The Stress Sources of Nursing Students

Nursing training in the university level aims to solve the health problems of the patients by using the knowledge, attitude and skills of the individuals, yet it may be positive or stressful for the individual (Kang, Choi, & Ryu, 2009; Money, 2007). Students may experience stress in different fields, therefore; the insufficiency of theoretical training, lack of skills in clinical practices, to take the responsibility of the patient, time pressure, lack of motivation and accommodation, social life, relationship with the opposite sex, new responsibilities, living in a new environment may be perceived as stress (Güler & Çınar, 2010; Martos, Landa, & Zafra, 2011; Özkan & Yılmaz, 2010; Öztürk Can, Öner, & Çelebi, 2009; Seyedfatemi, Tafreshi, & Hagani, 2007; Sheu, Lin, &

Nursing training in the university level aims to solve the health problems of the patients by using the knowledge, attitude and skills of the individuals, yet it may be positive or stressful for the individual (Kang, Choi, & Ryu, 2009;Money, 2007).Students may experience stress in different fields, therefore; the insufficiency of theoretical training, lack of skills in clinical practices, to take the responsibility of the patient, time pressure, lack of motivation and accommodation, social life, relationship with the opposite sex, new responsibilities, living in a new environment may be perceived as stress (Güler & Çınar, 2010;Martos, Landa, & Zafra, 2011;Özkan & Yılmaz, 2010;Öztürk Can, Öner, & Çelebi, 2009;Seyedfatemi, Tafreshi, & Hagani, 2007;Sheu, Lin, & Hatice ÖNER ALTIOK The Stress Sources of Nursing Students * Hwang, 2002; Warbah et al., 2007).Sources of stress also vary in accordance with the students' years.It has been stated that third year students' level of stress is higher (Edwards, Burnard, Bennett, & Hebden, 2010), and the senior year students' depression mark averages are higher (Temel, Bahar, & Çuhadar, 2007).
Different studies show that second year students complain about the course load and their spiritual symptoms are higher (Alparslan, Yaşar, Dereli, & Turan, 2008;Dinç, Kaya, & Şimşek, 2007;Jimenez, Navia-Osorio, & Diaz, 2010;Tutuk, Al, & Doğan, 2002;Tanrıverdi & Ekinci, 2007).It is thought that these differences in the research findings may depend on culture, class and perceptions.When the national studies are examined, it has been shown that the sources of stress are most common in the second year and the reason is heavy professional courses in terms of both theory and practice (Alparslan et al., 2008).These stress factors may cause some negative changes in the psychosocial lives of the students.Fall in academic performance, serious health problems may occur if the student perceive stress as a negative thing (Edwards et al., 2010;Luo & Wang, 2009;Seyedfatemi et al., 2007).The training process is a significant preparation phase in terms of the student's professional role (Howkins & Ewens, 1999).During the training process professional socialization theory distinguishes as a guide (Howkins & Ewens).Cohen (1981), who has studies regarding the professional identity development, has defined professional socialization as the individual's gaining all kind of knowledge, skills and values and internalization them.The individual begins to adapt to the new culture and behaviours as the new member of the profession (Cohen).The professional socialization process is defined in four phases which are dependency, negative/independent, co-dependency and inter-dependency (Cohen;Cohen-Scale, 2003;Howkins & Ewens, 1999).During this process, the student's professional values increase, the professional roles are structured, and the personality traits start to change (Du Toit Dlitt, 1995;Howkins & Ewens).This process may be prevented by stressful life events.
The negative effects of stress on students' professional identity development have been emphasized in many studies (Edwards et al., 2010;Luo & Wang, 2009;Seyedfatemi et al., 2007).When the effects of second year stress are explained through the professional socialization theory, it has been found out that it causes some negative results such as leaving school, and the heavy course load causes burnout and thus students need more help especially in this phase.
At this phase, trainers are responsible to decrease the level of stress and prepare programs (Karaöz, 2002).While reaching both national and international studies on student nurses' sources of stress, national studies based on the professional socialization have not been encountered.When the national studies are examined, it has been found out that these studies had been done descriptively and quantitatively (Alparslan et al., 2008;Erbil, Kahraman, & Bostan, 2006;Güler & Çınar, 2010;Kartal, Çetinkaya, & Turan, 2009;Tanrıverdi & Ekinci, 2007;Temel et al., 2007;Tel, Tel, & Sabancıoğulları, 2004;Yıldırım, Hacıhasanoğlu, & Karakurt, 2008).When the results and the groups of the studies are evaluated, it is seen that they are mostly repetitive and only situation determination is done.However, when internation-al studies are examined, it is seen that the subject had been dealt with within the frame of professional socialization and the studies had been carried out accordingly (Cohen-Scale, 2003;Dalton, 2005;Du Toit Dlitt, 1995;Gray & Smith, 1999;Howkins & Ewens, 1999).In this study, the fact that second year students' sources of stress have been aimed to determine by using qualitative research design, and to reveal the students' perceptions of their own issues will contribute in terms of professional development and provide a new point of view to the studies in the related fields and form a base for future studies.

Purpose
In this study, it was aimed to find out stress sources of second year nursing students.To this end, the study aimed at answering the question "what are the second year students' individual and social sources of stress during their clinical and theoretical training?"

Research Design
This study was a qualitative phenomenological study.Phenomenology is not merely a philosophical approach but a research method where special methods employed to find out the perceptions, interest and experience of an individual (Hesse-Biber & Leavy, 2006).Interview is main data collection for a phenomenological study.Phenomenology aims to describe and define experience and reveals the perception and thinking process of an individual (Speziale & Carpenter, 2003).

Study Group
The study was carried out at Adnan Menderes University, Health School [ASYO], Department of Nursing between June and September 2011.Fifteen second year students of nursing training constituted the sampling of the study.Maximum variety sampling was used in the study; thus, sex, age, place of living, income, and satisfaction with the college were considered while determining the sampling.Fifteen students 53% (8) of whom were females and 47% (7) of whom were boys were included in the sampling.The average of age the students was 22. 67% (10) of the students shared a house with their friends, 26% (4) of the students resided in a public or private dormitory, and 7% (1) of the students lived with their parents.60% (9) of the students stated that their income was equal to their expenses while 33% (5) of them stated that their in-come was less than their expenses, and 7% (1) of them stated that their income was more than their expenses.None of the students reported to have worked during college.60% (9) of the students stated to be satisfied with the college.40% (6) of them stated to be unsatisfied with the college.Nursing School was ranked first by 53% (8), last by 20% (3), and medium by 27% (4) of the students.

Data Collection Instruments
"Student information form and depth interview method" was used to collect about the students." The students were asked an open-ended question at the beginning of the interview as "What are the second year students' individual and social sources of stress during their clinical and theoretical training?"The semi-structured depth interviews were made with the students.The interviews were recorded.

Data Analysis
The data were analyzed inductively.The data were coded for analysis by classifying according to their meanings (straight in -line coding) and the related codes were put together (vertical coding) and the themes were formed by integrating the core categories identified in the vertical coding (selective coding), and then were interpreted.

Validity Reliability
Some precautions were taken in order to increase the validity and reliability of the study.
i) The students recordings were transcribed after the interviews, and the transcriptions were sent to the related students and they were asked to check the transcriptions and thus participant approval was granted.Moreover, in the content analysis, the categories were specified wide enough to include themes and sub-themes, and narrow enough to exclude irrelevant concepts.These interrelationship between these categories, themes and sub-themes were checked and coherence was granted.
ii) In order to increase the external validity of the study, the research process and activities were explained in a detailed way.
iii) In order to increase the internal validity of the study, the findings were provided without interpretation.Besides, the researcher and an academic member who is experienced in qualitative research method coded the collected data sep-arately, and the coding were compared and the category, theme, and sub-themes were identified.
iv) In order to increase the external reliability of the study, the researcher defined the activities in a detailed way.Furthermore, the raw data and the coding were kept by the researcher so as to be examined by another person.

Ethics
Before beginning the research, The Ethical Board Approval was granted by Dokuz Eylul University Invasive Clinic Evaluation Commission.The required permission was obtained from Aydın Health College Directorate.The aim and the contribution of the study were explained to the students who accepted to participate voluntarily, and then written approvals were obtained.

Results
Four interrelated categories and themes and subthemes related to these categories were determined related to the answers of the students to the question "what are the second year students' individual and social sources of stress during their clinical and theoretical training?"The category, themes and sub-themes related to the research question were explained below:

Clinic
The sub-themes which are judgmental attitudes, the fear of getting low marks, being warned, the insistence/pressure about care plan, the status, distinguishing between students have arisen from the theme "the sources of stress related to the trainer in clinical practices." Most of the students have stated to be under pressure for fear of being graded by the trainer.The patient care plans which the students are responsible for during the practice process are another source of stress.The students have stated to have lost motivation as a result of the trainers' attitudes and behaviors.The sub-themes related to the theme "the sources of stress experienced with the physician" are medical students' humiliating nurses, not protecting oneself, disrespectful attitudes of physician towards nurses, being excluded from the visits, and the hierarchy between therapist and nurse.
The theme "the sources of stress experienced with nurses" are nurses' humiliating students, not accepting male students, not being appreciated by nurses, pressure, making requests which are not related to nursing, and behaving passively before the therapist.
The reason of stress related to this theme is the nurses' not embracing the students and abusing them.
The another theme "the sources of stress experienced with patients" is patients who cannot control their emotions, patients who ask private questions, not accepting male nurses, female patients who do not accept male nurses, and not trusting student nurses.
The male students have stated to feel frightened to be misunderstood while dealing with female patients.
The sub-themes related to the theme "the sources of stress experienced with patients related to herself/ himself " are being afraid of the unconscious patient, the difficulty of addressing to a patient, feeling bored when not being able to answer the question asked by a patient, having difficulty in asking private questions, not being able to control her/his emotions, and the fear of making a mistake.They have stated that as a result of being in the patient's room permanently, they have difficulty in not exceeding the limits.
The students have said that they are affected by the patient's pain and could not control their emotions.
There are students who feel uneasy while asking some sexual questions to patients.The theme "the sources of stress related to the practices" is not practiced in the clinic, the fact that some topics which are not covered in the theoretical training may be encountered during the practice, being with patients all the time, and improper condition of dressing rooms.
Being with patients all the time causes communication and relationship problems.The students have explained the lack of personal spaces in addition to the university's not caring about them.

Theoretical Training
This category has been specified to determine the sources of stress the students experience during their theoretical training in the college.The themes related to this category are the sources of stress experienced with the trainer, the sources of stress related to the student, and the sources of stress experienced with other students.
The sub-themes related to the theme "the sources of stress experienced with the trainer" are the trainer's not having good presentation skills, not caring about students, not motivating students.The students have stated that the method of the trainer has affected both their motivation and comprehension during the theoretical training.
"The sources of stress related to the student" is not participating in the courses actively, not wanting to participate in the courses, the heavy study load, the fear of not being able to catch up, low levels of course motivation, the courses' being too complicated, and test anxiety.The students experience the fear of not being able to catch up as a result of the heavy study load deeply.The sub-themes related to the theme "The sources of stress experienced with other students" are grouping, communication problems, the inequality in the number of male and female students, not sharing the course notes, and students' being grade-focused.The students have emphasized that groupings are common within the classroom.

Social Life
This category explains the sources of stress students encounter in their social lives.The themes related to this category are accommodation, university life, and family attitudes.The sub-themes related to accommodation are the responsibility sharing with the house mate and not being able to find accommodation.
The sub-themes related to university life are the lack of social activities in the university and groupings.The students have stated that they could not live a university life fully as a result of heavy study load.The sub-theme related to the family attitudes is the negative prejudice of the relatives to nursing.One student in specific has stated that her/his family has not wanted her/him to prefer this profession.

Personal
This category has been used to define the sources of stress about the student's her/his own personal traits.
The themes related to this category are lack of self confidence, not being able to control her/his emotions, time management, and thinking mistakes.
The sub-themes related to the theme "lack of self-confidence" are self-effacement, not being able to express oneself, and not being able to say "no".The sub-themes related to the theme "not being able to control her/his emotions" are not being able to control anger and sentimentality.The students who have mentioned sentimentality have also stated to have experienced difficulty in controlling her/his emotions.
The theme "time management" is not being able to organizing study time and fun time.The sub-themes related to the theme "thinking mistakes" are exaggerating the problems, being overtly perfectionist, degrading oneself, ending friendships as a result of e minor problem, the fear of being misunderstood, judging and blaming oneself and pettishness.

Discussion
The students' sources of stress have been identified under four main categories which are clinical practice, theoretical training, social and personal lives.
In other studies related to the subject, the students' sources of stress are identified as academic and clinical, personal/social and the clinical practices are reported to create the highest level of stress (Martos et al., 2011;Pryjmachuk & Richards, 2007;Timmins, Corroon, Byrne, & Mooney, 2011).In the clinical practice, the supervisions in which the performance of students are evaluated to create extra stress on students and some documents used in patient care are stated to be useless (Laitila, Elina, Riitta, Kirsi, & Leena, 2007;Mahat,1998;Martos et al.;Pearcey & Draper, 2008;Timmins et al.).In practice though, the trainer should be role model who supports the student's professional development and increases her/ his motivation (Andrews et al., 2006;Çimete, 1998;Jerlock, Falk, & Severinsson, 2003;Laitila et al.).
Clinical practices have to be environments where students socialize professionally and learn the professional culture, yet they have been an extra burden for students as a result of the hierarchy between students and physician (Andrews et al., 2006;Dalton, 2005;Seyedfatemi et al., 2007).An environment where students are welcomed and praised will increase their self-respect and self-confidence and help them feel more powerful (Bradbury-Jones, Sambrook, & Irvine, 2011;Elçigil & Yıldırım Sarı, 2011;Levett-Jones, Lathlean, Mcmillan, & Higgins, 2007;Papp, Markkanen, & Bonsdorff, 2003).
Another stress nursing students experience in the clinical environment is related to patients.In the literature, students state that they feel stressed out for fear that the relationship they build with a patient may harm them (Gorostidi et al., 2007).Moreover, a male nurse's caring a female patient is still being regarded as odd (Suikkala & Leino-Kilpi, 2001).Another study shows that negative attitude of patients affect students' stress level (Suikkala & Leino-Kilpi, 2005).
Students feel uneasy for stressors stemming from themselves.In the literature, it is emphasized that students experience loss of control in their relationships with patients as a result of insufficient practice (Gorostidi et al., 2007;Timmins et al., 2011).The fact that students do not have dressing rooms increases the effects of other problems.A positive experience may change students' perceptions of nursing and affect their emotions positively (Pearcey & Draper, 2008).
Theoretical training is another source of stress because nursing training aims to support the processes of learning and decision making (Jerlock et al., 2003).It is not easy to acquire these skills.The trainer has some responsibilities, but they have complained about students' indifference and lack of empathy (Keçeci & Taşocak, 2009;Norman, Buerhaus, Donelan, Mccloskey, & Dittus, 2005).The academic concerns experienced by students regarding training have been emphasized in various studies, (Jimenez et al., 2010;Seyedfatemi et al., 2007;Warbah et al., 2007).Jimenez et al., academic stress, heavy workload, tests, the fear of failing and concerns related to the academic staff have been identified.As a result of these, students have stated to experience conflicts in their professional, personal and family lives (Norman et. al.).
Students experience stresses resulting from other students under the category of theoretical training.Communication problems are perceived as problem and may result in depression (Mahat, 1998;Temel et al., 2007).Besides theoretical training, students have stated to experience difficulties in balancing responsibilities related to school, family and other fields (Norman et al., 2005).Altunay and Öz (2006) state that the students who participate in social activities feel better because of the development in these skills and cope with stress more effectively.
Another source of stress is explained in the family attitude theme.A student states that her/his family criticized her/him for preferring nursing.The negative opinions of the society towards nursing affect students' opinions negatively (Ünlü, Özgür, & Babacan Gümüş, 2008).However, the family has a great role in social support and making an individual feel better (Kahriman & Yeşilçiçek, 2007).
Another source of stress for students is examined under the personal category.The students feel lack of self-confidence in general.Confidence is crucial for being able and sufficient in one's profession (Kutlu, 2009).Idczak (2007) states in a study that students feel less confident before a patient who has a lot of medical knowledge.This case decreases students' self perceptions (Edwards et al., 2010).
The theme "not being able to control her / his emotions" has been examined with the sub-themes of difficulty in controlling anger and sentimentality.Idczak (2007) emphasizes that students are afraid of their patients.It is stated that students who are not able to control her/his emotions sufficiently in clinical experiences have high levels of stress and anxiety (Por, Barriball, Fitzpatrick, & Roberts, 2011).
Thinking mistakes theme and definitions of students' self-thinking types emphasize that judgmental or negative feedback especially by the trainer create disappointment and loss of self-confidence (Brown et al., 2003).Ousey (2009) states that by setting the connection between theory and practice and by providing an effective learning environment and social structure, the trainer helps student gain the professional role.The professional identity concept of students will change with the experiences in the training process (Kelly & Courts, 2007).
The results of the findings indicate that students experience internal and external stress and need to improve social and coping skills.The lack of these skills causes internal stresses to be external.It is recommended to consider this situation in curriculum evaluation studies, and to organize social skills and recklessness training groups towards making the individual more powerful.