An Evaluation of Stress in Nursing Placements

Abstract

Aim

To review current research and evaluate stress in nursing placements from the student’s perspective and identify an area for service improvement. Methods: A critical review of the literature using a systemic search of the databases CINAHL and Medline.

Findings

The most common sources of stress relate to; fear of unfamiliar situations, mistakes with patients, handling medication and medical equipment. In general, no changes occur at the different stage of the student’s university education or placement.

Conclusions

It is vital that students are helped to realise what their stressors are and appropriate ways in which to cope with them. As it’s is recognised that elevated levels of stress and burnout may have a negative effect on patient care and increased rates of errors (Aiken et al. 2002, Van der Linden et al. 2005, Elfering et al. 2006). By teaching students to recognise stress and develop effective coping mechanisms, there is potential for service improvement paving the pathway for a positive nursing career.

Contents

Summary………………………………………………4

Chapter 1: Introduction……………………………………..5

Chapter 2: Methods……………………………………….8

Chapter 3: Critical review……………………………………9

Chapter 4:  Plan to implement service improvement………………….17

Conclusion…………………………………………….22

References…………………………………………….23

Appendices

Summary

What is known about this topic?

• Quantitative methods dominate research on nursing student stress
• A search of the literature reveals a considerable number of studies focused on nursing students’ views and placement experiences;

What does this review add?

The means of implementing a service improvement plan by preparing students for potential stressors in clinical placement, this can help students be able to develop coping mechanisms for their future career such as stress management training.

Keywords: Nursing student, stress, clinical placements, burn out.

Chapter 1: Introduction

The feeling of being under endless psychological or emotional pressure can turn into stress when you feel unable to cope with demands (NHS Choices, 2017).

Student nurses are not only forced to deal with the academic stress whilst attending university but in addition to this they face the stress and pressure at their workplace during clinical placements across all years. Some of the most common and reoccurring factors resulting in stress are: a feeling of being overwhelmed, time pressures excessive workloads, making decisions, continuous changes and a fear of mistakes whilst on placement (Bennett et al, 2001, Bennett, 2002; Jones and Johnston, 2000; Mcvicar, 2003).

A report from The Royal College of Nursing found that nurses experience stress when they are unable to cope with the work load or environment (RCN, 2015). It’s important to recognise that stress in turn not only effects the person but can adversely affect the delivery of patient care.

Being a nurse can mean high work demands with a combination of too much responsibility can result in a loss of compassion for patients and increased incidences of clinical errors and therefore effecting the quality of care given to patients (Teng, 2010).

Some of the stressors of being a nurse are continuous throughout their career. Nursing is a job that is constantly changing through evidence-based research. Maintaining competences throughout their career can be challenging. Keeping up to date with local policies, manual handing, training courses etc. It’s imperative for nurses and midwives to practice in line with the best available research and to achieve this they must ensure any information or advice given is evidence base, including information related to using any healthcare products or services (NMC, 2015). ‘’Nurses must maintain the knowledge and skills needed for safe and effective practice’’ (NMC, 2015).  Nurses work in environments that are constantly changing and developing, this can be stressful for students to adapt.

Therefore, the emphasis should be targeted at student nurses and incorporated into their training placements.Stress is a ‘’psychological factor that influences the academic performance and well-being of nursing students’’ (Sawatzky 1998). This has lead to the development of a large body of research aimed at determining the levels and sources of stress in the training of future nurses (Burnard et al. 2008; Pryjmachuk & Richards 2007b; Timmins & Kaliszer 2002).

According to research explored throughout this paper, the most common sources of stress are related to clinical placements. Some of these are common to those reported by registered nurses, such as: work load, caring for acutely ill patients, staffing levels and work dynamics. (Rhead, 1995; Snape and Cavanagh, 1995).

This dissertation will explore the sources of stress in nursing students. I will be focussing on two central themes: Stress and burn out; stress in novice and experienced nursing students.

At the end of this paper, a service improvement plan will look at informing students about possible stressors associated within their profession and introducing interventions to support the development of coping capacity for clinical practice (Pulido‐Martos, 2011).

Findings of this study and the literature reviewed support the need to implement stress management training. Suggestions are made for development in clinical practice and future studies should help students cope better. Therefore, academic staff need to be aware of students’ academic performance and their clinical placements, particularly those students who perceive greater stress and show poor health.

To make the most of clinical experience, academic staff must be able identify existing stressors in the clinical practice setting and understand adaptive student responses. (Rhead, 1995; Snape and Cavanagh, 1995).

The plan will highlight the importance of recognising stress within students. It will help students be able to manage, seek support and prepare them for potential future stressors and burnout.

Chapter 2: Methods

To begin a critical review on a chosen topic, it is central to be able to conduct a search strategy. The Nursing and Midwifery Council (2015) states nurses must practice in line with the best available evidence. The role of the nurse requires you to evolve and develop in an ever-changing work environment to deliver the best possible care.

2.1 Search Strategy

By using the University of West of England (UWE) library search, databases such as MEDLINE and CINAHL was used to identify the most up to date primary journals.

The database search is found in Appendix A. The keyword search can be seen in Appendix C. The most current evidence is found in journal articles (Aveyard, 2010). The databases used were selected as they are both sources of primary research, assessed as highly ranked in originality and efficiency. One of the competencies for entry to the register of the Nursing and Midwifery Council (2010) in the UK, in relation to research, is that: All nurses must appreciate the value of evidence in practice, be able to understand and appraise research, apply relevant theory and research findings to their work, and identify areas for further investigation.

Inclusion and exclusion criteria were identified to reduce bias (Burns, 2015). The criteria are in Appendix B.

2.2 Limitations

It was not possible to review all suitable literature relating to the chosen topic. Due to the limited amount of the UK primary research on this subject, an Australian and Spanish journal article was used based on transferability to UK healthcare (Webb and Roe, 2007).

When conducted a database search its recognised that that the most recent up to date papers in the last ten years will allow you to make quality evidence-based results. Cronin, Ryan and Coughlan (2008) state that ten years is appropriate if the amount of information available is appropriate. However, Tappen (2011) suggests that limiting a search like this can exclude significant original research that may have been done previously. There was adequate current research to adequately review this topic within ten years. However, the use of secondary research articles was used outside the ten-year date. Summary of primary papers used can be found Appendix E.

2.3 Critiquing tool

Using the Holland and Rees (2010) structured critical framework for quantitative research articles was used. All four chosen primary papers were quantitative. Holland and Rees (2010) stated that their quantitative framework is used to identify the strength and weaknesses of the research articles.

The framework recommends that the technique in which they use to analyses data can be a useful tool in finding out the type of the research study whether it is a quantitative or qualitative study. They also stated that when appraising a research article for quality we should look at the research question and the objective whether these are stated clearly and if the research design use was the most appropriate (Holland & Rees,2010).

2.4 Main themes

The two central themes in chapter 3 include: Stress and burnout in nursing students; stress experienced in novice and experienced nursing students.

Chapter 3: Critical review

This chapter will explore the central themes arising from four primary research studies exploring the stress experienced by student nurses while being on placement.

Some of the main sources of stress experienced by nursing students are experienced by normal academic student at university courses. Sources of academic stress include exams and assignments (Howards, 2001; kipping, 2000). In relation to workload, nursing students experience more long hours of study and an associated lack of free time. Nursing students have reported to experience higher levels of stress and more physical and psychological symptoms than compared to any other academic students (Beck et al. 1997).

3.1 Stress and burnout in nursing students

The first two papers critiqued were Gibbons (2010) and Edwards et al (2010) they explored stress and burnout in nursing students. Both papers are quantitative studies and was critiqued using the Holland and Rees Framework tool. Gibbons (2010) overall aim was to explore the relationships between sources of stress and burnout. Edwards et al (2010) aim was to investigate nursing students’ experiences of stress throughout three years of their training.

From reviewing the papers most of the studies employ a quantitative method. Using a descriptive quantitative design can provide reliable results. By using questionnaires this method is a convenient, cost and time effective means of gathering such data. According to Aveyard and Sharp (2013) quantitative research on its own provides less details on behaviour and attitude of the participant. They suggest that quantitative and qualitative research should be used alongside each other to provide a mixed method research design.

Gibbons (2010) paper expressed that it is apparent that sources of stress in nursing students cause as psychological distress. An in-depth survey was conducted involving 171 third year nursing students. Several types and styles of questions evaluated students stress levels which could potentially lead to distress. ‘’Support, control and coping styles were also measured, along with their potential effect on burn-out’’ (Gibbons, 2010).

Questionnaires are affordable way to gather quantitative data, one limitation is when not presenting questions face-to-face is that the respondents may have different interpretations of the questions. Without someone to explain the questionnaire fully and ensure everyone has the same understanding, results can be subjective (Debois, 2016).

The study was approved by the university ethics committee. The information sheet handed to students emphasised that participation was entirely voluntary and that their participation would be protected and confidential. that being involved would have no effect on course progression and that confidentiality would be maintained always. By obtaining ethical approval they are indicating that they have accepted ethical standards of a honest research study which could increase the desirability potential (Ellis, 2003).

Gibbons (2010) results indicated the most common factors which lead to distress were in student clinical placement rather than an academic environment.

Lack of knowledge, control and support were also great indicators. Initiatives to promote support and self-efficacy are to be expected to have the more immediate benefits in enhancing student well-being (Patterson, 2013).

As there are limited number of resources available suggesting the relationship between stress levels differ over the three years of training. Edwards et al (2010) focus was to’’ investigate nursing students’ experiences of stress during three years of their undergraduate nursing programme’’. This allowed a fair representation of stress experienced throughout the students 3-year training. Edwards et al (2010) research has shown that there are indeed differences in student psychological well-being across the academic year. Students took part in the ‘stress in nurse education survey’ and the ‘culture free self-esteem inventory’ at several different of stages throughout the course.

The ethics committee passed the research proposal. An information sheet about the study and a consent form was administered and completed.

However, in a cross‐sectional study, Lindop (1991) reported differences in stressors by academic year. The students agreed on the stressors related to education. However, when the analysis of specific situations such as taking exams or work load was observed, the students in second and third years experienced higher levels of stress. Throughout the report the statement that stressful experiences in the clinical placement but were more intense in the last years of their training was true (Lindop,1991).

While there are a considerable number of studies showing levels of stress between nursing students, there are very few facts that highlight a relationship between stress levels and time (Edwards et al, 2010). The one longitudinal study (Deary et al, 2003) found increasing levels of stress as their training progressed. Stress was measured at the beginning and then at the end of the first year whereas all other variables were measured again during the second and third year.

Burnard et al. (2008) reported data from a series of cross-sectional surveys in student nurses in each year of training and found no evidence of changes in the intensity of stress during training. Accordingly, there is need of a longitudinal study of student stress over time. Longitudinal studies allow researchers to gain a better insight, rather than just taking a one-off result it will allow comparisons over time and then identify causes. A weakness of longitudinal studies may be that people chose to discontinue the study, and the people who remain in the study may not end up being representative of the starting sample (Sasat et al, 2002).

Various aspects of self-esteem in nursing students were investigated across three years of nurse training in two countries and no relationship was found between self-esteem and year of study (Sasat et al, 2002).

Three longitudinal studies conducted in the UK provided conflicting evidence. Randle (2003) found that although many students commenced their nurse training with average levels of self-esteem as classified by the ‘Tennessee Self Concept Scale’ by the time they finished their education their self-esteem had fallen to the point that 95% of the students perceived themselves as anxious, depressed and unhappy. By contrast, Begley and Glacken (2004) found that students’ self-esteem rose as they neared the end of their education programme, although their overall self-esteem levels at their highest were only average.

Edwards et al.’s (2010) study provides information on sources of stress at five separate times over the first three training courses. Though they found substantial differences in stress experienced by course, they did not report the differences in academic stress and clincal placement stress. However, the study suggested that the most intense sources of stress remained stable throughout the training.

Other research focused on cross‐cultural comparisons. Timmins & Kaliszer (2002) conducted a review of studies that examined the sources of stress among nursing students from different countries and compared Ireland with those results. They found that the most common sources of stress are placement environment. Burnard et al. (2008) compared data from five countries (Albania, Brunei, Czech Republic, Malta and Wales) with comparable results.

Pryjmachuk and Richards (2007) research suggests that it is the image of being a student that is deemed stressful rather than being a student nurse and that balancing the role of student with the hassles of everyday living is responsible for student stress. However, overall when compared to students from other academic courses, research has shown that nursing students experience higher levels of physiological and psychological symptoms than other students in general (Beck et al., 1997).

Stecker (2004) found comparable result to (Beck et al, 1997) and credited this to the fact that nursing students were more likely to have outside employment during their academic training, leading to less time for studying and more job and financial stress (Stecker, 2004).

Incorporating stress management training for nursing students is a positive shift for service improvement, educating students and providing them with coping mechanisms will employ a wellbeing culture and overall positive patient outcomes.

3.2 Stress experienced in novice and experienced nursing students

The last two papers I critiqued was exploring students just beginning their training and students coming to an end of their 3-year degree and how stress affects them. Jimenez et al (2010) reported from a study to identify the differences from inexperienced students without any healthcare knowledge prior to starting the training and experienced nursing students’ reports of stress. For this study, a descriptive quantitative and cross-sectional design was followed. The ethics committee of the university approved the research protocol. The students who took part in the research were unpaid volunteers.

Nursing students are under considerable stress during their clinical placements, this can lead to student’s education and health at risk. However, there is little evidence about the stress experienced by nursing students and its impact on their health throughout clinical placements (Chesser‐Smyth, 2005).

The study carried out from Spanish students from three years of their nursing training, they had a high response rate of 71%of 357 students. The information collected were over an 8-month period. For this study, a descriptive quantitative and cross-sectional design was followed with a sample stratified by year. With this design, the independent variable is experience level (novice-experienced) throughout the nursing programme (year), whereas the dependent variables are the students’ scores measuring stress (Jimenez, 2010).

Perhaps the most significant limitation of this study is that it was a cross-sectional study. Cross-sectional data on all variables is only collected once it would be useful to conduct a longitudinal study to follow the students as they progress throughout the years to explore the pattern of changes in stress perception and adaptational responses (Jimenez, 2010). The aim of this study was to examine differences in perceived stress in novice and experienced nursing students. The results revealed no differences between year of study or experience groups regarding overall measures of stress (Elliot, 2002).

Giving to the literature, it is reasonable to think that first year students should show symptoms with more intensity than older students. However, Watson et al. (2008) reported that stress increased as the nursing programme progressed.

Jimenez et al (2010) study revealed that second-year students showed poorer health, with more anxiety and more common symptoms than students in other years. However, no differences were found for psychological symptoms. These results are consistent with other studies that also showed students to be more susceptible to stress from clinical practice in their second year (Bell 1984, Lo 2002).

Jimenez et al (2010) have compared different academic courses regarding the sources of stress associated with clinical practice. In Jimenez et al.’s (2010) study, stress from academic workload and clinical stressors, was apparent with greater strength by second-year students than first-year students.

The second paper within this theme looked at stress experienced in novice students as they begin their first clinical placement. Levett Jones et al (2015) explored the concerns experienced from nursing students as they begin their first clinical placement. The aim of the study was to discover the concerns of first year from an Australian university as they prepare for their first clinical placement as student nurses.

Students completed an online ‘readiness for practice’ survey consisting of 22 items. Surveys are relatively easy to administer and cost-effective. However, respondents may not feel comfortable providing answers that present themselves in a negative way, this is a limitation to the study. The results of the survey relied on student feedback to open- ended questions. Summative qualitative content analysis was used during the research this is a method of research that changes qualitative data into quantitative statistics (Levett-Jones, 2015).

55% responded to the open-ended question. According to (Debois, 2016) it’s desirable to get a result rate of 80% or more from a smaller sample rather than a low response rate from a larger group of participants. The results of the open-ended question were then analysed into to potential stressors to the student including; lack of preparation, dying patients and working outside competences (Levett-Jones, 2015).

The aim of the study was to gather information regarding first year nursing students’ perceptions of their readiness for practice and the impact of a one-semester long preparation for practice course. Ethical approval for the study was obtained from the university ethics committee prior to contacting potential participants (Levett Jones, 2015).

The most common concern expressed by students was in relation to the feeling of not knowing enough and not being ready for their first placement. Students described a level of expectation that they need to live up to on placement and a fear of making mistakes (Levett Jones, 2015).

There is widespread agreement that clinical placements are of importance to nursing education and specially designed to facilitate great learning opportunities (Levett-Jones and Bourgeois, 2015). The first clinical placement experience is critical to nursing students’ confidence (Trede, 2012). It provides an insight that introduces students to the knowledge, skills, behaviours, attitudes and values of registered nurses.

The quality of placements, and students’ initial clinical learning experiences, generate a range of intense emotional responses from excitement, exhilaration, joy and pride through to confusion, anxiety, fear and stress (Levett-Jones and Bourgeois, 2015). Importantly, the experiences encountered during the first placement and the way in which students process their feelings are key determinants of students’ decisions to withdraw from the nursing course (James and Chapman, 2009; Killam and Heerschap, 2013).

Several studies have identified that nursing students experience elevated levels of stress on their first clinical placement (Moscaritolo, 2009; Sendir and Acaroglu, 2008; Shaban et al., 2012; Sheu et al., 2001), and that this can negatively impact their learning, performance and professional growth (Sun and Sun, 2011; Khater et al., 2014). Students who struggle to adjust to their role during the first placement are also at risk of low self-esteem and depression (Wang et al. (2010).

Clarke & Ruffin’s (1992), Thyer & Bazeley’s (1993) and Williams’ (1993) also focused on new students in nursing. Williams (1993), used only descriptive statistics to analyse the items in a disaggregated way. The students showed the highest concern for keeping their grades up, fear of making a mistake with a patient and learning clinical procedures. Thyer & Bazeley (1993) studied first-semester Australian students and the areas in which students experienced higher levels of anxiety linked with the assessment of work throughout the course and work load.

An aim of both (Jimenez et al, 2010) and (Levett-Jones, 2015) was to examine differences in perceived stress in novice and experienced nursing students. The results revealed no differences between either year of study regarding overall measures of stress

Future research should consider reviewing papers that have used qualitative methodologies to contribute information to this work. Under each theme, participants describe emotional responses that range from manageable anxiety to overwhelming anxiety and fear. It’s impossible to get rid of anxiety is impossible in nursing students however, enhancing student’s capacity for emotion resilience has the potential to improve student performance and emotional well-being while being on placement. (White, 2014).

Finally, while nursing students worldwide share much in common, being aware of cultural features relating to stress and health during the programme of study contributes to a better understanding of stress in the nursing population, which is why studies from diverse cultures are useful (Thyer & Bazeley,1993).

Nursing students are entering a career that is both rewarding and emotionally demanding. Elevated levels of stress combined with low levels of self-care contribute to emotional exhaustion and burnout in the nursing workforce. Employing stress management training will allow students to practice mindfulness and build emotion regulation, enhance resilience and self-care. Overall having a positive impact on the NHS and patient saftey (Foureur et al., 2013).

Chapter 4: Plan to implement service improvement

This part discusses the role of service improvement methodology and how it’s changing the quality of care delivered. The Plan, Do, Study, Act (PDSA) model will be used to structure and implement the service improvement plan (Langley, 2009). The use of the PDSA model is recommended by The NHS Institute for innovation and improvement (2008) to test ideas before fully implementing them. Appendix C shows the four stages of the PDSA cycle.

Janes and Mullan (2007) observed that ‘if the NHS is to achieve the level of transformation required to ensure a ‘culture of continuous improvement must be developed’, in which every member of staff can engage in new ways of working’. Quality improvement remains high on the political and professional agenda (Royal College of Nursing 2015) and should be seen in the context of recent failures in quality of care, such as those at Mid Staffordshire NHS Foundation Trust (Francis 2010).

The NHS and its patients depend on its staff to deliver the high-quality services that people have a right to expect. In turn, those staff should expect to be appropriately treated and supported both when they are at work and when they are unable to work due to ill-health. This is reflected in the NHS Constitution, which committed the NHS to “provide support and opportunities for staff to maintain their health, well-being and safety” (NHS Constitution, 2015).

It is crucial that students are helped to realise what their stressors are and appropriate ways in which to cope with them. By enabling students to identify stress and are able to deliver effective coping mechanisms, we can help them potentially for the rest of their future as registered nurses.

4.1 Key findings from Chapter 3

Chapter 3 highlighted that future research should consider reviewing papers that have used qualitative methodologies to contribute information to this work. To date there has been a lack of research focusing on students’ perceptions and concerns prior to clinical placement experience, and the issues that are of most concern and why. While clinical skills and knowledge are essential for safe clinical practice this study has identified that focused attention to students’ emotional well-being, resilience and self-care is also imperative (White, 2014).

4.2 Plan

The plan will be to implement stress management training which focuses on increasing a person’s ability to deal with stress, to help students recognise stress and ‘’how to cope’’ strategies. This in turn will help them when transitioning from students to registered nurses (Sassenberg et al., 2014).

As reported by the NHS Five Year Forward View (2014), the NHS should provide a service for their staff to support their mental health and well-being and listen to staff concerns and create a service that is easily assessable. By looking after the staff of the NHS, the report suggests this in turn will make staff able to cope with their potential stressors and provide high-quality care to their patients.

The Boorman NHS Health & Wellbeing Review (2009), an independent review commissioned by the Department of Health. They found that ‘hospitals that that prioritised staff health and wellbeing performed better, with improved patient satisfaction, higher quality scores, better outcomes, higher levels of staff retention, and lower rates of sickness absence’.

The report showed that if the NHS had lower sickness rates due to stress related illnesses they could in turn drastically cut staff costs. This would provide the NHS with a much healthier work environment which would believe would have higher patient satisfaction rates, lower mortality and higher recruitment. (The Boorman report, 2009).

The national NHS Staff Survey provides the most substantial views of staff working in the NHS. In 2017 they found that ‘38.4% of staff felt unwell due to work-related stress in the last 12 months’, this has ‘worsened from 36.7% in 2016’ (NHS staff survey, 2017). This suggest that programmes currently running to target the well-being of NHS staff are not well in placed. By targeting and preparing students for potential stressors in clinical placement, this can help students be able to develop coping mechanisms for their future career. My initial ‘plan’ of the PDSA cycle would be to deliver compulsory lectures and seminars on stress management to ensure student nurses feel prepared and adequately supported in dealing with stressful situations while on placement. NICE, (2014) approve training courses and lectures as they are often used to educate healthcare professionals about the latest developments in their field.

Students from the beginning of year one will be taking part. The lectures and seminars will be delivered by educational nurse lecturers. Sessions will be 60-90 minutes long as this is what Lynch et al (2008) suggests for group work interactions. Sessions will involve:

• How stress can affect you
• Dealing with stressful situations that can happen on placement
• Registered nurse speakers and how they deal with stress at work
• Healthy eating, exercising and shift patterns
• Coping mechanisms;

Mindfulness-based stress reduction has likewise demonstrated promising results in healthy individuals (Sharma and Rush, 2014). A growing literature also describes the beneficial impact of mindfulness practice on student well-being (Chen et al., 2013; van der Riet et al., 2015). White (2014) promotes the concept of mindfulness as underutilised in nursing and argues both the potential benefit for nursing students’ well-being and an enhanced capacity for sustaining therapeutic engagement in clinical practice. Incorporating primary teaching of mindfulness activities into preparation for practice sessions for first-year students could help develop a skill that will serve them well throughout their education and clinical practice.

4.3 Do

This programme would be commenced with the hope that the outcome of the implemented change will be an improvement, with student nurses receiving suitable support. Nurse educators play an essential role in establishing a core nursing workforce by ‘designing, implementing, evaluating and revising nursing educational programmes’ for future nurses (Langley et al, 2009).

Leadership is a crucial role in nursing, and that they are now more likely to act as leaders a in a clinical environment (Richardson, 2010). Acting as a role model of professional behaviour for students and newly qualified nurses to aspire to (NMC, 2015).

One of the features of modern nursing leader is the need to be resilient. Resilience is the ability to cope with the stresses and challenges (Jormsri, 2004).  Being able to have a positive attitude reflecting on and learning from situations. Nurses should be a role model of students to learn and reflect from, seeing registered nurses being able to cope with everyday stressor in clinical placement, will provide a building block for nursing students to learn.

By testing the change on a small scale this will allow to assess its effectiveness without fully implementing and consider future change.

There are multiple barriers that needs to be addressed to support student nurses. Factors, such as students’ self-motivation, drive and desire to improve are crucial too. Intentions and goals can impact on how much people want to change. Their priorities and commitments may also interfere with their ability to change the way they deal with stressful situations (NICE, 2007).

Seminars require teamwork to adequately support one another and respecting fellow student’s opinions. This can be received as a barrier to change as a lack of student contribution, this can be due to lack of motivation or lack of interest. However, this can be overcome by keeping seminar work short, using videos, presentations, guest speakers and quizzes. Having a means of students leaving feedback and suggestions at the end of each session to then incorporate into the next session (Larrabee, 2009).

Numerous factors may help staff foster a positive attitude to change. A workplace where there is strong leadership, and everyone is determined on improving patient outcomes is likely to develop motivated staff with a desire for continuous improvement (NICE, 2007).

However, when trying to implement changes barriers such as a maintain long term change. If staff attitude changes, staff members leave it may be difficult to maintain any changes that have been introduced overall (Ellis, 2003).

Helping staff understand the most recent evidence based will allow staff to gain insight and knowledge of what needs to change and why change occur. Evidence shows that staff are often unaware with the latest guidance (NICE, 2007).

4.4 Study

Al Wahbi (2014) research has found that there is a direct need for feedback to be received following teaching programmes to improve learning. Therefore, I would evaluate the effectiveness of the programme by providing all student nurses with a questionnaire before clinical placement to assess how students manage stress. A questionnaire would also be used after they complete their clinical placement to evaluate whether students feel they are able to manage stress, then comparing the results from both questionnaires.

NICE guidelines suggest a questionnaire is an effective way of exploring the knowledge, beliefs, attitudes and behaviour of a group of geographically dispersed healthcare professionals (NICE, 2014).

Students may not be honest with their answers because the feeling of being weak or being judged. This is a weakness when using questionnaires. To overcome this barrier assuring students that their privacy is valued and that the process is confidential (Norwood, 2010).

A strength of using a questionnaire, is that you can capture emotional responses of the students when conducting them face to face. You are able observe ‘body language and facial expression’.

4.5 Act

What would occur in this stage of the plan would depend on the findings of the study stage. After examining the results from the questionnaires, more suggestions for future PDSA cycles will be made, depending on any positive or negative outcomes of the initial cycle. If it found that student nurses that took part in the lectures and seminars feel more supported and were able to cope with better with stressful situations, I would continue the stress management training. If the results showed that student nurses were unable to manage stress and feel more supported, I would suggest PDSA would be needed in the future.

Future changes may involve having regular clinical placement visits from a member of university staff to have debriefing sessions after a stressful situation. Therefore, future evaluation should be considered.

Langley et al (2009) propose constantly reviewing the implemented change to adapt to changes and struggles it should be constantly reviewed to adjust to participants feedback and involvement and make any necessary changes to make it work efficiently (NICE, 2007).

Adverse results may require a root cause analysis or re-mapping of the process to identify why the improvement has not been successful. There may be a simple solution that can be implemented through another PDSA cycle, or there may be a more fundamental problem: the sustainability of the improvement may not have been secured (NICE, 2007).

By encouraging healthcare professionals to read the evidence underpinning the guidance on the related topic and getting involved in the development of guidance. They can suggest topics, comment on recommendations and contribute to future improvement (Tappen, 2011).

Conclusion

The aim of this dissertation was to explore nursing students experiences of stress in placement. After critically analysing evidence of the topic findings were then produced to create a service improvement plan. There is a clear majority of research that suggest that nursing is an emotionally demanding and stressful profession. To protect future student nurses from burnout and stress induced illnesses, students must be able to deal with potential stressors and maintain a healthy well-being. (Levett-Jones 2015).

Making sure all research and change are evidence-based, this allows nurses to provide high-quality patient care based on research and knowledge. (RCN, 2015). Despite barriers when implementing change, nurses are making a difference in patient outcomes by providing evidence-based research (NMC, 2015).

Although it has been recognised that stress is a part of a nurse’s everyday life, prolonged stress levels can consequently effect patients outcomes (Wright 2014). The Francis inquiry (2013) which associated elevated level of stress with a decline in patient care and compassion within the NHS. Its important to recognise that student and nurses cannot avoid stress and the nature of the job but to establish how they adjust to stress is dependent upon the competence of their coping behaviours (Seyedfatemi et al., 2007 cited Shaban et al 2012).

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Appendices

Appendix A – Databases used

CINAHL (The Cumulative index to Nursing and Allied Health Literature)	CINAHL was used as it is the most comprehensive electronic database for nurses, consisting of millions of articles (Norwood, 2010).
MEDLINE	Medline was used as the topic Nursing students and stress has a medical base.

Appendix B

Inclusion	Rationale
Published last 10 years	To ensure the most up to date research
English language papers	To ensure comprehensive understanding of research
Research from Australia and Spain	Due to their comparative nature and the potential to correlate to healthcare in the UK

Exclusion	Rationale
Registered nurses	This dissertation is focused on nursing students
Published before 2008	Prevent out of date research
Non-English language paper	To prevent inaccuracy in translation

Appendix C – PDSA cycle

Appendix D – Key words searched

1. Nursing students
2. Student nurses
3. Stress
4. Burn out
5. Clinical placements
6. Lack of support
7. Coping
8. Stressors
9. Novice student nurses
10.  Experienced student nurses
11.  Year one placement
12.  Final year placement
13.  Mentor support
14.  Academic support

Appendix E – Summary of primary research papers

Gibbons (2010)   Quantitative	Stress, coping and burn-out in nursing students.  To explore the relationship between sources of stress and psychological burn-out and to consider the moderating and mediating role-played sources of stress and different coping resources on burn-out.
Edwards et al (2010)   Quantitative	A longitudinal study of stress and self-esteem in student nurses. It is well recognised that nurse education/training can be a stressful experience and that self-esteem is an essential predictor of stress.
Jimenez et al (2010)   Quantitative	Stress and health in novice and experienced nursing students.   This paper is a report of a study conducted to identify the differences in novice and experienced nursing students’ reports of stress and health
Levett Jones et al (2015)   Quantitative	What are the primary concerns of nursing students as they prepare for and contemplate their first clinical placement experience?  the aim of this study was to explore the concerns of first-year Bachelor of Nursing Students from one Australian university as they prepared for their first clinical placement