Accepted Manuscript Perceived stress among Macao nursing students in the clinical learning environment Ming Liu, PhD, RN, Professor, Ken Gu, PhD, Epidemiologist, Associate Professor, Thomas K.S. Wong, PhD, RN, Chair Professor, Roger Watson, PhD, Professor, Min Z. Luo, PhD, RN, Associate Professor, Men Y. Chan, PhD, RN, Lecturer PII:
S2352-0132(15)00048-4
DOI:
10.1016/j.ijnss.2015.04.013
Reference:
IJNSS 122
To appear in:
International Journal of Nursing Sciences
Received Date: 29 December 2014 Revised Date:
21 April 2015
Accepted Date: 24 April 2015
Please cite this article as: M. Liu, K. Gu, T.K.S. Wong, R. Watson, M.Z Luo, M.Y. Chan, Perceived stress among Macao nursing students in the clinical learning environment, International Journal of Nursing Sciences (2015), doi: 10.1016/j.ijnss.2015.04.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
M. Liu
ACCEPTED MANUSCRIPT Perceived stress among Macao nursing students in the clinical learning environment
RI PT
Running head: “Stress of Macao nursing students in clinical practicum”
Authors:
a Ming Liu, PhD, RN, Professor, School of Health Sciences, Macao Polytechnic
M AN US C
Institute.
a Ken Gu*, PhD, Epidemiologist, Associate Professor, School of Health Sciences, Macao Polytechnic Institute.
b Thomas K.S. Wong, PhD, RN, Chair Professor, Knowledge Transfer and Consultancy Company Limited, Hong Kong.
c Roger Watson, PhD, Professor, The University of Hull, Hull, UK. a Min Z. Luo, PhD, RN, Associate Professor, School of Health Sciences, Macao
D
Polytechnic Institute.
TE
a Men Y. Chan, PhD, RN, Lecturer, School of Health Sciences, Macao Polytechnic
EP
Institute
Correspondence: Ken Gu, Associate Professor, School of Health Sciences, Macao
AC C
Polytechnic Institute, Rua De Luis Gonzaga Gomes, Macao SAR. Telephone: +853 85993439, Fax: +85328753159. E-mail:
[email protected]
Acknowledgement The authors gratefully acknowledge the valuable contributions of Dr. Joanna Radwanska-Williams in the preparation of this manuscript. The project was sponsored 1
M. Liu
ACCEPTED MANUSCRIPT
by the Macao Polytechnic Institute Research Fund (Code: RP/ESS-03/2012). Conflict of Interest
AC C
EP
TE
D
M AN US C
RI PT
The authors declare no conflict of interest regarding this research and paper.
2
ACCEPTED MANUSCRIPT ABSTRACT Objective: This study aimed at investigation of the stress perceived by Macao nursing
RI PT
students in the clinical learning environment. Methods: A cross-sectional research was designed and 203 nursing students in a
public higher education institute were recruited. The Stressors in Nursing Students
M AN US C
Scale-Chinese Version (SINS-CN) was used to measure nursing students’ stress. Data analysis includes descriptive analysis and analysis of variance.
Results: The overall SINS-CN mean score was 3.33 (SD = 0.49), while the scores for different dimensions were: clinical, 3.44 (SD = 0.54), education, 3.35 (SD = 0.62), finance and time, 3.31 (SD = 0.72), confidence, 3.21 (SD = 0.60), and personal
TE
D
problems, 3.03 (SD = 0.68). Among 10 most common stressors, four belong to the clinical dimension, four to the education dimension, one to the confidence dimension,
EP
and one to the finance & time dimension. Analysis for factors associated with stress
AC C
indicated that no statistical significance was found in most demographic variables, except year two students’ stress scores were significantly lower than those of students in other years (p values were between 0.000 and 0.026). Conclusions: Macao nursing students, to some extent, experienced stress in clinical learning environment and the stress level was higher than that of Hong Kong nursing students. The most common stressors were related to clinical and educational 1
ACCEPTED MANUSCRIPT dimensions. The study suggests that teaching and learning modalities and the workload of nursing students should be reviewed.
RI PT
Keywords: Student, nursing, stressors, Macao
1. Introduction
M AN US C
Stress refers to a dynamic interaction between the individual and the environment [1]. This interaction may lead to cognitive, emotional and behavioral alteration [2]. Nursing as a caring profession has been known to be a stressful occupation [3]. Nursing students who engage in a wide range of clinical duties during their learning in
D
clinical settings share similar stressors as professional nurses experience. In addition,
TE
nursing students also have stress related to their educational studies and
EP
personal/social experience [4]. Stress can be deleterious to individuals and lead to physical and psychological distress [5]. This psychological distress may hamper
AC C
students’ academic performance and hence impede their pursuit of the nursing career temporarily or permanently [6]. What is more, stress and psychological distress may have negative effects on nursing graduates in the workforce [7]. Existing evidence indicates that nursing students have higher levels of stress than students in other disciplines [8,9], but stress varies at different education levels of nursing students and different nursing programs [7,10-11]. Common sources of stress in 2
ACCEPTED MANUSCRIPT nursing students basically include: a) academic-related concerns such as workload, lack of knowledge, examination, teaching style; b) clinical practice for example, lack of competence, taking care of death and dying, shifting, supervision, assessment; c)
RI PT
relationships with others (clients, peers, teachers or other health professionals) [12]; and d) personal factors such as gender, age, new surroundings away from home,
M AN US C
family structure, financial burdens and job roles [4,7,13].
Study on nursing student stress in the Macao Special Administrative Region of Republic of China (Macao SAR) is very limited. Vong and colleagues used a convenience sampling method to recruit 77 nursing students to complete a self-developed scale of nursing student stress [14]. The psychometric properties of the
TE
D
scale were not presented. The results indicated that the average level of stress was moderate and the clinical practice and academic workload were the first and second
EP
ranked stress factors. Another unpublished study was conducted by Li [15]. Its main
AC C
purpose was to explore the effect of personal characteristics of nursing students on stress and coping strategies [15]. There are two nursing education agencies in Macao, a charity agency which was founded in 1923 and a government-funded agency, founded in 1964 [16]. Together with Macao's political system, the Macao nursing education system has experienced remarkable changes in the past 15 years since the return of Macao’s sovereignty from 3
ACCEPTED MANUSCRIPT Portugal to the People's Republic of China (PR China) in 1999. Nursing education has been transformed from hospital-based training to tertiary education based, from a
RI PT
three-year diploma program to the“3+1” supplementary bachelor degree (three-year diploma plus one-year of supplementary study), and then to the current four-year baccalaureate degree program [16].
M AN US C
Simultaneously, clinical practice has been reformed from supervision and
assessment of students by clinical nurses to one that typifies the cooperative work of the nursing faculty and clinical nurses [16]. The advantage of doing this is ensuring the quality of students’ learning in clinical practice. However, it may cause more stress to students. In an Annual School-Student Dialog in one of the public universities in
TE
D
Macao, some nursing students reported that ‘they are overloaded with work because assignments and assessment usually come from both nursing faculty and clinical
EP
supervision nurses’. Another unpublished report from the Student Affairs Office
AC C
indicated that among 18 different disciplinary programs, the nursing program students ranked the highest in ‘Level of Academic Challenge’ [17]. In addition, students may be overwhelmed by and feel stressed in Macao’s complex multicultural clinical environment. Although about 95% of the population is Chinese [18], Macao was a Portuguese colony for more than 400 years, resulting in a very multicultural society. The original multiculturalism has been compounded in 4
ACCEPTED MANUSCRIPT recent years by a dramatic increase of immigration and tourism, making the healthcare services situation even more complicated and challenging [19]. A simple
RI PT
example is the increasingly multilingual environment, where three languages (Chinese, Portuguese and English) consisting of four dialects (Cantonese, Mandarin, Portuguese and English) are in daily use in clinical settings.
Nursing students often report
M AN US C
experiencing difficulty in such a multilingual working environment. Therefore, it is important for us to understand the stress perceived and stressors experienced by our nursing students so that we can prevent the undesirable impacts incurred in the current situation of healthcare provision in Macao. The general aim of this study was to investigate the stress perceived by Macao nursing students in the clinical learning
TE
D
environment. The specific objectives of the study were: a) to measure the level of stress perceived by nursing students; b) to identify the sources of nursing student
EP
stress in the clinical learning environment; and c) to analyze the factors that are
AC C
associated with stress experienced by nursing students. 2. Methods
2.1 Study design
The study was a cross-sectional descriptive design using self-administered questionnaires for data collection.
5
ACCEPTED MANUSCRIPT 2.2 Setting and sample The study took place in a public higher education institution in Macao SAR. All
RI PT
students studying in the nursing program were recruited to minimize sampling error. The total number of nursing students was 231. Excluding 20 students who
participated in the instrument test-retest reliability study, there were 211 participants
M AN US C
in the main study.
2.3 Ethical consideration
Approval was sought from the Research Ethics Committee of the study setting before conducting the study. Permission for using the questionnaire was granted by the
TE
D
original corresponding author. All participants were assured of anonymity and confidentiality. A signed consent form was obtained from those who were willing to
AC C
EP
participate in the study before data collection.
2.4 Measurements/Instruments Data collection instruments included the demographic profile and the Stressors in Nursing Students Scale-Chinese Version (SINS-CN). The validity of the SINS-CN has been established in a previous study and the internal consistency with Cronbach’s α is > 0.7 [20]. The original SINS-CN is a 43-item, self-administered questionnaire 6
ACCEPTED MANUSCRIPT covering clinical, confidence, education and financial sources of stress [20]. The questionnaire uses a five-point Likert scale from 1 ‘being not at all stressful’ to 5
RI PT
‘being extremely stressful’[20]. The validated version among Macao nursing students consists of 43-item with five dimensions with Cronbach’s α 0.96 for overall scale and 0.67~0.94 for sub-dimensions [21]. A test-retest reliability with 2-week interval was
M AN US C
0.82 for the overall instrument and 0.70~0.88 for the sub-dimensions [21]. 2.5 Data collection /Procedure
The researchers delivered the questionnaire to all 211 participants at the end of a single semester at the point in time when each level of students finished their clinical placement. The completed questionnaires were collected from the returning boxes
EP
2.6 Data analysis
TE
D
after two weeks. These questionnaires and data sheets were stored in a locked cabinet.
AC C
The Statistical Package for the Social Sciences (SPSS version 20) was used in performing data analysis. Descriptive statistics were used to analyze the socio-demographic data and stress level as well as the common stressors of students. Post hoc was used to compare the mean scores of the five factors among the four years of students.
7
ACCEPTED MANUSCRIPT 3. Results
3.1 Demographic characteristics of participants
characteristics of participants were presented in Table 1.
M AN US C
3.2 Level of stress and common stressors
RI PT
Totally, 203 valid responses were obtained with a 96% valid return rate. Demographic
The overall SINS-CN mean score was 3.33 (SD = 0.49), while the scores for different dimensions were: clinical, 3.44 (SD = 0.54), education, 3.35 (SD = 0.62), finance and time, 3.31 (SD = 0.72), confidence, 3.21 (SD = 0.60), and personal problems, 3.03
D
(SD = 0.68). The ten most highly scoring common stressors perceived by students are
TE
presented in Table 2. Among them, four stressors belonged to the clinical dimension
EP
(items 3, 9, 24, 39), four to the education dimension (items 1, 4, 7, 18), one to the
AC C
confidence dimension (item 33), and one to the finance and time dimension (item 22).
3.3 Factors associated with stress The researchers further explored the demographic variables which might affect the students’ stress. However, no statistical significance was found in most variables except year of study. The p-values were found significant in the statistic results between year of study and total mean score and each of the five dimensions. In further 8
ACCEPTED MANUSCRIPT analysis for multi-group comparison, we found year two students’ stress scores (including the five dimensions) were significantly lower than those of students in
RI PT
other years (with p values between 0.000 and 0.026), as shown in Table 3.
M AN US C
4. Discussion
4.1 Level of stress and common stressors
The results revealed that Macao nursing students, to some extent, experienced stress in the clinical learning environment and the stress level was higher than that of Hong Kong nursing students [22]. Macao and Hong Kong have a lot of similarities in terms
TE
D
of nationality, political system, social structure and economy; however, nursing education is, to some extent, different. Nursing in higher education in Hong Kong is
EP
quite mature, while in Macao it is still in its transition period to a four-year tertiary
AC C
education degree with an extensive clinical practice component [19]. Moreover, the arrangement and management of clinical placement might have attributed to the level of stress reported in the results. The multicultural and complex clinical environment certainly had an impact on the students’ stress. As mentioned in the introduction, students could have felt challenged and stressed by the multi-language clinical environment. Leong stated that even the students majoring in languages in Macao, e.g.
9
ACCEPTED MANUSCRIPT Translation and Interpretation majors, have to cope with three formidable languages and several dialects [23]. It suggests that school should help students build up their
RI PT
language ability by employing more strategies, e.g. adding Portuguese leaning in the curriculum, facilitating mandarin leaning and practicing opportunities.
Among the top ten common stressors ranked by Macao nursing students, most of
M AN US C
them were clinical and education related stressors. Particularly, the first and second most common stressors encountered by students were due to stress from the clinical dimension, such as ‘Fear of making a mistake in clinical placement’ (M = 4.00, SD = 0.93) and ‘Having too much clinical responsibility’ (M = 3.86, SD = 0.71). These findings are consistent with the previous findings by Wilson and by Mahat [24, 25]. The
TE
D
high stress scores could be a result of inadequate preparation and lack of confidence. Students often worry that any mistake they make will affect their grade and even their
EP
status. According to the currently implemented clinical placement regulations in the
AC C
studied school, a student who makes any mistake in invasive procedures, administering oral medications, or procedures causing any injury to clients, would be suspended from his/her clinical placement. The student is then asked back to the school laboratory to practice the skills until judged “satisfactory” by the School Pedagogical Committee, whereupon the student is allowed to resume his/her clinical practice. Besides, the students’ fear could have been exaggerated by the preceptors’ 10
ACCEPTED MANUSCRIPT high expectations of the students’ performance, particularly on the part of clinical preceptors [25, 26]. A special training program is needed to equip clinical preceptors’
RI PT
knowledge and skills in precepting students in clinical environment. The other most common stressors were related to the heavy workload. The
findings supported those from the studies in Hong Kong and Taiwan [27, 28]. This might
M AN US C
be a result of the heavy curriculum with too many clinical placement hours compared to those in western countries. According to the California Board of Registered Nursing, nursing students in the United States are only required to complete about 1,000 hours of clinical practice before graduation [29]; the University of Notre Dame in Australia requires 1,240 hours of clinical placement [30]. The 4-year Bachelor of
TE
D
Nursing program in Macao was designed with 160 learning credits, among which 46 credits (1,840 hours) are clinical placement [31]. In each clinical unit, students are
EP
required to submit at least three assignments including a clinical learning plan,
AC C
clinical reflections and case study reports. In addition, both clinical supervision nurses and academic teachers are required to assess the performance of each student, which might have caused additional stress to students. Considering the present study findings, the researchers suggest that the teaching and learning modalities and the workload of nursing students should be reviewed.
11
ACCEPTED MANUSCRIPT 4.2 Factors associated with stress Among all demographic variables, only ‘year of study’ was found to have a
RI PT
significant effect on students’ stress. Post-hoc analysis demonstrated that the second year students claimed to experience less stress than their peers in the other three class groups both for the overall stress scale and sub-dimensions (p < 0.05, Table 3). This
M AN US C
result is inconsistent with the findings of the previous studies reported from other countries. A study conducted by Rajesh Kumar in Iran found that the first year
students had the highest level of stress compared with other senior year students [32]. She explained that the higher stress level experienced by first year students could be a result of being placed in an unfamiliar environment, separation from the families and
TE
D
the demand of forming new social groups apart from academic pressures and clinical training. Interestingly, a study conducted in Malaysia found that second year students
EP
in fact claimed to be more stressed than other year groups [33]. It is therefore
AC C
appropriate to postulate year of study as an independent factor that may affect the nursing students’ experience and perception of stress, though the effect is very much dependent on curricular context. Reviewing the curriculum design and organization of clinical placement in the studied school, the researchers noted that no special feature was found in year two study except more extra-curricular activities than in other years of the program. These activities might have helped students enhance their adaptation 12
ACCEPTED MANUSCRIPT to and management of the stress induced in the clinical environment. In view of this uncertain association, we recommend a longitudinal cohort study be conducted to
associated factors.
RI PT
assess the possible changes of stress perception of Macao nursing students and the To further understand the student’s experience and perception, a
qualitative study including, but not limited to the use of in-depth interview and
M AN US C
story-telling should be carried out either together with the longitudinal study or on its own.
5. Limitations
This study used cross-sectional design, so the data were collected at a single time
D
point. The pattern, consistency and intensity of stress over time were not assessed.
TE
Future study should incorporate a longitudinal cohort design to improve the present
EP
research methodology. In addition, as previously mentioned, Macao SAR has two higher nursing education institutions, one charity-funded and another
AC C
government-funded. This study setting was confined only to the government-funded institution. Therefore, generalization of the results should be cautioned. Dimensions of SINS-CN questionnaire does not address local issues such as multiculturalism and language issue, a modification and validation of scale study may be needed.
6. Conclusions
13
ACCEPTED MANUSCRIPT Macao nursing students, to some extent, experienced stress in clinical learning environment and the stress level was higher than that of Hong Kong nursing students.
RI PT
The most common stressors were related to clinical and educational dimensions. Except for the variable ‘year of study’, all other demographic variables did not show any statistically significant effect on students’ stress. Comparative results analysis
M AN US C
indicated that year two students experienced less stress than other peer groups. To further understand the student’s experience of stress in learning, the researchers consider it necessary in the future to conduct a longitudinal study on a cohort of
AC C
EP
TE
D
students, and if possible, complementary work with a qualitative procedure.
14
ACCEPTED MANUSCRIPT REFERENCES [1] Kohler JM, Munz DC, Grawitch MJ. Test of a dynamic stress model for
RI PT
organizational change: Do males and females require different models? Applied Psychology: An International Review 2006; 55 (2):168-191.
[2] Pulido-Martos M, Augusto-Landa JM, Lopez-Zafra E. Sources of stress in
M AN US C
nursing students: A systematic review of quantitative studies. International Nursing Review 2011; 59(1): 15-25.
[3] Lim J, Bogossian F, Ahern K. Stress and coping in Australian nurses: A systematic review. International Nursing Review 2010; 57:22-31. [4] Pryjmachuk S, Richards DA. Mental health nursing students differ from other
TE
D
nursing students: Some observations from a study on stress and coping. International Journal of Mental Health Nursing 2007; 16(6):390-402.
EP
[5] Chang EM, Hancock KM, Johnston A, Daly J. Jackson D. Role stress in nurses:
AC C
Review of related factors and strategies for moving forward. Nursing & Health Sciences 2005; 7(1):57-65. [6] Al-Kandari F, Vidal V. Correlation of the health-promoting lifestyle, enrollment level, and academic performance of College of Nursing students in Kuwait. Nursing and Health Sciences 2007; 9(2): 112-119. [7] Deary I, Watson R, Hogston R. A longitudinal cohort study of burnout and 15
ACCEPTED MANUSCRIPT attrition in nursing students. Journal of Advanced Nursing 2003; 43 (1): 71-81. [8] Jones MC, Johnson DW. Distress, stress and coping in first-year student nurses.
RI PT
Journal of Advanced Nursing 1997; 26(3): 475-482. [9] Beck DL, Hackett M B, Srivastava R, McKim E, Rockwell B. Perceived level and sources of stress in university professional schools. Journal of Nursing
M AN US C
Education 1997; 36(4): 180-186.
[10] Lindop E. A comparative study of stress between pre- and post-Project 2000 students. Journal of Advanced Nursing 1999; 29(4): 967–973.
[11] Burnard P, Edwards D, Kim B, Thaibah H, Tothova V, Baldacchino D, et al. A comparative, longitudinal study of stress in student nurses in five countries:
TE
D
Albania, Brunei, the Czech Republic, Malta and Wales. Nurse Education Today 2008; 28(2): 134-145.
EP
[12] Timmins F, Kaliszer M. Aspects of nurse education programmes that frequently
AC C
cause stress to nursing students – fact finding sample survey. Nurse Education Today 2002; 22: 203-211. [13] Brown H, Edelmann R. Project 2000: A study of expected and experienced stressors and support reported by students and qualified nurses. Journal Advanced Nursing 2000; 31(4):857-864. [14]Vong LY, Iu CM, Chan CY, Un LB. Nursing students’ clinical practice stress. 16
ACCEPTED MANUSCRIPT Macau Journal of Nursing 2003; 2(1): 27-29. [15] Li RL. A survey study of the stress of nursing students in practice period and
RI PT
their coping strategies in a nursing college in Macau. Unpublished Master’s Thesis. Library of Macau University of Science and Technology 2013.
[16] Liu M, Yin L, Zhu MX, Yuan HB. Lived experiences of clinical preceptors: A
804-808.
M AN US C
phenomenology study. Journal of Nursing Education Today 2010; 30(8):
[17] Yung E. Student engagement survey 2014. Macao Polytechnic Institute (unpublished report) 2014: 4-10.
[18] Statistics and Census Service (DSEC in Portuguese). (2013). Demographic
20, 2014 from
TE
D
statistics. Government of Macao special administrative region. Retrieved January
EP
http://www.dsec.gov.mo/Statistic/Demographic/PreliminaryResultsofthe2011Pop
AC C
ulationCensus/PreliminaryResultsofthe2011PopulationCensus.aspx. [19] Liu M, Lam B, Fong P, Yuan HB. Nursing shortage: The facts and strategies in Macao society. The Online Journal of Issues in Nursing 2012; 18(1): 1-9. [20] Watson R, Chen Y, Ip M, Smith G, Wong T, Deary I. The structure of stress: Confirmatory factor analysis of a Chinese version of the stressors in Nursing Students Scale (SINS). Nurse Education Today 2013; 33(2):160-165. 17
ACCEPTED MANUSCRIPT [21] Liu M, Gu Q, Wong KS, Watson R. Validation of stressors in nursing students scale-Chinese version (SINS-CN) in a population of Macao nursing students.
RI PT
Chinese Nursing Research 2015; 1(1): 25-30. [22] Watson R, Deary I, Thompson D, Li G. A study of stress and burnout in nursing students in Hong Kong: A questionnaire survey. International Journal of Nursing
M AN US C
Studies 2008; 45(10): 1534-1542.
[23] Leong SL. English language teaching in Macau: Sharing, reflecting and innovating. Macau Research 2003;16: 212-228.
[24] Wilson M. Nursing students’ perspective of learning in a clinical setting. Journal of Nursing Education 1994; 33(2): 81-86.
TE
D
[25] Mahat G. Stress and coping: Junior baccalaureate nursing students in clinical settings. Nursing Forum 1998; 33(1): 11-19.
EP
[26] Liu M, Zhu MX, Da, HX, Yuan HB. Clinical nursing preceptors’ perceptions of effective characteristics of clinical teaching: A qualitative study. Journal of
AC C
Macao Polytechnic Institute 2009; 3: 18-27. [27] Chan C, So W, Fong D. Hong Kong baccalaureate nursing students’ stress and their coping strategies in clinical practice. Journal of Professional Nursing 2009; 25(5): 307-313. [28] Sheu S, Lin HS, Hwang SL. Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice: The effect of 18
ACCEPTED MANUSCRIPT coping behaviors. International Journal of Nursing Studies 2002;39(2): 165-175. [29] The California Board of Registered Nursing. Professional and vocational
RI PT
regulations: Division 1426. Required curriculum; prior approval. California: The California Board of Registered Nursing. Retrieved March 28, 2014, from http://www.rn.can.gov.
M AN US C
[30] NC Board of Nursing. Clinical practicum. Retrieved April 6, 2014, from http://www.nd.edu.au/broome/schools/nursing/clinical-practicum.
[31] Government Bulletin of Macao SAR. Boetim official da regiao administrativa especial, de Macau-1 Serie[In Chinese and Portuguese] 2013: 610-614. [32] Rajesh Kumar N. Stress and coping strategies among nursing students. Nursing
TE
D
and Midwifery Research Journal 2011; 7(4): 141-151. [33] Gurbinder Kaur JS, Hamidah H, Blackman I, Wotton K, Belan I. Perceived stress
EP
related to nursing education and its influence on nursing students’ academic and
AC C
clinical performance. Med & Health 2011;6(2): 86-97.
19
ACCEPTED MANUSCRIPT Table 1 Demographic Data (N=203) Demographic Characteristics
No.
%
45
22.2
158
77.8
Male Female
M AN US C
Age Mean = 20.8 (SD = 2.9) Year of students Year 1
54
26.6
53
26.1
53
26.1
43
21.2
173
85.3
Christians
14
6.9
Catholics
8
3.9
Buddhists
8
3.9
173
85.2
D
Year 2
TE
Year 3
Religions
AC C
No religion
EP
Year 4
RI PT
Gender
Parents’ marriage status Married
1
ACCEPTED MANUSCRIPT Single
11
5.4
Divorced
19
9.4
3
1.5
10,000~20,000
21
10.3
20,000~30,000
95
46.8
M AN US C
50,000 MOP
68
33.5
16
7.9
AC C
EP
TE
D
*MOP: Macao Pataca (1 US $ = 8.00MOP)
2
ACCEPTED MANUSCRIPT Table 2 Common Stressors Perceived by Nursing Students (N=203) Item
Stressors
Rank
Mean (SD)
Fear of making a mistake in clinical placements
3
Having too much clinical responsibility
22
The lack of free time
33
Fear of failing in the course
1
1
4.00 (0.93)
2
3.86 (0.71)
3
3.79 (0.98)
M AN US C
9
RI PT
No
3.77 (0.94)
The amount of classwork material to be learned
5
3.75 (0.73)
7
Examinations and placement gradings
6
3. 67 (0.94)
24
Criticism from peers or senior staff
7
3.66 (0.94)
18
Having too much to learn
8
3.65 (0.89)
39
Feeling responsible for what happens to patients
9
3.63 (0.88)
4
The difficulty of the classwork material to be learned
10
3.50 (0.73)
AC C
EP
TE
D
4
3
ACCEPTED MANUSCRIPT Table 3 Comparison between Year Groups with Overall SINS-CN and Sub-Dimensions Year 1
Year 2
Year 3
Year 4
sub-dimensions
(n=54)
(n=53)
(n=53)
(n=43)
Mean score (SD)
F
P
5.63
0.021
2.98* (0.51) 3.46 (0.37) 3.37 (0.44)
Clinical
3.58 (0.62)
2.99* (0.54) 3.57 (0.42) 3.48 (0.43)
9.33
0.000
Confidence
3.39 (0.63)
2.98* (0.62)
3.24 (.46)
3.21 (0.60)
7.74
0.000
Finance & time
3.31 (0.74)
2.97* (0.72)
3.36(0.62)
3.59(0.75)
3.27
0.022
Education
3.34 (0.52)
3.02* (0.71) 3.34 (0.52) 3.40 (0.60)
4.80
0.003
3.14
0.026
3.25(0.78)
2.78* (0.65) 3.03 (0.56) 3.04 (0.67)
TE
Personal problem
M AN US C
3.57 (0.54)
D
Overall scale
RI PT
Scale and
AC C
EP
*p < 0.05
4
