Methodological considerations

Most studies have had a quantitative focus and, although there are clear benefits to using a quantitative approach in this area of research, there is also a need to complement quantitative findings by using qualitative measures for furthering our understanding (Gibbons et al. 2010). The majority of studies were descriptive, cross-sectional and quantitative. One study was experimental and two studies were qualitative, with one study noted to use mixed methods by the use of one open ended question and thematic analysis combined with survey results (Suresh et al. 2012). The use of quantitative measures are useful for objective measures such as sources of stress, but are unable to investigate the student experience and may restrict the in-depth understanding of the student’s reaction to stress. Therefore, future studies should pay more attention to qualitative approaches for investigating clinical stress among nursing students. In particular, using a mixed methods design would address one notable gap in the literature and provide a more robust picture of the student experience with stress during clinical placement. Most of the studies were cross-sectional, and only two were longitudinal. This indicates that the changing nature of clinical stress has not been explored fully in the current

literature. Future studies should aim to address this gap; however, the varying and constantly developing nature of nursing programmes does make designing effective longitudinal studies challenging as this would require consistency of both the

participants and the programme. Sample size and response rate

Sample size and nature were varied in these studies, ranging from 6 to 1707 nursing students, with many being convenience samples. This implied that the generalizability of the literature findings is limited in those studies with small sample sizes. It is highly recommended for nursing researchers by Labrague et al. (2016); Alzayyat and Al-Gamal (2014); Galbraith and Brown (2011) that sample sizes must be statistically significant so that the results can be transferred and applied in other similar settings. Response rates were also found to be highly

variable ranging from 26-33% in one study (Suresh et al. 2012) to 100% in another (Timmons & Kaliszer 2002)

Instruments

There was much variability in the selected instruments and measurements used as can be seen in table 2.2. Only four tools were used twice or more with two studies choosing to use researcher designed questionnaires. The variability is also evident in the structure and content of the instruments that were used; however, all instruments did aim to report on clinical stressors among nursing students.

Table 2.2 Instruments and Reported Reliability and Validity Instruments

Quantitative

The Stress in Nurse Education Questionnaire (2): reliability and validity not

reported

The Culture Free Self-Esteem Inventory: not reported

The Perceived Stress Scale (3): Cronbach’s α= 0.89 and one week retest reliability of

0.60 (p< 0.01)

The Bio-Psychosocial Response Scale: Cronbach’s α= 0.09 and one week test-retest

reliability was 0.72 (p<0.001), Guttman reliability coefficient = 0.83 (p<0.001)

Modified Nurse Stress Scale: Cronbach’s α = 0.92. Spearman-Brown split half method

used for reliability = 0.80 (p>0,001)

Nurse Stress Scale: Cronbach’s α= 0.89-0.93 and test retest reliability 0.81 (p<0.001) Clinical Stress Questionnaire: reliability and validity not reported

KEZAK : reliability and validity not reported STAI: reliability and validity not reported

Lai’s Personality Scale: Cronbach’s α= 0.62 reported by Chen & Hung (2014) The Coping Behaviour Inventory (2): Cronbach’s α=0.76 and one week retest

reliability of all for factors 0.57, 0.57, 0.59, 0.55 (p<0.001)

The Physio-Psyhco-Social response scale (2): Construct validity supported by factor

analysis and Cronbach’s α= 0.90 and one week retest reliability was 0.72 (p,0.001)

General Health Questionnaire: Internal validity and test-retest reliability

demonstrated in numerous studies

Index of Sources of Stress in Nursing: Cronbach’s α exceeded 0.7 for all factors and

deemed to have face validity

Generalized Self-Efficacy Scale: Cronbach’s α= 0.75-0.92 and is supported from

multiple studies

Marlow-Crowne Social Desirability: adequate reliability and validity demonstrated

from multiple studies

Brief COPE: Cronbach’s α exceeded 0.8 for all factors and deemed to have face validity Research Designed Questionnaire (2): Timmons & Kaliszer (2002), reliability and

validity not reported. Blomberg et al. (2014) reported reliability of scale based on intraclass correlation coefficient (0.81) and standard error of measurement (0.90) reported satisfactory reliability.

Qualitative Methods:

Semi-structured focus Group, thematic analysis

Semi-structured telephone interviews, thematic analysis Open ended question

This table highlights that the majority of instruments used reported acceptable reliability and validity, with the exception of Timmons & Kaliszer (2002) questionnaire and KEZAK & STAI (Gorostidi et al. 2007).

Theoretical perspective

The most commonly used theoretical underpinning found in the literature is Lazarus & Folkman (1984) Transactional Theory. In the studies that discuss a theoretical framework McKenna & Plummer (2013), Sheu et al. (2002), Jimenez et al. (2009) & Gibbons et al. (2011) the Transactional Theory is used exclusively. Jimenez et al. (2009) integrates Pollock’s Adaptation Nursing Model (Pollock 1984) along with the Transactional Theory (Lazarus & Folkman 1984) and Sheu et al. (2002) further developing their own framework from the Transactional Theory (Lazarus & Folkman 1984) to formulate a hypothesis. Furthermore, for those

studies that provide an operational definition of stress, Lazarus & Folkman’s (1984) definition is almost exclusively used with the exceptions of Gibbons et al. (2008) as mentioned previously.

In Lazarus & Folkman’s (1984) Transactional model of stress, stress can be interpreted through primary and secondary appraisal. The primary appraisal refers to the initial perception about a stressor and whether it is judged to be positive (leading to eustress), negative (leading to distress) or neutral. The secondary appraisal refers to the coping responses the individual draws on. Interacting between the perception of stressors and the individual’s response are a number of moderators, which include self-efficacy, perceived control, support and coping styles (Jimenez et al. 2009).

According to this theory, a stressor is perceived as stressful when the situation is appraised by the person as taxing or exceeding his/her resources and endangering his/her well-being (Sheu et al. 2002). Stress is not categorized as good or bad, but rather it is classified according to the degree, types, and situations in which it arises. Coping is thought of as the changing cognitive and behavioural efforts made in response to demands that are appraised as taxing or exceeding the resources of an individual, which can then affect health in physical, psychological and social aspects (Sheu et al. 2002).

The functions of coping include managing or altering the problem causing the distress (problem-focused coping) and regulating the emotional response to the problem (emotion-focused coping). Problem-focused coping includes defining the

problem, generating alternative solutions, weighing, and choosing the alternatives in terms of their costs and benefits, as well as action. Whereas, emotion-focused coping, which includes either lessening or increasing emotional distress. However, no single coping strategy is considered superior to any others. Sheu et al. (2002) highlight Lazarus and Folkman’s (1984) view that physical, emotional and social behavioural responses are the results of a person’s evaluation and adjustment to stress.

McKenna & Plummer (2013) illustrate that using primary and secondary appraisal can be applied to student nurses coping with stress in clinical education. Through primary appraisal, nursing students are able to recognize the presence of stressors in the clinical environment that could jeopardize their resources and wellbeing. During the process of secondary appraisal, nursing students experiencing stress in clinical education reduce or eliminate stressors by making efforts to change the stressful conditions, so that they are not perceived as stressors.

Although the studies that did make a point of outlining a theoretical

underpinning chose to use Lazarus & Folkman’s (1984) theory, many still chose not to disclose what theory, if any were used. This lack of transparency can result in misinterpretation of many aspects of research, as application of a theoretical perspective gives context to how the researcher interprets and reports their findings.