Clark, Cynthia M. PhD, RN, ANEF, FAAN; Nguyen, Danh T. BS, RN; Barbosa-Leiker, Celestina PhD
While mild stress levels can motivate students to complete assignments, meet deadlines, achieve on examinations, and increase creativity and inspiration, higher levels of stress accompanied by ineffective coping can result in undesirable effects such as feelings of anxiousness, defeat, and tension.1 Nursing students also experience stress stemming from challenging curricula, demanding coursework, mastering large amounts of complex material, participating in high-stakes testing, and coping with stress experienced in the clinical settings, which is often accompanied by a lack of confidence.2-11 Additional stress is experienced when the demands of everyday life such as work, family, and finances are compounded with the academic demands of school.3,6,7,9,11,12 The effects of stress may be further amplified for nontraditional nursing students who often experience financial pressures and the added demands of reentry into higher education.13 Tully9 found psychiatric nursing students (n = 35) to be significantly distressed and to have limited coping skills; this condition frequently worsens as the program progresses.14
Unfortunately, high levels of stress during nursing education can lead to the development of physical illness and psychological distress such as digestive disorders, irritable bowel syndrome, sleep disturbance, and frequent headaches.15-18 In some studies, students reported high levels of anxiety and panic attacks throughout their education, whereas others experienced symptoms of eating disorders, depression, and poor self-image.9,12,16,17,19 The high-stress academic environment combined with responsibilities of life and inordinately lofty expectations for achievement can lead to burnout, dropout, and student attrition.14,20-23
Because nursing students experience high stress from a variety of sources, they use a number of coping strategies, which tend to fall under 1 of 2 categories. The first category includes working through or mitigating stress by more positive means such as seeking emotional support from classmates and others, organizing and planning to manage workloads, sharing difficult experiences with faculty, exercising, and seeking spiritual guidance.3,7,11,16,24 The second category of coping includes avoiding the situation altogether or attempting to medicate the effects of stress through alcohol and drug use, overeating or undereating, disengagement, apathy, procrastination, and dropping out.3,7,11,16,24 An avoidance coping style was the strongest predictor of adverse psychological well-being.25 Some students expressed their stress by arguing with family and friends, cheating to pass nursing courses and examinations, and going into “survival mode” to make it through the program.14(p51)
Nursing students need effective coping strategies to successfully manage the myriad stressors of their nursing education. Mentoring programs help reduce student anxiety and improve academic performance by providing focused and deliberate student support,26 resulting in less stress, increased self-esteem, and enhanced ability to cope with difficult situations.27 Other effective stress management strategies include yoga, progressive muscle relaxation, breathing exercises, meditation, and mental imagery.28
Academic incivility on American college campuses is a growing concern and may be a contributing factor to faculty and student stress.14,29 This dynamic relationship can also occur in the reverse; stress may be a contributing factor to academic incivility. When stress levels are heightened and poorly managed, the potential for incivility increases.29 Faculty incivility such as being rigid and inflexible, making demeaning remarks, showing favoritism, and using poor or outdated teaching practices contributed to student stress levels.29 In the same study, several stressors were identified as major contributors to student incivility including burnout from demanding workloads; stress related to family, school, and work demands; and competition in a high-stakes academic environment. Furthermore, attitudes of student entitlement and faculty superiority combined to create a stressful learning environment. Clark29 concluded that when stress levels are minimized and coping strategies are strengthened, the potential for civility and deeper learning is enhanced.
Despite an increasing body of research on stress, coping, and its possible consequences, the relationships among stress, coping, and academic civility have been relatively unexplored. This study was conducted to examine nursing students’ perceptions of stress, coping, faculty-student and student-student relationships, and methods to promote civility in nursing education and how these perceptions of civility change over time. Our research questions were as follows:
1. Are there significant changes in overall civility, quality of faculty-student and student-student relationships, and hours spent per week in stress-reducing activities?
2. What are the top stressors for nursing students, most effective ways to cope with stress, top strategies to improve the quality of student-faculty relationships, top strategies to improve the quality of student-student relationships, and most effective ways to improve civility in the nursing program?
This was a descriptive, repeated-measures, survey design used to examine nursing students’ perceptions of stress, coping, faculty-student and student-student relationships, and ways to promote civility in nursing education.
Participants and Procedure
Institutional review board approval was obtained to conduct the study. Once consent was obtained, nursing students in a BS program in the northwest region of the United States completed a 13-item questionnaire. All responses were collected anonymously and reported as aggregate data. Students were given the opportunity to decline responding to the survey without impacting their grades or their standing in the nursing program.
The survey was administered in 2010, 2011, and 2012 during the sixth week of the nursing students’ sophomore, junior, and senior years using a paper-and-pencil format. The study examined nursing students’ perceptions of stress, coping, faculty-student and student-student relationships, and ways to promote civility in nursing education. Responses were collected from the cohort of 68 nursing students on entry into their nursing program (n = 54, 79.4% response rate), 12 months into the nursing program (n = 68, 100% response rate), and at the end of the nursing program (n = 66, 97% response rate). The initial number of respondents was lower because 14 students were absent during survey administration because of course scheduling conflicts.
A mixed-method survey questionnaire was designed by the author (Dr Clark), based on an extensive review of the literature, researcher expertise, and consultation with content experts. The survey was pilot tested by 10 nonnursing college students and 3 faculty experts who reviewed the survey for content validity, readability, and logical flow. Slight revisions were made to the survey based on faculty and student feedback derived from pilot testing. Four items assessed multiple constructs (civility, stress, and quality of relationships); thus, these Likert-type items are intended to be analyzed item-by-item (ie, reliability is not applicable).
The 13-item survey contained 4 demographic items including age, gender, ethnicity, and year in the nursing program. Four quantitative items measured nursing students’ perceptions of (1) level of civility in the nursing program using a 6-point Likert scale (ranging from 6 extremely civil to 1 not civil at all); (2) quality of student-faculty relationships using a 6-point Likert scale (from 6 excellent to 1 extremely poor); (3) quality of student-student relationships using the same 6-point Likert scale; and (4) number of hours spent per week in stress-reducing activities.
Five open-ended questions garnered students’ perceptions of the top 3 (1) stressors for nursing students, (2) most effective ways to cope with stress, (3) strategies to improve the quality of student-faculty relationships, (4) strategies to improve the quality of student-student relationships, and (5) most effective ways to improve civility in the nursing program. The 4 constructs were analyzed item-by-item and therefore not summed to create a total score.
Quantitative data were analyzed using SPSS version 22 (IBM, Armonk, New York). To examine change over time in the quantitative survey items, a 1-way between-groups analysis of variance (ANOVA) was used. Note that repeated-measures analysis was not used as identifiers were not collected over time and not all participants took the survey repeatedly. Therefore, the groups are treated independently in the analyses.
Narrative responses stemming from the 5 qualitative research questions were analyzed using textual content analysis.30 Key words or phrases were quantified by the researchers; inferences were made about their meanings and categorized into themes. Verbatim comments were reviewed by the researcher and 2 outside reviewers until all parties were confident the analysis was a valid representation of the participants’ comments. The narrative responses from the participants were organized into themes, ranked in order of the number of responses and described according to each research question.
The respondents were predominantly female (91%) and white (86%), with an average age of 27.93 (SD, 7.97) years during their sophomore year. Preliminary item analysis indicated that the quantitative items were normally distributed based on skewness (<3) and kurtosis (<10) statistics. Table 1 presents the mean levels of civility, quality of student-faculty relationships, quality of student-student relationships, and number of hours spent per week in stress-reducing activities.
Results indicated that there was a significant difference in overall level of civility across groups (F2,188 = 6.27, P < .01). Bonferroni post hoc tests revealed that level of civility significantly decreased from sophomore to senior year; civility in the junior year did not differ from the sophomore or senior year.
There were no differences in hours per week spent in stress-reducing activities across the groups (F2,188 = 0.89, P = .41). Quality of student-faculty relationships differed across groups (F2,188= 19.22, P < .001), and Bonferroni post hoc tests revealed that the quality of relations significantly decreased from sophomore to junior year and then remained at that level in the senior year (nonsignificant difference from junior to senior year). However, there was no difference in quality of student-student relationships across the groups (F2,188= 1.96, P = .14).
Stressors and Coping Strategies
Themes were derived from student narratives, ranked in order of the number of responses, and presented according to each research question. The top 3 stressors for nursing students remained consistent over the 3-year study period: demanding academic workloads; balancing time, work, school, and family; and finding time to relax. Other stressors included financial concerns, grade competition, and sleep problems. As the study progressed, students identified additional stressors not reported in the first year of the study including faculty incivility, stress related to studying for the licensing examination (NCLEX), and achieving required scores on placement examinations in year 2 and pressure to succeed and fear of failure in year 3. The top 3 most effective coping strategies also remained consistent over the 3-year study period: talking and spending time with family, friends, and pets; exercising and getting outdoors; and organizing, planning, and prioritizing. Other coping strategies included engaging in self-care practices and seeking help from supportive faculty and/or counselors. The Table, Supplemental Digital Content, displays the perceived student stressors and coping strategies in greater detail, http://links.lww.com/NE/A141.
Strategies to Improve Relationships
Students also identified several strategies to improve student-faculty relationships. The top 3 strategies remained consistent over the 3-year study period: using effective and respectful communication, engaging in faculty-student activities, and seeking a better balance and clarity of assignments and examinations. Additional strategies included receiving greater encouragement from faculty and replacing adjunct faculty with faculty from the school of nursing. Students also identified several strategies to improve student-student relationships including engaging in social and extracurricular activities, being less competitive and more team oriented, and varying student group and clinical laboratory team structures. Strategies to improve student-faculty and student-student relationships are detailed in the Table, Supplemental Digital Content 2, http://links.lww.com/NE/A142.
Lastly, students were asked to identify strategies to improve civility in the nursing program (Table 2). The top 3 strategies included effective and timely communication; faculty encouragement, organization, and flexibility; and engaging in social and/or extracurricular activities. Students also suggested providing forums for open dialogue about civility and establishing and enforcing behavioral norms and expectations.
Discussion and Implications
Civility levels over the 3-year study period revealed a decrease in overall levels of civility and faculty-to-student civility. Factors such as accumulated experience of students and more opportunity to experience uncivil behavior may have contributed to this result. Understanding student perceptions of stress, coping, and relationships provides an opportunity to implement strategies that can enhance civility levels in nursing programs and thus increase learning, program satisfaction, and student retention. Several strategies suggested by the respondents to create civility may be captured by implementing comprehensive and continuous “civility” instruction throughout the nursing curriculum. For example, new student orientation programs might focus on raising awareness about the impact and consequences of incivility on the teaching-learning environment as well as on the nursing profession and the practice setting. Students at the beginning of their nursing education need to know what is expected of them regarding professional behavior and what they can expect from others.31 Formal orientation is vital to helping students understand what civil professional behavior is and how to integrate it into their nursing practice. Civility awareness for incoming students can be done during general student orientation as well as a more focused orientation once students enter the nursing program. Before classes officially begin, newly admitted nursing students can participate in a full-day program to discuss what it means to be a nurse, professionalism, ethical conduct, and the importance of civility. It is everyone’s responsibility in the school of nursing to reinforce civility, professionalism, and observance of the mission, values, and norms of the school. Most importantly, these initiatives need to be “lived” and openly discussed throughout the program—not only at orientation but threaded throughout the program.31
Civility content can be integrated into theory and clinical courses using didactic instruction, case studies, self-reflection exercises, role-playing activities, and clinical simulations. Using problem-based learning strategies and simulation exercises with live or filmed actors is an effective way to educate students on civility content and ways to address the “reality shock” between what students learn about the practice of nursing and the interactions they may experience in the workplace.32 In addition, the use of cognitive rehearsal (CR) has been shown to be an effective coping strategy for addressing incivility.33 Cognitive rehearsal involves teaching modalities that include a didactic presentation, interactive instruction and practice sessions, and use of verbal responses to effectively address uncivil behavior. Evidence shows that when uncivil behaviors are addressed in an effective way, such as using a CR strategy, and when simulated in the classroom, incivility is more likely to be reduced.15,33,34
Students in this study identified effective communication as an important strategy to improve the quality of student-faculty relationships and to enhance civility. Some of the most valuable tools in our “civility toolbox” are engaging in meaningful conversation, actively listening, and showing genuine interest in others. Facilitating critical conversations on the topic of civility begins with and must continue throughout a student’s nursing education. Teaching our students about the importance of communication requires more than discussion—it requires simulating, demonstrating, practicing, and rehearsing these fundamental skills over and over. Postclinical debriefings and self-reflection assignments can be used to bring attention to uncivil incidents and how to successfully address them. This allows students a safe place to relate their experiences, share their impressions, receive constructive feedback, and learn appropriate ways of managing such situations.14
It is also important for students and faculty to cocreate norms of behavior in nursing classroom and clinical courses. Civility that is closely associated with the students’ desire for respect, and abiding by the “golden rule” does not mean we all agree. In fact, faculty in higher education have a responsibility to create teaching-learning environments where lively debates and spirited discussions flourish. Faculty need to create “safe learning spaces” that foster social discourse and encourage critical argument. Therefore, cocreating class norms is critical to providing a foundation for debating challenging issues. Mutually agreed-on norms provide a basis for desired classroom behavior. One way to facilitate this process is to ask, “What behaviors do we want to see in our learning environment, and what behaviors do we not want to see? How will the norms be enforced, and what will the consequences be if the norms are violated?” Once the norms are identified, it is everyone’s responsibility to reinforce and monitor adherence to them and to periodically evaluate how the norms are working. Norms are living agreements that provide a civility touchstone for students and faculty—and provide a framework for working, collaborating, and learning together. When faculty and students work together to craft classroom norm, all parties are more likely to abide by them.14
Likewise, systemic approaches, such as conducting student and faculty civility indices14,35 and using the Pathway for Fostering Organizational Civility (PFOC),14 may be helpful in raising awareness and improving civility on a larger scale. The civility indices are designed to enhance civility acumen, engage participants in conversation, and measure self-perceptions of civility. The indices also may be used to assess perceived civility in others. The civility index is a short survey that lists 20 common civil behaviors for both faculty and students whereby the respondents rate themselves (and others) using a civility ranking. Results from the indices offer students, faculty, and administrators a glimpse into the civility landscape at their institutions and infuse awareness and readiness to recognize these behaviors in the student and faculty population. Once awareness has been raised, the PFOC is a practical step-by-step process for nurse leaders to use to create and sustain systematic, cultural change.
Students suggested hosting social activities between faculty and students to improve relationships and to foster civility. For example, nursing programs might host a faculty-student social event at which scholarship initiatives are showcased in a professional poster exhibit coupled with a formal reception to celebrate nurse’s week or a similar special occasion. Journal clubs, picnics, and brown-bag luncheons to discuss and debate topics of interest are useful venues for bringing together faculty and students. In some schools of nursing, students and faculty participate in fitness activities, discussion groups, and small group seminars to discuss hot topics in nursing education and practice. Other examples include pinning ceremonies and convocation celebrations that commemorate and honor the successful completion of the nursing program.
Because this study includes 1 cohort of prelicensure nursing students from 1 school of nursing in the northwest United States, the findings may lack generalizability to other academic settings and student populations. Self-report studies, especially those measuring perceptions, have limitations. Perceptions of stress, coping effectiveness, relationships, and incivility are open to individual interpretation—behavior that may be perceived as uncivil by one person may not be perceived the same way by another. The study included only student perceptions, making the findings incomplete because faculty perspectives were not addressed. The survey used in the study is a newly created tool and requires further testing.
As nursing students progressed through a 3-year prelicensure nursing program, their perceptions of the overall civility and relationships between students and faculty revealed a slight although statistically insignificant decrease. On the other hand, as students identified factors that might contribute negatively to the civility level and their relationships with students and faculty, they also identified ways to enhance civility in nursing education including threading civility content throughout the course of the nursing curriculum, cocreating norms, and using CR and simulation.
The study findings underscore the pivotal role that civility plays in students’ perception of stress, coping, and program satisfaction and add a fresh voice to the nationwide initiative to promote civility in nursing education. Rather than using a top-down approach with new policy development or workshops, this study advocates for a more grassroots approach with the focus on equipping students with knowledge and skills and allowing them to be the leaders in their nursing profession.
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