Family Involvement in Nursing Homes: Effects on Stress and Well-being
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Stress in Nursing University Students and Mental Health
Submitted: June eighth, 2017 Reviewed: December 7th, 2017 Published: September 19th, 2018
DOI: ten.5772/intechopen.72993
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Abstract
Stress is a physiological response that impacts the cognitive, emotional, behavioral, and social components. It too involves the adaptation of the organism, the coping resources, and the environment. In immature people, stress tin be triggered by social interactions or school requirements. This chapter is a narrative review analyzing scientific bibliography from the principal databases (NIH, Scielo, Redalyc) that explored the main stressors and their effects on nursing students. These stressors include the intendance of patients, assignments and workloads, bookish evaluations, and negative or hostile social interactions. Data include the deleterious effects of stress in nursing students as feet, low, inhibiting learning, and burnout, which negatively bear on their academic evolution and health. Finally, some interventions to reduce the impact of stress are discussed. Conclusion: Stress responses in nursing students vary in duration and intensity during their academic training; final effects depend on the coping mechanisms, private resource, and infirmary environment. The effects of stress on nursing students touch on on academic performance but could also trigger several psychiatric disorders as depression or anxiety, as well equally other associated problems such as sleep disorders, alcohol, and psychoactive drug consumption, which in the curt and long term may touch on the patient care.
Keywords
- nursing students
- stress
- psychiatric disorder
- scholar stress
*Address all correspondence to: fpulido@unpa.edu.mx
ane. Introduction
The term stress comprises the physiological and psychological responses that prepare the organism to cope with stimulus chosen stressors that are interpreted as challenging to the individual [1]. Deleterious effects of stress have been observed from the first scientific description of stress by Selye [2]. Traumatic events can trigger intense stress response on the organism, while daily routines as job, economical, or academic pressures can arm-twist balmy responses of stress during prolonged periods of time; in both cases, stress responses can exist contradistinct producing deleterious effects on health [iii]. Although today the concept of stress has been extensively used and discussed, at least 2 different perspectives of stress must be mentioned: 1 is organic and the other is psychological [four]. Tabular array 1 shows the primary similarities and differences of these two perspectives.
| Perspective | Differences | Similarities |
|---|---|---|
| Organic | Stress like an uncontrolled response by the organism that can be pleasant or unpleasant | Stress as an adaptive procedure and the development of the organism'south abilities |
| Psychological | Stress seen as a process of transaction between surroundings and individual that is emphasizing the cognitive office and the response of the organism to the stimulus, not only by physiological reactions |
Tabular array 1.
Perspectives of the concept of stress.
Adapted from: Holahan [4].
Another bespeak of view proposed that stress occurs due to demands that exceed individual resources, affecting the adaptive, cerebral, and emotional capacities of the subject field [five]. From this perspective, psychological stress has 3 types of cognitive assessments. In the first cognitive evaluation, the field of study discards or recognizes the threatening, beneficial, or insignificant situations based on personal beliefs, self-efficacy, goals, and situational factors. In the secondary cognitive evaluation, the subject estimates the ain resources of coping, including the skills to change the situation or reducing the aversive impact. In the concluding cerebral stage, the subject perceives and reinterprets the stressful situation; that is, there is a reevaluation of a situation that originally was considered threatening and is reinterpreted every bit benign. In nursing students, stress tin can be produced when the demands are perceived as excessive and uncontrollable, and its effects are related to wellness problems [half-dozen, 7]. Table 2 describes the classification and impact of stress on health.
| Kind | Clarification | Bear upon on health | Examples |
|---|---|---|---|
| Acute | It comes in daily life environment, is short in duration, and has no severe effects on wellness. This type of stress helps the individual develop coping skills | Emotional agony; muscle, tummy, and intestinal problems; and transient over-excitation | Loss of a loved one |
| Episodic | This type of stress is intense and repetitive without existence established as chronic | Prolonged agitation, severe and persistent headaches, migraines, hypertension, chest pain, and heart disease | Individuals with personality type A (DSM-V) and people who develop in hostile environment |
| Chronic | Intense, repetitive, and exhausting and leads to the development of diseases | Violence, nervous breakdowns, middle attacks, strokes, cancer, and fifty-fifty suicide | Traumatic experiences of childhood and suffering some affliction |
Table 2.
Classification of stress.
Adapted from: Herrera [8].
Another theoretical perspective on stress is Neuman's model, which considers stress equally the product of the instability of a client organization (private-environment-staff), in which stressful elements join in [9, 10, 11, 12]. Although some stimuli that are generated within the limits of the client's system are stress-producing, they trigger a outcome that can exist positive or negative; it makes necessary to explore the results that stress produces in nursing students during academic preparation. The stressors that nursing students face daily would be the following: (a) Intrapersonal forces occur inside the private, such equally conditioned responses, thoughts, and sensations. (b) Interpersonal forces refer to negative relationships between students, patients, and staff, due east.g., the expectations of the patient or pupil most the function in a hospital. (c) Extra-personal forces occur outside the individual, such as the educatee's economical circumstances [9, 10]. Thus, interventions to reduce stress should be routed in iii directions. The goal of primary prevention is to reduce the possibility of facing a stressor or reduce the possibility of a reaction. In secondary prevention, intervention is made after the client responds to the symptoms of stress. The customer'southward internal and external resources are used to reinforce internal resistance, reduce reaction, and increase resistance factors. Tertiary prevention takes place afterward active treatment or the secondary prevention phase; it aims to ensure that the patient recovers the optimal stability of the organisation in Neuman's model [9, xi, 12].
In summary, stress should be seen as the result of the interaction between the environment and the individual; in the instance of nursing students, the specific stressors are related to factors of academic life and hospital practices, which are oft intense, repetitive, and exhaustive (meet Effigy 1).
Figure ane.
Model stress in nursing student. Note: This figure illustrates the interaction betwixt the nursing student and the stressors.
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2. Stress and wellness in nursing students
Exploring the effects of stress in students is important in many aspects, just two are outstanding. Commencement, most of the students are immature, and the effects of stressful events in young can concluding until adulthood, increasing the adventure of suffering mental health disorders [13, 14] amid other risks on health [15]. Mental health in nursing students will be reviewed in Section five. 2d, stress tin reduce learning skills [16] indispensable in academic environments; the reduction of learning skills is a factor of great importance since it reduces the resources of students to attain academic success. It is known that stress is triggered past stimulus co-ordinate to the historic period of the person [17]. In this sense, school environments can betrayal individuals to stressors equally harassment past peers, schoolwork force per unit area, and being treated careless by teachers; all these stressors can be severe enough to produce psychosomatic pain, psychological complaints such equally feeling unsafe and nervous, irritability, sadness, and depression [18, nineteen]. The effects of stress in school can negatively touch social dynamics between peers and teachers, and these in turn can produce more than stress that in result triggers mental health problems such every bit anxiety and depression [xx, 21].
Prevalence of academic stress is very high in health students, especially in nursing and medicine students according to several reports [22, 23, 24, 25, 26]. Thus, the importance of studying the stressors in nursing students lies in the deleterious effects on cognitive operation and wellness, i.e., the evolution of mental disorders such every bit depression, feet, eating disorders, sleep, and substance use [27], but also experience of stress can result in students experiencing ineffective communication and inefficient at work, decreasing the quality of health-intendance services [24].
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iii. Social stressors in bookish life
Social stressors affecting nursing students can exist grouped according to the experience of formative knowledge and applied knowledge. Determinative knowledge element refers to the academic life of the nursing student. In a study that included 81 postgraduate students in full-time and function-fourth dimension nursing in Jamaica, the authors found that fifty% of participants indicated experiencing the moderate level of stress related to the program of report. The highest stress scores were related to the training, the final result of the exams, and the academic load of the student [28]. These findings are similar to those constitute in Latin American students, in which 89 students of nursing from Lima (Peru) reported in 2005 excessive academic workload, bookish examination, and lack of fourth dimension to complete academic assignments every bit the main stressful stimuli during grooming [29].
Regarding the styles of coping stress, according to a longitudinal enquiry with 249 Spanish nursing students, at that place exist differences betwixt coping styles related to sexual practice, being women who use more an emotional coping approach than men, while male students tend to use more behaviors as alcohol and drug consumption to cope with stressful situations. Surprisingly, the emotional coping observed was positively correlated with neuroticism and negatively with friendliness and scrupulousness.
Finally, the authors demonstrated that nursing students experienced an adaptation to the stressful events during academic life when comparing last year students with the first yr nursing students [26]. Similarly, stress and resilience scores in a cohort study of 1538 undergraduate nursing students in Cathay showed an influence of bookish progress (years) on the stress scores; senior students reported lower stress scores compared to less advanced students [30]. Also, a cross-sectional study of 474 nursing students from three dissimilar universities in Communist china found high scores on two subdimensions of the stress part scale: part of conflict and role of ambivalence. This ways that the main cause of stress is because nearly students accept no idea what activities they are going to do during their stay in the infirmary. Additionally, the authors demonstrate that when the student has a very well-defined identity every bit a nurse he or she tends to take low scores of stress [31].
When students experience practical knowledge, stressful situations are mainly related to the nurse–patient interaction, which implies specific care according to the illness and needs of the patient, in addition to the application of knowledge and skills during nursing practices (run across Section 4.ane). For example, a qualitative study analyzed seven Iranian nursing students and found that the social environment of hospitals is stressful enough during their kickoff practices, where students experience feelings of being inefficient, followed by existence ignored, and too feel ineffective advice, sadness, and ambiguity of the activities they are assigned to practice [24]. Additionally, experiencing the death of a patient is considered an extremely stressful situation for nursing students [32]. In another example, using an adaptation of the Student Nurse Stress Alphabetize (SNSI) to Turkish nursing students, it has been plant that there are four stressors in students: academic load, clinical concerns, personal issues, and interface worries. The factor with greater influence was the personal problems of the patients, while the factor with the lower influence was the academic load. This means that the problems related to the patient tend to be more than stressful than another stressors [33].
Besides, it has been shown that the sense of cocky-efficacy is positively correlated to active coping styles every bit planning, positive reinterpretation of the context, acceptance of the event, and emotional support during the first clinical practice; all these are observed in 394 polish students during the offset year of the career. This means that the student tends to experience less stress when they feel ready to successfully perform a procedure to the patient. In the aforementioned way, people with low perceived stress tend to accept a high sense of self-efficacy [34].
In all previous studies, the stress levels were increased when the pupil started clinical practicing, i.e., the awarding of knowledge and upstanding and legal responsibility about the intendance of the patient; this stress response tin differ according to private differences. One of those differences seems to exist gender, every bit shown in a research in which 215 nursing students from Murcia showed that women had college stress scores than men during clinical practice, in subjects related to emotional items (contact with the suffering of others, emotional implications with the patient); these findings do non hateful in whatever sense that women are less fix to cope with stress, only women are probably more than empathic with the patient. Besides, in that location is a statistically significant human relationship betwixt age and subjects experiencing impotence or uncertainty in a given situation, excessive overload of work, and lack of cognition of a clinical situation, specially in students under 21 years of age [35]. In contrast, in a study that included 45 students of the University of Murcia, it was found that men get more than stressed than women; this statistically significant difference between both sexes was present on the topics related to the management of new technologies, contact with the suffering of others, non knowing how to control the relations with the patient, and the business organization about the results of the evaluation in practice [36]. In short, the showtime professional practices like social service prove to exist more stressful for nursing students than theoretical preparation because pupil are required to put into practice all the acquired knowledge and skills in a real context. So, experience stress during nursing do could be due to a possible discrepancy betwixt curricula and do, in addition to the structural conditions found in near Latin American hospitals [37, 38].
Some other social factor producing stress in students can be related to cultural differences due to nationality or cultural identity. Ethnically, various nursing graduate students, including Latin, have reported difficulties to adapt in school due to cultural differences during bookish life in foreign countries; that is, these students felt the need to validate their capacities and skills to others, based on the fact that native students recognized their differences as evidenced past skin tone or language. In these cases, feelings of isolation and marginalization are experienced when the environment do not recognize their cultural identity. These students tend to feel they are non socially integrated or fully accepted, which causes stress and increases the probability of compunction and desertion [39, 40]. In the same study, protector factors confronting the stress produced by cultural differences, such as services of fiscal aid that alleviates monetary worries, social activities, consignment of a kinesthesia mentor, accomplishment, or progress of bookish goals, were also identified [40]. All these supports findings reported in Mexican American students that related academic success with financial assistance, bicultural relations, and experiencing authentic caring relationships from institutional agents, family unit, and peers [41].
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four. Neuroendocrine responses in stressed nursing students
Inquiry about the effects of stress on nursing students has been developed since the early 1970s; nevertheless, the effects on the hormone levels and other physiological functions in nursing students have been scarcely reported until now [42]. Stress hormones, i.due east., cortisol, are produced by hypothalamic-pituitary-adrenal axis. The paraventricular nucleus of the hypothalamus produces corticotropin-releasing hormone (CRH), which in turn stimulates the pituitary to produce adrenocorticotropin (ACTH). Then, ACTH stimulates the adrenal cortex to secrete cortisol in lodge to increase energy availability [15, 43], but in a long term, this response tin can be deleterious. On healthcare professionals, the explored deleterious effects of stress on physiological status comprise alterations on energetic metabolism and trunk mass [44]. Additionally, stress hormones impair plasticity in the hippocampus of animals [45] and human beings, affecting learning skills [16] and contributing to the evolution of pathologies as anxiety and depression [46, 47]. For these reasons, the study of physiological effects of sustained loftier stress hormones in nursing students is a key factor to understand the deleterious effects of stress. In this sense, measures of salivary cortisol seem to be useful to explore the effects of different environmental stressors and anti-stress interventions [48].
iv.i. Stress-related cortisol response in nursing students
Studies of cortisol levels in nursing students have been performed under several circumstances in which students are exposed to different kinds of stressors. For instance, 21 nurse anesthesia students were tested on salivary cortisol levels during 3 days for baseline measures; after that, 16 continued the experiment and experienced a session of
Additionally, nursing students are required to complete clinic practice; this procedure often implies roofing nighttime shifts. It has been documented that night shifts in nurses are stressful enough to change the cyclic rhythm of cortisol secretion after 5 days when compared to nurses with day shifts. At to the lowest degree 2 days off seem to be necessary to restore the circadian rhythm of cortisol [52]. Moreover, in a Brazilian report, nurses (46 females, 11 males) had higher levels of salivary cortisol (564.one ng/mL) on work day than cortisol levels (354.1 ng/mL) on days off [53]. These data should be taken carefully since samples were collected past participants itself under dissimilar uncontrolled circumstances, and values reported in abstract are dissimilar to values reported on tables. Information technology is logical to presume that nursing students doing clinical practice under nighttime shifts and loftier workload are vulnerable to changes in cortisol patterns, and so night shifts and workload are other stressors that may be affecting wellness in nursing students.
On the other paw, measures of cortisol obtained from 26 female nursing students in the quaternary year of school in Osaka showed that salivary cortisol (μg/dL) did non significantly change 10 min before an academic examination (0.148 ± 0.024), immediately afterward the test (0.156 ± 0.037), and ii h after the test (0.102 ± 0.034) [54]. In contrast, the aforementioned study found increases of salivary immunoglobulin A (IgA) and salivary chromogranin A (CgA) in response to the stress of examination. This finding contrasts with other studies in which salivary cortisol levels changed in response to examination in inferior and senior nursing students [55]. Plasma cortisol levels were as well measured in 92 female nursing students (19–21 years one-time) from Suzhou Wellness College under school and clinic conditions during a month. Although results of this study suggested a modest increase of feet in clinic conditions measured with the State Anxiety Inventory (SAI), cortisol levels did not vary significantly [42]. Authors suggest that plasma cortisol could be a good marker for acute stress but not for the chronic effects. All together, these findings propose that salivary cortisol measures in healthy nursing students vary according to the kind of stressor and the schedule of exposition.
Finally, in a study on 69 health professionals from a palliative care unit, including 32 nursing administration and 30 nurses that met the burnout criteria with the
iv.2. Effects of anti-stress interventions on endocrine responses of nursing students
Several anti-stress interventions have been implemented with the aim to reduce stress in nursing students and professionals, just most of these works are based in self-reports of a decrease in symptoms of stress, and they lack of physiological measures as stress-related hormones. In this sense, few works have explored the furnishings of anti-stress manipulations on endocrine responses in students to test the efficacy of these interventions. For example, nursing students (sixteen–xx years quondam) from a nursing college in Taiwan which take scored eight points or college on the
Information technology has been reported that physical activities can improve the impact of stress. For example, 18 nursing students who practiced a traditional Chinese do called Qigong twice a week for 10 weeks had lower scores of low, anxiety, or stress than 16 command students interviewed with questionnaires DASS-21 and PHQ. This improvement was related with a decrease in salivary cortisol concentrations [46], which agrees with the beneficial effects of practise in the brain functions at the preclinical level [47].
Taken together these findings propose that cortisol is non strongly correlated to the stress experienced past nurses or nursing students in different circumstances. Studies from other healthcare professionals point out the same findings. In physicians and paramedics, cortisol showed very niggling variation in response to the stress produced in high-allegiance patient simulation used for training, while salivary alpha-amylase appeared to be more sensitive than salivary cortisol to measure stress in a imitation prehospital surround [58].
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five. Stress and mental disorders
Mental illnesses are a health problem with high prevalence in the young adult population [59, 60]. Within this population, students are highly vulnerable, especially in the areas of wellness sciences. Careers as medicine, dentistry, and nursing are very demanding physically, intellectually, and emotionally for the students, who are exposed to high levels of stress during their formation. Particularly, in the concluding year of student training, they are exposed to severe emotional stress and exhaustion. The stressors they confront come up from unlike means such every bit academic factors, the demands of proper performance in clinical practice, bookish assessments, and hereafter expectations near employment [lx]. In add-on, social, emotional, and concrete pressures, every bit well as family unit and personal bug, bear on pupil's learning ability and academic performance [61] and predispose the immature students to the development of mental disorders such as feet and depression [62, 63, 64]. The impact of stress on nursing students tin impact the nurse–patient relationship; nurses have more than interaction during and afterward an intervention with the patient. Similarly, being exposed to environmental stressors could lead to dissatisfaction and burnout in nursing staff [65, 66, 67].
It is estimated that up to 55% of young adults report depressive symptoms, burnout, and increased frequency of alcohol consumption during their life as pupil [68, 69] and virtually 42% of students develop a mental disorder, a state of affairs that predominates in the female gender with a prevalence of 62% of this population, with an average age of onset of 23.5 years [seventy]. The most mutual mental disorders affecting students are anxiety disorders, particularly in women [60], and they also report higher levels of stress than men [71]. Seventy-5 to ninety percent of medical students, including nursing, increase alcohol and tobacco consumption particularly in the last twelvemonth of their medical education [72]. Most of the cases (72%) feel a state of emotional well-being that helps to cope with the experienced psychological stress they are exposed to, despite being aware of the consequences of excessive alcohol and tobacco consumption [72]. Something similar has been reported in nursing students, where stress, environmental influences, social credence, and easy availability of alcohol, as well every bit anxiety generated past the difficulty of the educational program, are factors that increment alcohol consumption in this population [73]. In the general population of these students, 44.four% report feeling emotionally stressed and develop some mental disorder.
On the other paw, subjects exposed to stressors but with a network of emotional support reported feelings of happiness; so, it is suggested that support networks help to decrease susceptibility to develop mental disorders [70]. The absence of such emotional back up networks in students increases the risk of developing some mental disorder; students reported having some concrete illness or mental disorder diagnosed past a psychiatrist with no significant differences on prevalence between careers of the health science, such as medicine, dentistry, and nursing [70]. Additionally, it has been observed that factors such as religious do are a potential factor for resistance to mental disorders, such as alcoholism, feet, depression, suicide charge per unit [74, 75], and burnout [68].
These data support the idea that there is a strong relationship between the physical and psychosocial stresses to which nursing students and other wellness careers are exposed, with the susceptibility to develop some mental disorder, and that the presence of some religious beliefs and social support networks, such as the family unit, diminishes the susceptibility to the evolution of such disorders.
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vi. Decision
There is plenty of show that nursing students are exposed to high levels of stress during their training. Among the most frequently stressors mentioned in literature are excessive workload, lack of time to reach academic assignments, examination, interaction with patients, and negative interactions with peers and family. At the bookish level, the stressors can be the result of a gap betwixt the academic preparation and the practical training or the environments produced in universities and hospitals. In this sense, the educational models must contemplate simulations of the real life that the students volition face at work. Such programs must also include the development of social, emotional, coping, and buffering skills. Levels of stress on nursing studies are potent enough to change secretion of cortisol with potential deleterious furnishings. Concrete and psychosocial stress in nursing and healthcare students increased susceptibility to develop some mental disorder, and social support networks diminish the susceptibility to the development of such disorders. Thus, stress must be considered during the formation of nursing students to optimize their academic performances and avert deleterious furnishings.
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Submitted: June 8th, 2017 Reviewed: December 7th, 2017 Published: September 19th, 2018
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