Stress and Coping Strategies of the Nursing Students in the University of Tabuk , Saudi Arabia

Background: Nursing students are valuable human resources. Detection of potential stress among nursing students is crucial since stress can lead to low productivity, low quality of life, and suicidal ideas. Identifying factors affecting stress among nursing students can help nursing educators to find ways to decrease stress. The study aimed to determine the stress and the coping strategies of the Second-year nursing students in Department of Nursing, University of Tabuk. Method: A descriptive, cross sectional design was used in this study to assess students’ stress and sources of stress among nursing students as well as identifying the coping strategies used by students. There are 60 respondents of the study which consists of the female and male second year nursing student that are selected through total population sampling method. The researchers utilized quantitative descriptive design and made use of a standardized questionnaire. Result: Findings of this study revealed that majority of the respondents are female and belongs to the age bracket between 1821 years old. Further, the respondents experienced various sources of stress and the commonly identified stress are related to academics. The most common coping strategy utilized by the respondents is “listening to music”. Conclusion: It is recommended to conduct stress management workshop for students in order to assist them with their stress experiences. In addition, to provide a better learning environment to students by organizing extracurricular activities, student’s club or student organizations that will enhance the well-being of the students.


Introduction
Stress problems are very common with many people reporting experiencing extreme levels of negative stress. When stress is considered as something that occurs repeatedly across the full lifespan, the true incidence of stress problems is much higher. Stress involves the "Set of emotional, physical, and cognitive reactions to a change". Thinking about stress as a reaction to change suggests that it is not necessarily bad, and sometimes, could even be a good thing. Other life changes such as losing a job or an important relationship are more negative, and also stressful. An individual's experience of stress varies in intensity between high and low. How intensely stressed an individual feel in response to a particular event has to do with how much we need to accomplish in order to meet the demands of that situation.
Professional preparation of a nurse in the Institute of Nursing, is largely determined by their initial adjustment and ability to cope with changes necessary for their academic preparation [1]. Nursing school is very demanding with its paperwork and skills performance [2]. Nursing students are under vast amounts of stress due to the demanding and rigorous academic coursework and high expectations of clinical performance [3]. stated that some of the most common stress and anxiety factors for undergraduate nursing students were first time clinical experiences, fear of making a mistake, being able to perform clinical skills, evaluations from faculty, lack of support by nursing personnel, and a discrepancy of what is taught in class versus what is practiced at clinical rotations. Other stressors include food changes, unbalanced diets, varying environments, monetary problems, self-expectations, and expectations from classmates and family [4]. The second-year nursing students experienced greater amounts of overall perceived stress levels than third year and fourth year baccalaureate nursing students [5][6][7]. Most of the nursing program start the clinical learning in their first semesters of the academic study.
Coping refers to the continuous efforts to handle external and/or internal stressors. Stress coping, as described by researchers such as Lazarus and Folkman, implies a more specific process of cognitive appraisal to determine whether an individual believes he or she has the resources to respond effectively to the challenges of a stressor or change. The strategies individuals select to cope with problematic events affect levels of perceived stress, with stress persisting if the way of coping is ineffective [8], stated that the use of effective coping behaviors decreases the negative consequences of stress.
There has been an increased interest in stress research in recent times in developing countries among students and workers. The soaring interest in stress research is probably because we live in a world that includes many stressful circumstances and stress has been tagged a global phenomenon [9]. Therefore, this study identified the stress factors and the coping strategies employed by the male and female second year of nursing students in the University of Tabuk, Saudi Arabia. This study is deemed beneficial in promoting the coping strategies which can be used by student and other students in the University of Tabuk. It may also serve as a basis for intervention to help students cope with stress.

Research Design
A descriptive, cross sectional design was used in the end of February to April (2019), in Department of Nursing, University of Tabuk. The study aimed to assess students' stress and sources of stress among nursing students as well as identifying the coping strategies used by students.

Participant and Sampling Technique
The study determined the stress and the coping strategies among a convenient sample of 60 respondents of the second-year nursing students in Department of Nursing, University of Tabuk. All student's male and female in the Baccalaureate-nursing program in their second year were invited to participate in the current study.
The researchers chose the second-year student as their respondents for reason that during this year the second-year are starting to have nursing courses and this is quite different from what they have in preparatory where they are only having basic sciences. Students in the nursing program begin laboratory and theoretical nursing subjects experience during the sophomore year and continue to have complex, rigorous, and unique experiences throughout the junior and senior years. The student must demonstrate satisfactory academic achievement in required course work prescribed by the curriculum.
The researchers utilized total population sampling method, specifically total Population Sampling Technique (TPS). TPS is more commonly used where the number of respondent's s is very small. All second years' students who are currently enrolled whether regular or irregular and are willing to participate will be considered in the study. The new courses in Nursing during their second year may brought about new experience for them and thus may bring about increased stress among the second-year nursing students. Therefore, the researcher was keen to assess students' stress and sources of stress among the second year of nursing students as well as identifying the coping strategies used by students.

Research Instrument
The researchers utilized a survey questionnaire to gather the needed data. They used a pre-constructed questionnaire in English from, [10] with 22 closed-ended questions on stress factors and 17 on coping strategies. The first part of the survey questionnaire regarding the patrician's demographic data consisting of age, civil status and position among siblings are constructed by the researchers. However, the second part of the questionnaire regarding the stress factors and coping strategies of the respondent's. For the reliability and validity of the research, the questions were pilottested before administration. The questionnaire required 5 min to complete. The questionnaire was reviewed before administration by two nursing assistant professors in the Nursing department for content validity, its reliability. The respondents were given detailed instructions on how to complete the questionnaire and informed about the objectives of the study. They were assured of the confidentiality of their responses and that no harm or legal consequences would result from the study.
This part of the questionnaire will be answered by the students using a 5-point Likert scale:

Data Gathering Procedure
To gather the needed data for the study, a letter of request to conduct was prepared by the researcher's and the research adviser and then signed by the research course lecturer and was submitted to the Department Head and the Ethical Research Committee for approval. After the approval to conduct the study, the researchers personally administered the questionnaire to the female second year nursing student. For the collection of data of the male respondents, the researcher's adviser asked the assistance of the second-year level adviser in the male section to distribute and retrieve the survey questionnaires. Authors clearly explained the study objectives to the respondents and obtained written consent from all of them. Their right to refuse participation and their right to confidentiality were communicated. There were no potential risks from the research.

Ethical Consideration
Permission was sought from the Ethics committee of the Department of nursing to conduct the study. Participants were made clear about the objectives and plan of the study. The researchers explained the purpose of the study and an information sheet with the details of the study was provided, and respondents were assured that participation was voluntary. Confidentiality of the collected data was assured, unless the self-report questionnaires suggested that the respondents was severely stressed and unable to cope, thereby, they were referred for support. All participants have singed the consent for their participations. Participants were informed that they have the right to not participate in the study or withdraw from the study at any time. Care was taken to preserve their identity and not to disclose them to respect their choice to retain them, and information was provided about the benefits to participants.

Data Analysis
The responses were scored quantitatively on a five-point Likert scale ('Strongly agree', 'agree', 'true some-times', 'disagree' or 'strongly disagree'). The data were collected on Microsoft Excel sheets as percentage distribution. Data were analyzed using the Statistical Package for Social Science (SPSS) version 22.0 (IBM Corp, Armonk, New York). Percentage and frequency were used to determine the respondents' demographic profile. Moreover, weighted mean and average weighted mean were utilized to determine the respondent's stress factor and coping strategies.

Results and Discussion
This section contains the results and the discussions of the study. The results of the study are presented in a table form in order to facilitate easy understanding of the results, the (Table1) shows that out of 60 respondents, there are 23 males (38.3%) and 37 females (61.6%) who participated in the study.  As to the age of the respondents, result show that 53of the respondents belong to the age group of 18-21 years old and the other 7 belong to the age group of 22-25 years old. As to the respondent's civil status, majority are single which comprises of 53and only 7 are married. Moreover, as to the respondents position among siblings, it can be gleaned from the table that most of the respondents which comprise of 12 or belong to the first order in the family; 9 or belong to second order; 5 or are on the third order ; 8 or are on the forth order; 6 or belong to the fifth order; 5 respondents or are on the sixth order; 4 respondents or belong to the seventh order; 2 respondents or are on the eighth order; 3 respondents or are on the ninth order; and lastly, 4 respondents or belong to the tenth order in the family. There are 2 respondents or however which answered that they do not belong from the 1 st to the tenth order, hence they belong to the 11 th order in the family.
( Table 2) shows Stress factors of the Nursing Students in the University of Tabuk. It can be gleaned from the table that the top 7 nursing students Stress factors are as follows: "Frequent Tests"; "Lack of time to study the material to be tested" both with the same weighted mean "Studying at night"; and "Concern about trying to learn all the content", both with " Studying material that I consider unnecessary for my professional qualification" (WM 3.60); "Difficulty in memorizing the content"; and "Heavy demand  This result can be corroborated with the study by [11] wherein it was pointed out that College students has the most stressful daily hassles, and that the most irritating daily hassles were usually school related stressors such as constant pressure to study, too little time, writing term papers, taking test, plans and boring instructors". Moreover, a study as cited by [12] cited some of the major stressors for nursing students include academic workload, heavy examination schedules, feelings of reservation about nursing as a career choice etc. In addition, another study by [13] concluded that students have the same academic stressors as other college students such as the midterm and final exam papers, research papers and other assignments. Moreover, a study conducted by [14] in Calabar, Nigeria revealed that undergraduate nursing students experience moderate to high level of stress.
In our study, the respondents identified the following stress factors causes their stress at times: "Missing classes"; "The amount of material covered on tests"; "Many tests at the same time"; "Test subject matter goes beyond what was covered in the classroom"; Volume 03; Issue 07 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501 "Amount of details required by teachers"; "Dealing with new forms of assessment, such as the objective structured practical and problem-based learning"; "Amount of extracurricular activities"; "Daily activities unrelated to school (e.g. paying bills, cleaning house"; "Teachers' lack of time; "Feelings of guilt at giving more priority to personal life than to studies"; "Competitiveness among students"; "Waking up very early to go to school"; "High parental expectations"; "Family problems"; "Marriage and children". The item with the lowest weighted mean is the stress factor on marriage and children. This can be corroborated with the result of the demographic profile of the respondents wherein only 7 out of 60 respondents are married. The majority of the respondents were female and were currently in Year 1 to Year 3. The study revealed that approximately 5%-7% of respondents had experienced a past-year relationship crisis with family members, romantic partners or peers. Around 40%-87% were able to maintain a healthy lifestyle, meaning they kept up a balanced diet, exercised, took in some entertainment, kept up hobbies, slept adequately and could have some quiet time by themselves. A relatively low percentage suffered from past-year chronic ill-health (5%, n = 33). Fewer than 2% (n = 12) self-reported a psychiatric disorder, while 8.5% (n = 56) of respondents reported a family history of psychiatric disorder. Only five respondents were current smokers and less than 14% (n = 92) were current drinkers. Four respondents used drugs illicitly and approximately 4% gambled. Most respondents perceived their physical and mental health as good.
The result of our study was similar to another study by [15] that conducted in the school of nursing at a private university in California identified that nursing students who spent more time per week on homework and studying for exams tend to be more stressed and cynical. Students enrolled in graduate level courses tended to be more cynical and exhausted. Undergraduate students demonstrated a stronger sense of professional efficacy. Certain recreational activities were found to be related to stress, cynicism and exhaustion levels, suggesting students with a recreational outlet may be better able to cope. Significant associations between students' hours spent on academic work and family circumstances may provide an explanation of academic pressures.
( Table 3) shows that the different coping strategies of the second-year nursing students in University of Tabuk. As shown in the table that the items: "Listening to music", is the highest coping strategies utilized. The second coping strategy is "Identifying with models of physicians who prioritize their quality of life. Followed by "Studying the minimum needed to pass subjects"; and "Going out to dinner" respectively. All of the above mentioned items were rated as agree by the respondents which implies that they have been utilizing these coping strategies to overcome their stresses. This can be corroborated with the qualitative study conducted among students wherein employing non-physical and positive coping strategies was the most salient theme that emerged from the data which included listening to music as an activity could deal with various academic stresses in a relaxed manner [16]. According to the student's response on the coping strategies, the students seems to identify a model who prioritize their quality of life. This can be corroborated in the study as cited by [17] wherein it was noted that education has a positive impact on professional identification for almost half of the students. Thus, the empirical evidence is that identified a positive impact of education on students' attitudes and preferences. Moreover, the concept of professional identification is frequently used, particularly in research on teacher education and nursing education, but without an explicit and common definition [18][19][20][21].  As for the other coping strategies, the respondents answered as True sometimes are as follows: "Going for walks"; "Respecting my physical limits, avoiding spending many hours without sleeping"; "Getting together with family and friends"; "Student rights", " academic guidance office" ;eating well"; and avoiding comparing grades with other students with a weighted mean of, "Student Council"; "Cooking"; "Reading non-medical literature; "Skipping classes to perform activities that give pleasure like sports;", "Watching football games on television", and lastly "Going to the cinema on weekends". The result of the coping mechanisms of the students implies that sport leisure's are not usually employed as their usual coping mechanism.
Predictors of stress and coping was also explored in College of Nursing at University of Hail, Saudi Arabia using regression analysis in probing the association of the demographic variables affecting the perceived stress and coping among nursing students in the north-western region of Saudi Arabia. The Majority of the respondents were below 26 age group and were female. As to civil status, most were married. A large number were from the regular nursing program and has a relatively low Grade-Point-Average (GPA) of below 2.36 (52%) compared to those with high GPA above 2.36 (48%; n=200). The study revealed that an overall stress of 20.52+7.57 was computed which pertained to moderate stress level. This also means that on the perceived stress scale, majority of the Saudi nursing students achieved a total score equivalent to moderate stress. This may imply that Saudi nursing students experience the same amount of stress as with other nationalities [22].
In a descriptive study design conducted by [23] regarding assessment on stress and ways of coping among first year nursing students which utilized questionnaire to 90 nursing students from baccalaureate degree programs at a university in Turkey. Results of the study revealed that the most reported stressors at the both data-collection times were self-confident and optimistic approach.
These findings indicate the need for stress management programs specific to the needs of nursing students. Given the detrimental effects of stress on health and academic performance, college administrators should consider incorporating stress management training into orientation activities for nursing students.
A study in a Nursing College by [24] was done to identify and analyze the stress, stress reactions and coping strategies among nursing students. The identified causes of stress among nursing student were: tests, grades, competition, time demands, professor's class environment and concern about future careers are major sources of academic stress. Stress in nursing students comes from many sources especially academic aspect, which is highly stressful for students that may even lead to drop out in the program. Students cannot avoid stress but their ability to cope with the stressor is important in achieving success in the academic performance. Thus, managing stress effectively and seeking coping strategy in an appropriate way is very important for preventing the negative effects of stress [25].
Although there have already been studies conducted on this topic, the researchers conducted this study in the Nursing Department of University of Tabuk to identify the stress factors and coping strategies of the second year nursing students which may serve as a basis to help students deal with stress. Many studies have found that nursing students have high level of stress compared with other students. The stress can be altered and influenced by the coping strategies they choose to employ. .

Conclusion
The aim of this descriptive study was to assess stress levels and stress factors among Baccalaureate Saudi nursing students as well as identifying the coping strategies employed by students during their Nursing Education. The result of this study emphasize that the second-year nursing students experienced various sources Volume 03; Issue 07 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501 of stress and the commonly identified according to rank are the stress factors related to academics. It is least likely that they experience stress related to family concerns. The evaluation of coping strategies during stressful events may help in devising the strategies to minimize stress and effective to coping methods. Researchers recommended conducting stress management workshop for students in order to assist them with their stress experiences. To further, conduct the study on stress factors and coping strategies among other students in the different colleges in of the University. For future researchers to conduct this study in a qualitative method in order to explore more on the stress experienced by the students and the coping strategies they employ.