop (1991) found that individual stressful experiences were similar for students who left and those who stayed in the training program. His conclusion was that 'people who remain appear to have a strong sense of determination: a need to achieve and to see things through to the end' (Lindrop 1991 p 119). He thus acknowledges the significance of personality in the stress/coping/adaptation process. Lindrop's study also revealed that those who stayed had benefited more from the support of their peers. On the other hand, the reason why most students left was related to the negative attitude of nursing staff towards learners. This reinforces Pollock's appreciation of the significant role of social support in successful coping. It also fortifies the paramount importance of 'care to the caregiver'. Although Carter's (1982) focus is quite different, her findings not only reflect a feminist perspective but also generate support for
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Pollock's model. Most studies assume nursing students' stress to be greater than that of their liberal arts peers. Carter, however, dispels this myth. She found that the stress levels and coping styles of the two groups were quite similar. Changes in women's values and expectations over the past two decades, according to Carter, have effected 'additional sources of stress, specifically role conflict and the need for independence and autonomy in controlling one's life' (Carter 1982 p 248). Resolutions oJ~the conflicts, according to Carter, 'will be dependent on the coping strategies the women have or can develop and the supportive interpersonal networks upon which they can rely' (Carter 1982 p 252).
Coping and adaptation Lazarus and Fo]kman (1984) define coping as 'constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person' (Lazarus & Folkman 1984 p 141): coping is viewed as a process. Based on their writings, Pollock, in her conceptual framework, includes problem- and emotion-focused coping as significant intervening variables. An important difference between these two concepts is that problem-focused coping is directed at managing or changing the situation causing the distress, whereas emotion-focused coping 'is directed at regulating emotional response to the problem' (Lazarus & Folkman 1984 p 150). Although this approach to coping is not directly addressed in the available literature related to students, numerous nursing studies report the effectiveness of problem- and appraisal-oriented strategies (Dewe 1987, Ceslowitz 1989, Rosenthal et a11989). Emotionorientated strategies, on the other hand, appear to be utilized less frequently (Rosenthal et a11989). Although Kelly and Cross (1985) found that nurses primarily used adaptive coping measures such as drawing on past experience, discussing the problem with others and basing their actions on their understanding of the situation, they also reported such maladaptive coping as crying, sleeping less and eating more. Maladaptive measures such as avoidance were reported in a third of respondents in McGrath et al's (1989)
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study of nurses in Northern Ireland. Other maladaptive measures reported in the literature include caffeine, alcohol and nicotine intake (Harris 1984, Robinson & Lewis 1990). Coping in nursing students has, however, not been completely overlooked. In an analysis of coping methods in returning RN/BNs, Lee (1988) found that 'the majority of re-entry students (82%) in the study used direct action as a coping method in dealing with stressful incidents' (Lee 1988 p 312), as opposed to palliation. Preparation against harm and the use of social networking were the predominant methods of direct action coping. Although age and maturity may have been influencing factors in this study, they were not addressed. Others have, however, found coping skills to be related to level of maturity (Mattson 1990) and to age (Sharpley & Scuderi 1990). Not surprisingly, like RN/BNs, generic students also report maladaptive coping measures. For example, Haslam et al (1989) found that examination stress was positively related to abnormal eating habits and dietary restraint in female (n -- 100) undergraduate students. According to the Adaptation Nursing Model, a person's level of adaptation is contingent on successful coping. Recognition of the erosive effects of stress and realization of the significance of successful coping for nursing students have given rise to various stress-reduction strategies. Stress inoculation programs, for example, have been tested and found to effect successful coping in this population (Foley & Stone 1988, Manderino & Yonkman 1985). Facilitating the students' independence and autonomy is also being acknowledged as paramount to coping and adaptation. To this end, teaching strategies are slowly changing. Additionally, courses related to women's studies are being recognised as effecting changes such as 'increased self-esteem, expansion of life options and goals, identification with other women, and identification of one's own experiences as a part of a larger social context' (Boughn 1987 p 31), thus serving to facilitate the coping process for the nursing student.
influenced by factors such as personality characteristics, constitutional predispositions, social supports and health practices. These generalized resistance resources (Antonovsky 1982) or buffers further explain w h y not all of those who experience high degrees of stress become ill and w h y some of these individuals appear to actually thrive on stress. Pollock's model focuses on the influence of two stress buffers: social support and the personality characteristic of hardiness.
Social support Research literature across the social science disciplines is replete with evidence detailing the benefits of social support. Studies involving nursing students are no exception, with documentation and recognition of the significance of social support dating back as far as the late 1930s (McKay 1978). Family and friends are the most common sources of support. However, in the educational setting, peer support and a sense of community (McCarthy et al 1990) are reported to play an important stress-buffering role. Additionally, the support of faculty is of paramount importance to the nursing student. For example, according to Sobol (1978), 'it is difficult for students to develop autonomy, selfrealization, and self-direction when it is not encouraged by the faculty' (Sobo11978 p 243). These attributes are repeatedly referred to in the literature as essential elements of successful coping. In contrast, traditional autocratic, dictatorial approaches to nursing education, which effect a sense of powerlessness in the student, are now being acknowledged as detrimental to the learning process (Griffith & Bakanauskas 1983). This sense of powerlessness, lack of control and support are the antithesis of what Kobasa has identified as characteristic of hardiness. There is thus an apparent close affinity between social support and this personality trait. This is reflected in the Adaptation Nursing Model, which proposes a positive relationship between the two concepts.
G e n e r a l i z e d resistance resources Although there are countless coping strategies available, all do not elicit an adaptive response. The ability to cope with the environment is
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Hardiness Although the concept of hardiness is an integration of various theoretical and empirical
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leads, the existential theory of personality (Kobasa & Maddi 1977) was central in its development (Kobasa 1979). The hardiness concept evolved from anecdotal evidence that not all of those who experience high degrees of stress become ill and that some of these individuals appear to actually thrive on stress (Kobasa et a11979). Research results of a 'merely modest relationship between stressful life events and illness symptoms' (Kobasa et a11982b p 391) added validity to these observations. Although, like Antonovsky, Kobasa is keenly aware of the growing list of variables which may buffer the organism against the debilitating effects of stress, she has focused on this particular aspect of personality. Hardiness is defined by Kobasa and associates (Kobasa et a11982a) as 'a constellation of personality characteristics that function as a resistance resource in the encounter with stressful life events' (Kobasa et al 1982a p 169). The sense of control, or belief that the course of events can be influenced by one's efforts or attributes, is derived from Rotter's et al (1962) concept of locus of control Commitment is essentially defined by Kobasa (1982a) as a belief in the truth, importance, and interest-value of what one is doing. Finally, challenge (Kobasa 1982b) is expressed as the belief that change rather than stability is normal in life and that the anticipation of change is seen as an opportunity for growth rather than as a threat to one's security. Together the three main elements of commitment, control and challenge form a personality style which effects coping by a buffering effect on the stress-illness relationship (Kobasa 1982a). Although most studies utilizing Kobasa's hardiness model have examined its buffering effects, perception of the stressful event has not been adequately addressed. Previous studies have focused primarily on actual stressors rather than on the individual's perception of those events. Pollock not only acknowledges the stressbuffering effect of hardiness vis-a-vis successful coping, but also recognizes the significance of perception of the stressful event on the outcome or level of adaptation. Additionally, she postulates a significant effect of hardiness on the perception of the stressful event, and of perception on successful coping: Hardiness may indirectly affect adaptation to chronic illness by influencing the individual's
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perception of the stressor (chronic iLllness), the coping strategies chosen, or the social resources used. Perception and the use of social resources were also significantly related to the presence of hardiness in the study of healthy adults (Pollock 1989 p 59).
Hardiness in nursing students Given the paucity of hardiness research within the population of nursing students and Carter's (1982) observed similitude between all female undergraduates, the examination of related studies is appropriate. In a mixed-gender sample of undergraduate students Banks & Gannon found that 'those higher in hardiness ~ended to experience less frequent stressors and to perceive the minor events they did experience as less stressful' (Banks & Gannon 1988 p 25). Ganellen & Blaney (1984) discovered a strong correlation between the commitment and challenge dimensions of hardiness and social support in female undergraduate students. However, they found that only the commitment dimension significantly buffered the effects of life stress. In an investigation of the mediating effects of health practices and hardiness in the stress-illness relationship, with a predominantly female undergraduate sample, Wiebe & McCallum concluded that 'hardy individuals may be more healthy because they practice better health behaviors than nonhardy individuals" (Wiebe & McCallum 1986 p 436). Other studies, however, have found the effect of health practices on health to be independent of hardiness (Kobasa et al 1982a, Kobasa et al 1985, Roth et a11989). Similarly, Hannah's (1988) study of 37 male and 59 female undergraduate students revealed no relationship between health behaviour and hardiness. However, the hardiness-health concern interaction was, in fact, significant. Pollock has attempted to dispel this confusion with her Health-Related Hardiness Scale (Pollock & Duffy 1990). This alternative to Kobasa's hardiness instrument was developed in response to unsolved measurement problems and as a means to acquire empirical evidence for the effect of hardiness on adaptation to actual and potential health problems. Pagana (1990) has pioneered the specific application of the hardiness concept to nursing students' appraisal of stress. To date, hers is the
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only published study of hardiness in the nursing student population. Although support for the hardiness hypothesis was found to be weak when applied to Lazarus and Folkman's theory, it did correlate positively with challenge and negatively with threat. Because the report of insignificant correlations between total social support and threat and challenge is contrary to those of numerous other studies, one must question these results. However, this study establishes a premise upon which to apply Pollock's conceptual framework to further stress research with the population of nursing students.
Recommendations Because there has been very little comprehensive research and because the application of theories and conceptual frameworks has been inconsistent, we have limited knowledge of the stress/coping/adaptation process in the nursing student population. The utilization of the Adaptation Nursing Model as an organizing framework for this review of the related literature establishes a logical framework for understanding the stressful nature of nursing students' educational experience. In addition, it provides supportive rationale for the utilization of the Adaptation Nursing Model as a framework for future research in this area. For example, faculty can influence the student's outcome by minimizing the actual stressors and providing social support. It may, however, be more important to examine ways to facilitate changes within the students themselves, as well as in their personal environments. Future research should also focus on ways of increasing students' ability to cope with the stressors of nursing education. For example, Fishman (1987) suggests that hardiness can be taught through techniques such as situational reconstruction, focusing, and compensatory selfimprovement. Encouraging nursing students to broaden their personal social supports and social networks could also go a long way to effect adaptation during their educational experience and throughout their lifetime. Hence, the Adaptation Nursing Model can provide nurse educators, practitioners, administrators and researchers with a framework for understanding nursing students' stress.
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Furthermore, the ease with which Pollock's model was adapted to this population suggests that it may be a useful and versatile framework for the nursing profession as a whole. References Antonovsky A 1982 Health, stress and coping. Jossey Bass, CA Banks J, Gannon L 1988 The influence of hardiness on the relationships between stressors and psychosomatic symptomology. American Journal of Community Psychology 16 (1): 25-37 Beck D, Srivastava R 1991 Perceived level and sources of stress in baccalaureate nursing students. Journal of Nursing Education 30 (3): 127-133 Bell M 1991 Learning a complex nursing skill: student anxiety and the effect of preclinical skill evaluation. Journal of Nursing Education 30 (5): 222-226 Boughn S 1987 A strategy for increasing student autonomy: women's health course. Nurse Educator 12 (6): 31-33 Carter E 1982 Stress in nursing students: dispelling some of the myth. Nursing Outlook 4:248-252 Ceslowitz S 1989 Burnout and coping strategies among hospital staff nurses. Journal of Advanced Nursing 14: 553-557 Dewe P 1987 Identifying strategies nurses use to cope with work stress. Journal of Advanced Nursing 12:489-497 Elfert H 1976 Satisfying and stressful incidents reported by students during the first two years of a new baccalaureate programme in nursing. Nursing Papers 8 (2): 36-43 Fishman J 1987 Getting tough: can people learn to have disease-resistant personalities? Psychology Today 21 (12): 26-28 Foley J, Stone G 1988 Stress inoculation with nursing students. Western Journal of Nursing Research 10 (4): 435-447 Fox D, Diamond L, Walsh R, Knopf L, Hogden J 1963 Correlates of satisfaction and stress with nursing school experience. Nursing Research 12 (2): 83-88 Ganellen R, Blaney P 1984 Hardiness and social support as moderators of the effects of life stress. Journal of Personality and Social Psychology 47 (1): 156-163 Griffith J, Bakanauskas A 1983 Student-instructor relationships in nursing education. Journal of Nursing Education 22 (3): 104-107 Hannah T 1988 Hardiness and health behavior: the role of health concern as a moderator variable. Behavioral Medicine. Summer: 59-63 Haslam C, Stevens R, Haslam R 1989 Eating habits and stress correlates in a female student population. Work and Stress 3 (4): 327-334 Harris J 1984 Stressors and stress in critical care. Critical Care Nurse 1:84-97 Helson H 1964 Adaptation-level theory. Harper & Row, New York Kelly J, Cross D 1985 Stress, coping behaviors, and recommendations for intensive care and medical surgical ward registered nurses. Research in Nursing and Health 8:321-328
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Kobasa S 1979 Stressful life events, personality and health: an inquiry into hardiness. Journal of Personality and Social Psychology 37 (1): 1-11 Kobasa S 1982a Commitment and coping in stress resistance among lawyers. Journal of Personality and Social Psychology 42 (4): 707-717 Kobasa S 1982b The hardy personality: toward a social psychology of stress and health. In: Sanders G, Suls J (eds) Social psychology of health and illness. Lawrence Erlbaum, Hillsdale, NJ Kobasa S, Maddi S 1977 Existential personality theory. In: Corsini R (ed) Current personality theories. Peacock Publishers, I1 Kobasa S, Hilker R, Maddi S 1979 Who stays healthy under stress? Journal of Occupational Medicine 21 (9): 595-598 Kobasa S, Maddi S, Kahn S 1982a Hardiness and health: a prospective study. Journal of Personality and Social Psychology 42 (1): 168-177 Kobasa S, Maddi S, Puccetti M 1982b Personality and exercise as buffers in the stress-illness relationship. Journal of Behavioral Medicine 5 (4): 391-404 Kobasa S, Maddi S, Puccetti M, Zola M 1985 Effectiveness of hardiness, exercise and social support as resources against illness. Journal of Psychosomatic Research 29 (5): 525-533 Lazarus R 1966 Psychological stress and the coping process. McGraw-Hill, New York Lazarus R, Folkman S 1984 Stress, appraisal and coping. Springer, New York Lee E 1988 Analysis of coping methods reported by returning RNs. Journal of Nursing Education 27 (7): 309-313 Lindrop E 1991 Individual stress among nurses in training: why some leave while other stay. Nurse Education Today 11 (2): 172-179 McCarthy M, Pretty G, Catano V 1990 Psychological sense of community and student burnout. Journal of College Student Development 31:211-216 McGrath A, Reid N, Boore J 1989 Occupational stress in nursing. International Journal of Nursing Studies 26 (4): 343-358 McKay S 1978 A review of student stress in nursing education programs. Nursing Forum 17 (4): 376-393 MacMaster E 1979 Sources of stress in university nursing students. Nursing Paper 11 (3): 87-96 Manderino M, Yonkman C 1985 Stress inoculation: a method of helping students cope with anxiety related to
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clinical performance. Journal of Nursing Education 24 (3): 115-118 Mattson S 1990 Coping and developmental maturity of RN baccalaureate students. Western Journal of Nursing Research 12 (4): 514-524 Pagana K 1988 Stresses and threats reported by baccalaureate students in relation to an initial clinical experience. Journal of Nursing Education 27 (9): 418-424 Pagana K 1990 The relationship of hardiness and social support to student appraisal of stress in an initial clinical nursing situation. Journal of Nursing Education 29 (6): 255-261 Pollock S 1984 The stress response. Critical Care Quarterly 3:1-13 Pollock S 1989 The hardiness characteristics: a motivating factor in adaptation. Advances in Nursing Science 11 (2): 53-62 Pollock S, Duffy M 1990 The health-related hardiness scale: Development and psychometric analysis. Nursing Research 39 (4): 218-222 Robinson J, Lewis D 1990 Coping with ICU work-related stressors: a study. Critical Care Nurse 10 (5): 80-88 Rosenthal S, Schmid K, Black M 1989 Stress and coping in a NICU. Research in Nursing and Health 12:257-265 Roth D, Wiebe D, Fillingim R, Shay K 1989 Life events, fitness, hardiness and health: a simultaneoas analysis of proposed stress-resistance effects. Journal of Personality and Social Psychology 57 (1): 136-142 Rotter J, Seeman M, Liverant S 1962 Internal w~ external locus of control of reinforcement: a major variable in behavior theory. In: Washburne N F (ed) Decisions, values and groups. Pergamon Press, New "fork Roy C 1971 Introduction to nursing: an adaptation model. Appleton-Century-Crofts, NJ Selye H 1956 The stress of life. McGraw-HilL New York Selye H 1974 Stress without distress. Lippinco ~t, New York Sharpley C, Scuderi C 1990 The relationship between sex, age, and heart rate reactivity to a psychological stressor: implications for student stress management. Journal of College Student Development 31:262-269 Sobol E 1978 Self-actualization and the baccalaureate nursing student's response to stress. Nursing Research 27 (4): 238-244 Wiebe D, McCallum D 1986 Health practices and hardiness as mediators in the stress-illness relationslq@. Health Psychology 5 (5): 425-438
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