CHAPTER I
INTRODUCTION
THE PROBLEM

Nursing school is an exciting, challenging adventure that will demand much of nursing students in terms of time and energy. Because nursing is a discipline comprising knowledge from many related fields, student nurse will be asked to learn to think critically, synthesize information, and then apply it to situations involving live people. (Dewit, 2003) A student may face many challenges and stressors. However, nursing students are likely to experience even “more stress” than their friends and colleagues enrolled in other programs. To support this statement, a study comparing the stress levels of various professional students found that nursing students experience higher levels of stress than medical, social work and pharmacy students (Beck, et al.1997). Even more poignant, another study showed that “one third” of nursing students experience stress severe enough to induce mental health problems such as anxiety and depression. (Pryjmachuk, 2004). One source of stress of nursing students is their Learning Experience. The related learning experience is a series of planned activities in the community that would prepare students technically and professionally should they decide to pursue higher education in the health profession. Specifically, in a selected College of nursing, BSN students spend a maximum of 24 hours a week for their duty wherein they engage in activities such as nurse-patient interaction, nursing procedures, construction of Concept Map, Nursing Care Plan and Drug Study, individual conference with their clinical instructors, and ward class. According to Kaplan (1993), the burnout behaviors of students are characterized by reduction in their performance. Students were found to be maintaining a façade of high achieving while succumbing to physical illness and emotional stress. The physical and psychological symptoms of stress are present such as irritability, inability to concentrate, insomnia, depression, muscular tension and aches, palpitations, lack of appetite and others. As to the effect of stress to the nursing student’s performance, Neufeld (1989) cited the Yorkes-Dodson Law. He contended that as arousal increases in response to stress, performance improves. However, as arousal increases with higher levels of stress, performance starts to decline. This conforms to the General Adaptation Syndrome where the individual may finally go into exhaustion phase. According to an informal interview with the Guidance Councilor in a selected College of Nursing, there are certain students who consult for assistance regarding the everyday stress that they encounter. There were even instances of suicidal attempts, drop-outs to subjects, absenteeism, misconduct behaviors, and failure to finish the course due to stress situations that exceeds their capacity to overcome it. Yet, despite these stressors and stress reactions manifested by nursing students, majority of the class manage to graduate within the expected time. Some even graduate with flying colors. What then were the stress management techniques utilized by these students? How have they been able to cope and adjust with the everyday stressors they encounter each day?
BACKGROUND OF THE STUDY This study will be conducted at a selected College of Nursing located in Makati City. This selected college of nursing is a private, non-sectarian school. Its vision is to be a center of excellence and a global trendsetter in the nursing education. The mission of the said College of Nursing is to develop globally competitive professionals nurses through innovative teaching-learning experiences, highly qualified faculty and staff, integrated information system, resources and new infrastructure with up-to-date technology, well-developed research program, continuous improvement of administrative capabilities, dynamic student services, active linkages locally and internationally and active alumni and parents involvement. The school envisions its students to imbibe the core values; namely, excellence, God-loving, self-discipline, caring, committed respectful, honest, teamwork and justice, in fulfilling its mission and vision. The level IV of Bachelor of Science in Nursing which focuses in Nursing 204. It is the implementation of concepts and principles and nursing management of the well and sick client (individual, family, community) from adulthood to the senescence stage of growth and development in any settings. The Related Learning Experience of Bachelor of Science in Nursing during the 1st semester is affiliated with 7th floor, Operating Room/Out patient Department, Male and Female Ward of Makati Medical Center, and Community at Cavinti, Laguna. Related Learning Experience is in the form of hospital and community experiences. While fulfilling tasks as a nurse in these areas of assignment, other nursing activities includes paper works, individual conferences, and quizzes. The researchers are interested in pursuing this study because the investigators would like to prove that stress is being experienced by Bachelor of Science in Nursing Level IV students as what the researchers are encountering. Another reason is that the researchers would like to determine the stress management techniques accessible to the students to relieve the stress.

STATEMENT OF THE PROBLEM
MAJOR PROBLEM: The study aims to describe the relationship between levels of stress and stress management techniques utilized by Bachelor of Science in Nursing level IV students in a selected College of Nursing in their RLE.

MINOR PROBLEMS:
Specifically, we sought to solve the following: 1. What is the demographic profile of the BSN IV as to: a. Age b. Gender c. Marital status d. Residence e. Financial status f. Clinical Area 2. What is the level of stress of BSN IV students in a selected College of Nursing in their RLE? 3. What are the stress management techniques utilized by BSN IV students in a selected College of Nursing in their RLE? 4. What is the extent of relationship between the levels of stress and stress management techniques utilized by BSN IV students in a selected College of Nursing in their RLE?

ASSUMPTION: All BSN IV students experience stress.

HYPOTHESIS: There is no significant relationship between the level of stress and stress management techniques utilized by BSN IV students in a selected College of Nursing in their RLE.

SIGNIFICANCE OF THE STUDY Primarily to the students, this study will enable them to determine level of stress and develop personal strategies to reduce stress which may post threat to their sense of well-being and disrupt their normal functioning in the related learning experience.

For clinical instructors, results of this study could serve as a guide in planning for activities or strategies that would help the students exercise control over the stressful situations in the Related Learning Experience.

For the administrators, this study will serve as a basis to encourage them to support and approve school activities which will benefit the students’ well-being.

For the different school organizations (Peer, AOL, TAG, VACS) and Student Council, this study will aid them to develop different organizational activities or programs that will help the student members to release their tension and manage stress.

For the future researchers, this study will serve as a reference and baseline information to further develop on studies that enhance the stress management techniques utilized by BSN students in the Related learning Experience.

SCOPE AND LIMITATIONS The study will focus on describing the relationship between the levels of stress and stress management techniques utilized by regular level IV Bachelor of Science in Nursing in their Related Learning Experience, enrolled in Remedios Trinidad Romualdez Memorial School-Makati Medical Center College of Nursing. Data which will be utilized in this study will be gathered from the nursing students through a modified questionnaire which is originally taken from the book “30 Days in Taming Your Stress” by Pegues, and “How to Use Relaxation for Health and Success” by Sheridan et al. during the 1st semester of school year 2009-2010. Limitations of the study include limited Philippine-based resources about college stress, specifically in the nursing course. This research does not include irregular students since they have less subjects giving them more free time; does not include academic field since RLE requires more physical, mental, social, intellectual and emotional effort than in academics; does not include difference between the stress management techniques utilized by different year levels in a selected College of Nursing since each level has different workload and activities..

DEFINITION OF TERMS
Bachelor of Science in Nursing students refers to the 4TH year regular students enrolled in RTRMS-MMC during the 1st semester of SY 2009-2010.
Related Learning Experience is a series of planned activities in the school, community and hospital that would prepare students technically and professionally. It provides the student’s exposure to the actual setting where they are able to render services and at the same time acquire learning.
Stress refers to the state or condition of restrictions, demand or constraints of BSN IV students in their RLE for their last 3 weeks during the second rotation of duty in the 1st semester of school year 2009-2010.
Acute Stress refers to stress that occurs suddenly, and lasting for a short period of time (minutes) during their RLE duty for the 1st semester of school year 2009-2010. It has a Stress Level Score of 1-11.
Moderate Stress refers to stress lasting for hours within their RLE duty for the 1st semester of school year 2009-2010. It has a Stress Level Score of 12-22.
Chronic Stress refers to an existing stress that lasts for days up to the rest of the 2nd clinical rotation for the 1st semester of school year 2009-2010. it has a Stress Level Score of 23-33
Stress management techniques refers to the ways employed by BSN students enrolled in RTRMS-MMC during the 1st semester of SY 2009-2010 to minimize stress in their Related Learning Experience.

CHAPTER II
REVIEW OF RELATED LITERATURE This chapter presents the literatures reviewed, which may be utilized in defining the methodology and/or interpretation of data. Literature reviewed includes local and foreign books, local and foreign researches, articles, and internet materials.

STRESS Stress can occur when an individual is faced to a numerous or new challenges. Stress can either be bad or good. Stressors such as activities and events can be good in the sense that it promotes personal growth and coping abilities. Stress on the other half, may cause an individual to experience an abnormal feeling that disturbs an individual’s mind and body. Stress management can be complicated or confusing because there are different types of stress- acute, moderate, chronic stress- with each with its own characteristics.

Potter, Patricia A. et al. Fundamentals of Nursing, 6th Edition. Stress and Coping, Philippines: Elsevier PTE LTD. 2006. People use the term stress in many ways. First, stress is an experience a person is exposed to, through a stimulus or a stressor. Stressors are disruptive forces operating within or on any system (Neuman, 1995). Stress is also the appraisal, or perception of a stressor. Appraisal is how people interpret the impact of the stressor on themselves, of what is happening and what they can do about it (Lazarus, 1999). Finally, stress is a general term that links environmental demands and the person’s capacity to meet those demands (Kasl, 1992). Stress in this concept refers to the consequences of stressor, as well as to the person’s appraisal of the stressor. There are two types of stress according to Selye: Distress, or damaging stress, and Eustress, stress that protects health. Eustress is motivating energy, such as happiness, hopefulness, and purposeful movement (Varcarolis, 2002). However the idea of healthy stress has become controversial because it is difficult to tell whether a person has benefited from stress or is coping by denying the stress in some way (ALdwin, 2000). Other types of stress are work stress, family stress, chronic stress, acute stress, daily hassles, trauma, and crisis.

Kozier, Barbara et al. Fundamentals of Nursing, 7th Edition. Stress and Coping. Philippines Pearson Education South Asia PTE LTD. 2004. Stress is a universal phenomenon. All people experience it. Parents refer to the stress of raising children, working people talk of the stress of their job, and students at all levels talk of the stress of school. Stress can result from both positive and negative experiences. The concept of stress is important because it provides a way of understanding the person as a being who responds in totality (mind, body, and spirit) to a variety of changes that take place in daily life. Stress is a condition in which the person responds to changes in the normal balanced state. A stressor is any event or stimulus that causes an individual to experience stress. When a person faces stressors, responses are referred to as coping strategies, coping response, or coping mechanisms. There are many sources of stress. They can be broadly classified as internal or external stressors, or developmental or situational stressors. Internal stressors originate within a person, for example, cancer or feelings of depression. External stressors originate outside the individual, for example, a death in the family, or pressure from peers. Developmental stressors occur at predictable times throughout an individual’s life. Within each developmental stage, certain tasks must be achieved to prevent or reduce stress. Situational stressors are unpredictable and may occur at any time during life. Stress can have physical, emotional, intellectual, social, and spiritual consequences. Usually the effects are mixed, because stress affects the whole person. Physically, stress can threaten a person’s physiologic homeostasis. Emotionally, it can produce negative or non-constructive feelings about the self. Intellectually, stress can influence a person’s perceptual and problem-solving abilities. Socially, stress can alter a person’s relationship with others. Spiritually, it can challenge one’s belief sand values. In Stimulus-Based Model, stress is defined as a stimulus, a life event, or a set of circumstances that arouses physiologic and/or psychological reactions that may increase the individual’s vulnerability to illness. While according to the Response Based Model, Selye (1956-1976) defined stress as “the non-specific response of the body to any kind of demand made upon it.” Schafer (2000) defined stress as the “arousal of mind and body in response to demands made upon it.”

Borbowski, Nancy. Organizational Behavior in Health Care. Jones and Bartlett Massachusetts. 2005.
Stress as an environmental event Stress can also be defined as a thing or event that triggers the adaptive physiological and psychological responses in an individual. The event creates change in the life pattern of the individual, requires significant adjuxtment in lifestyle and taxes available personal resources. The change can either be positive such as outstanding personal achievement or negative such as being fired from a job. The emphasis here is on change from the existing steady state of the individual’s life pattern. In Miller and Rahe’s study, it found that women react to life stress events at higher levels of response than men and that younger subjects rated more events at higher stress level than older subjects. It is unknown whether stress overload merely predisposes a person to illness or actually precipitates it, but there does appear to be a causal link. Individuals differ in their reactions to life events, and these variations are related to the degree to which the change is perceived as stressful. Positive coping mechanisms and strong social or familial support can reduce the intensity of the stressful life change and promote a more adaptive response. Lazarus and Folkman define stress as a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well being. A precipitating event is a stimulus arising from the internal or external environment and is perceived by the individual in a specific manner. Determination that a particular person/environment relationship is stressful depends on the individual’s conginitive appraisal of the situation. Cognitive appraisal is an individual’s evaluation of the personal significance of the event or occurrence. The event “precipitates” a response on the part of the individual and the response is influenced by the individual’s perception of the event. The cognitive response consists of a primary appraisal and secondary appraisal. A variety of elements influence how an individual perceives and response to a stressful event. These predisposing factors strongly influence whether the response is adaptive or maladaptive. Types of predisposing factors include genetic influences, past experiences and existing conditions. Genetic influences are those circumstances of an individual’s life that are acquired through heredity. Examples include family history of physical and psychological conditions and temperament. Past experiences are occurrences that result in learned patterns that can influence an individual’s adaptiation response. They include previous exposure to the stressor or other stressors, learned coping responses and degree of adaptation to previous stressors. Existing conditions incorporate vulnerabilities that influence the adequacy of the individual’s physical, psychological and social resources for dealing with adaptive demands. Examles include current health status, motivation, developmental maturity, severity and duration of the stressor, financial and educational resources, age, existing coping strategies and support system of caring others.

http://www.ahna.org/
Causes of Stress People can experience either external or internal stressors. External stressors include adverse physical conditions (such as pain or hot or cold temperatures) or stressful psychological environments (such as poor working conditions or abusive relationships).
Internal stressors can also be physical (infections, inflammation) or psychological. An example of an internal psychological stressor is intense worry about a harmful event that may or may not occur. As far as anyone can tell, internal psychological stressors are rare or absent in most animals except humans. Acute Stress is the reaction to an immediate threat, commonly known as the fight or flight response. The threat can be any situation that is experienced, even subconsciously or falsely, as a danger. Common acute stressors include: Noise, Crowding, Isolation, Hunger, Danger, Infection, and Imagining a threat or remembering a dangerous event. It becomes Chronic Stress when modern life poses ongoing stressful situations that are not short lived, and the urge to act (to fight or to flee) must be suppressed. Common chronic stressors include: Ongoing highly pressured work, Long-term relationship problems, Loneliness, and Persistent financial worries.

Cuevas, Frances Prescilla L. Public Health Nursing in the Phiippines, 10th Edition. Philippines: National League of Philippine Government Nurses Inc. 2007.
Promoting stress management This related literature reinforces the importance or significance of the study. Stress is an everyday fact of life and everyone experiences stress from time to time. Stress is any change that one must adapt to, ranging from the negative extremes of actual physical danger at exhilaration of falling in love or achieving some long desired success. And in between, day to day living confronts even the most well managed life with continuous streams of potential stressful experiences. Thus, stress is not only inevitable and essential but also normal part of life. However, normal dos not necessarily means healthy. Stress triggers hormones that change the way the body works and feels. These changes are nature’s way of helping the person cope with perceive threats. However, some cope with stress by behaving in a way that is unhealthy, like drinking, smoking or overeating. This is the reason why it is important to manage stress appropriately in order to avoid the unhealthy effects of inappropriate coping mechanism. Fortunately, stress management is largely a learnable skill. Everybody can learn to effectively handle stress even when pressures persist. It is not possible to live without stress. But one can learn ways to handle stress of daily life efficiently, and to manage reactions to stress and minimize its negative impact. However, it is important to remain attentive to negative stress syndrome and to learn to identify the situation that evoke them. When these symptoms persist, the risk for serious health problems is greater because stress can exhaust the immune system. Recent research demonstrates that 90% of illness is stress related.

Apruebo, Roxel, A. The Science of Psychology, 1st Edition. Philippines: Educational Publishing House Inc. 2009.
Process of Stress Stressful events may occur as sudden, unexpected, potentially life-threatening experiences or traumas qualify as catastrophic events, such as physical or sexual assault, military combat, natural disasters, explosions, plane crashes and accidents fall into this category. Life changes and strains include marital separation, illness in the family, difficulties at work, moving to a new place, and other circumstances that create demand with which people must adjust. Chronic stressors continue over a long period of time like living due to adverse economic conditions, residing in a high-crime neighborhood, being the victim of discrimination, and even enduring years of job pressures. Daily hassles involve irritations, heavy traffics, pressures, and annoyances that may not be major stressors by themselves but such effects aggravate to become significant. This frustration of daily commuting in heavy traffic can become so intense for some drivers display a pattern of aggression. People reactions to stressful events or stressors, such as catastrophic events, life changes and strains, chronic stressors, and daily hassles are contributing components of stress. The use of coping skills reduces inappropriate stress response and improves strategies in response to stress.

Cosmopolitan, January 2009 Edition. Philippines: Cosmo Summit Media
Get a Life
By: Zo Aguila Stress is an epidemic today, and to make it worse, we are in a situation where we are clueless about what is bugging the life out of us. According to the Foundation for Integrated Research in Mental Health in 2007, more than three out of five doctor visits all over the world are for stress related problems. And, while Filipinos are among the happiest people in the world, according to a study by World Value Survey, we are still subject to a lot of stress and suffer illnesses caused and made worse by it: high blood pressure, stroke, diabetes, ulcer, and heart disease. Today’s stressors are so real and so self-created that you wonder why they are there in your life at all (Ashima Puri, R.N.). And, the problem expectedly is, we all end up lamenting the symptoms instead of the main issue by bad moods and temper tantrums, lost appetites, nail biting and nasty headaches, and a million by-products in between. Stress is not all bad news. A certain level of pressure is good for us. The buzz of new challenges or the excitement of a new relationship keeps life interesting. What we call stress is more often than not, not really stress. According to the Encyclopedia of stress, ‘stress is one of the most frequently used but ill defined words in the English language. Stress can affect our physical capabilities by giving us headaches, bad tummy or feeling sick, back pain, trembling, sweating, sleeping difficulties, colds, or infections. It can also change our mental status such as feelings of panic or anxiety, irritability, depression, poor concentration, feeling helpless, lacking confidence, and not wanting to socialize. That’s why this article sited 5 Save Your Soul Strategies: a.) Cognitive Behavioral Therapy (CBT), b.) Stress management programs, c.) Aromatherapy, d.) Biofeedback, and e.) Swedish and Shiatsu Massage.

Stress relief & relaxation techniques, Judith Lazarus, 2000, NTC/Contemporary Publishing Group, Inc, Lincolnwood, Illinois-USA
Levels of stress
Acute Stress According to the APA, the most common form of stress is acute stress. Stressors defined as acute are the things that ruin your plans or your day: a flat tire, a missed deadline, an unplanned meeting with your child’s principal at school. The inevitable by-product of living, acute stress happens to everyone and tends to be manageable. These stressors don’t do the damage of chronic stress, but they certainly affect your mind and body. This is the king of stress that can easily be helped with the stress management and relaxation techniques.
Moderate stress Everyone meets at least one stressor everyday, but some people have a pattern of reacting as if everything is a big problem. People who chronically and “catasthrophize” have deep-seated pattern to address. These “awfulizers” also tend to be over arouse and tense, but are more anxious and depressed and angry and hostile. “Often, lifestyle and personality issues are so ingrained and habitual with these individuals.” Say Miller and Smith, “that they see nothing wrong with the way they conduct their lives. They blame their woes on other people and external events. Frequently, they see their lifestyle, their patterns of interacting with others, and their ways of perceiving the world as part and parcel of whom and what they are.” When the pain and discomfort of moderate stress get in the way of life as usual, that’s the time to seek out stress management, often in the form of intervention.
Chronic Stress Miller and Smith define chronic stresses away day after day, year after year. Chronic stress wears as the grinding stress and destroys bodies, minds and lives. It wreaks havoc through long term attrition. The worst aspect of chronic stress, say Miller and smith, “is that people get use to it” they forgot it theirs. People are immediately aware of acute stress because it is new; then ignores chronic stress because it is old familiar and sometimes almost comfortable.

COLLEGE STRESS College is advancement in education that deals with greater workload and academic pressures. Courses in colleges have different stressors, specifically in nursing, it consist of academics and RLE in the form of duty. Nursing students face up to different stressors such as paper works together with physical, social, emotional and logical challenges in their RLE

Henslin, James, M. Life in Society, 2nd Edition. USA: Allyn and Bacon. 2007 College certainly is a varied experience: challenging, with its many assignments, higher academic standards, and new vocabularies; frustrating when concepts don’t seem to sink in, the instruction seems too demanding, fulfilling, with the satisfaction that come from forming new friendships and the sense of accomplishments that comes with passing courses and mastering new ideas, and, at the end, threatening, when the world of work and career looms and, by comparison, college life suddenly appears comfortable and inviting.

http://www.ahna.org
Nursing Students Are at Greater Risk As a student you face many challenges and stressors. However, as a “nursing” student you are likely to experience even “more stress” than your friends and colleagues enrolled in other programs. A study comparing the stress levels of various professional students found that nursing students experience higher levels of stress than medical, social work and pharmacy students.(Beck, et al.,1997) Even more poignant, another study showed that “one third” of nursing students experience stress severe enough to induce mental health problems such as anxiety and depression. (Pryjmachuk, 2004) In addition to contending with exams, grades, long hours of studying, work, family and other personal commitments you are also faced with the challenges of clinical practice. Clinical practice has been identified as one of the most anxiety producing components in nursing programs. Lack of experience, fear of making mistakes, difficult patients, discomfort at being evaluated by faculty members, worrying about giving patients the wrong information or medication and concern about possibly harming a patient are just a few of the stressors for the beginning student nurse. (Sharif & Masoumi, 2005). Incorporating practices that can reduce some of the stress associated with all of these challenges is important, useful and essential to your well being. Stress management and self-care practices will help you navigate through nursing school and will also provide a wonderful foundation for creating a balanced and wholesome life. Now is the time to establish healthy habits of self-care that will serve you for a life time!

Seaward, Brian Luke. Managing Stress: Principles & Strategies for Health and Well-Being, 2006; 5th Edition. Massachusetts: Jones and Barlett Publisher.
School Stress A large body of research has demonstrated that emotional high level of stress debilitates psychological well-being, physical health, and task performance. A number of studies have focused on the source of students’ stress while in school, which are many. Students may report that someone hit them, kicked or punched them, or threatened them with a knife or gun, and that they have felt unsafe in school. Being made fun of in front of the class or by friends is also a source of stress, or being shouted at or screamed by the teachers. Being made to feel inferior and ashamed is a source of stress. Not being able to finish classroom work, or doing worse on a test than one should, are sources of stress. A change of teacher in one or more classes may also be a source of stress. Another source of stress is having someone take something from one’s locker. Students report that other throwing things and fighting in the lunchroom caused them anxiety and stress. Anything that affects the harmony and interferes with the classroom activities may be a source of stress and certainly affects academic functioning in the school situation (Grannis, 1992).
“Stressors and Coping Strategies of Students in Accelerated Baccalaureate Nursing Programs” by Marge Hegge and Sr. Vicky Larson A longitudinal study found that younger students do not perceive more stress than alder, more mature students. Neither age nor work experience was a factor influencing perceived stress in student nurses. Both associate degree and baccalaureate nursing students perceive the clinical instructor as the primary source of stress during clinical experiences. Interactions with clinical instructors were highly stressful events for 45% of the 107 junior student nurses. The most common stressful events for them included interpersonal relationships with instructors, ability to perform heavy workload and helpless feelings. The accelerated students in this study found religion and social support to be the most helpful in coping with stress, whereas denial and disengagement were least helpful to them. They experience moderate to severe stress during their academic experiences. Stressors reflect financial, personal, professional or academic challenges. They mobilize a variety of healthy coping strategies. Support systems among peers and family or friends are ways to helping them cope effectively with stress. Although faculty members cannot eliminate stress, they can alleviate it through pacing, scheduling and structured support systems. Faculty members can help students overcome their stressors and help students grow through the challenges of an accelerated program. This research suggests the need to determine the impact of stress and coping strategies on learning outcomes and academic success.

Dewit, Susan C. Student Nurse Planner, Version 3. USA: Elsevier Science. 2003
Dealing with stress Nursing school is an exciting, challenging adventure that will demand much of nursing students in terms of time and energy. Because nursing is a discipline comprising knowledge from many related fields, student nurse will be asked to learn to think critically, synthesized information, and then apply it to situations involving people. Becoming a nursing student automatically increases stress level because of the complexity of the information to be learned and applied, and because of new constraints on time. There are several ways students can consciously decrease the stress associated with school. One way is to become well organized so that assignments, deadlines or tests do not some as a sudden surprise by following a consistent plan for studying and completing assignments, students can stay on top of requirements and thereby prevent added stress. Carry as few units a possible to lighten the study loads.

Kozier, Barbara et al. Fundamentals of Nursing, 2004; 7th Edition. Stress and Coping. Philippines Pearson Education South Asia PTE LTD. As nursing students become involved in clinical assignments with clients, it is important that they prepare themselves for leadership roles. This does not mean they have to quickly earn how to lead a team of nursing staff. Instead, they first learn to become dependable and competent providers of client care. The nursing student has a responsibility for the care given to his or her clients and must assume accountability for that care. Nurses can experience stress on the clinical unit while trying to meet the multiple needs of assigned clients. One way to manage stress is through the use of time management. These skills involve learning how, where, and when to use your time. Because the nurse has a limited amount of time with clients, it is essential to remain goal oriented and to use time wisely. The nurse learns early the importance of using client goals as a way to identify priorities. However, the nurse must also learn how to establish personal goals and time frames.

Vidana, Lei Marie et al. Quality of Sleep and academic performance A correlational study. 2005 Experience a clinical duty followed by a tight whole day class schedule with quizzes and recitations, the researchers had observed that most of their classmates were sleeping during class hours, lacked interest in lessons, had decreased concentration and difficulty in the retention of the lectures following a sleepless nights.

Nursing students stress experiences in different clinical areas of the selected college of nursing by Fajardo, Goldiene Angeli et.al. 2004 College experience is one in which a transition from a period of dependence (on parents) to independence takes place. As you move from the unknown, the list of stressors a college student experiences is rather startling. Some of the most common stressors that college students encounter includes room-mate dynamics, professional pursuits, academic deadline (exams, paper, and projects), financial aids and loans, budgeting money, lifestyle behaviors, peer groups and peer pressure(drugs and alcohol), exploring sexuality, friendships, and intimate relationships. Here are some strategies for self management and coping with stress: use high priority goals as guide in making decisions, make your personal health a priority, know your personal response to stress, self-evaluate your responses frequently, use strategies that help you maintain balance and self-control, refocus on your priorities whenever you begin to feel overwhelmed, network with colleagues and members of interdisciplinary team, maintain an attitude of openness to new ideas, avoid over commitment, manage time effectively, recognize your own limitations, and affirm self-esteem and accomplishments

Stressful situation experience by the nursing students in the clinical area by Sales, Georgina et. Al. 1995. Experience related to clinical instructors, patients, personal knowledge and skill, environmental, resources, and self are perceived by the student to be stressful, therefore student’s experiences stressful situation in the clinical area.

STRESS MANAGEMENT TECHNIQUES In dealing with stressors an individual learns to formulate techniques in minimizing stress. The overall goal of stress management techniques is not to remove the stress itself but to reduce its negative effect in the body and mind.

Bessie, L. Leadership Roles and management Functions in Nursing Theory and Application, 5th Edition. Margins and Wilkins. 2006.
Coping with Stress Coping with stress can be defined as “an effort by a person or an organization to manage and overcome demands and critical events that pose a challenge, threat, harm or loss to that person and that person’s functioning or to the organization as a whole.” Coping is considered as one of the top skills inherent in effective managers. Stress is inevitable, but the degree of experienced stress can be modified in two ways: by changing the environment and by changing the individual. This is referred to as stress management. Stress management can refer to a narrow set of individual level interventions or a broader meaning that includes any type of stress intervention. However, for stress management interventions to be successful, they need to target characteristics of the individual worker, the job and the organization.

Gordon Edlin et al. Health and Wellness, 8th Edition. P. Jones and Bartlett. 2004
Individual Coping Strategies At the individual level, one of the well-documented techniques for reducing stress is through the relaxation response. However, relaxation is a reactive coping strategy as a result of an individual’s appraisal of a threat or harm/loss situation such as failing to meet a work goal or conflict with a colleague. Reactive coping strategies do very little if anything to solve the underlying problems; therefore, employees need to learn to use preventive and proactive coping strategies so that the fight-or-flight response is not automatically engaged at the first sign or stress.

Townsend, Mary. Psychiatric Mental Health Nursing, 5th Edition. P.F.A Davis Philadelphia. 2006.
Stress Management Stress Management involves the use of coping strategies in response to stressful situations. Coping strategies are adaptive when they protedt the individual from harm or strengthen the individual’s ability to meet challenging situations. Adaptive responses help restore homeostasis to the body and impede the development of diseases of adaptation. Coping strategies are considered maladaptive when the conflict being experienced goes unresolved or intensifies. Energy resources become depleted as the body struggles to compensate for the chronic physiological and psychological arousal being experienced. The effect is a significant vulnerability to physical or psychological illness. Adaptive Coping Strategies include Awareness, Relaxation, Meditation, Interpersonal Communication with a Caring Other, Problem Solving, Pets and Music. Awareness is the initial step in managing stress, wherein the individual becomes aware of the factors that create stress and the feelings associated with a stressful response. Stress can be controlled only when one recognizes that it is being experienced. As one becomes aware of the stressors, he or she can omit, avoid or accept them. Individuals experience relaxation in different ways. Some individuals relax by engaging in large-motor activities suc as sports, jogging and physical exercise. Still others use techniques such as breathing exercises and progressive relaxation to relieve stress. Practiced for 20 minutes once or twice daily, meditation has been shown to produce a lasting reduction in blood pressure and other stress-related symptoms. Meditation involves assuming a comfortable position, closing the eyes, casting off all other thoughts and concentrating on a single word, sound or phrase that has positive meaning to the individual. As previously mentioned, the strength of one’s available support system is an existing condition that significantly influences the adaptiveness of coping with stress. Sometimes just “talking the problem out” with an individual who is empathetic is sufficient to interrupt escalation of the stress response. An extremely adaptive coping strategy is to view the situation objectively. After an objective assessment of the situation, the problem-solving/decision-making model can be instituted as follows: 1. Assess the facts of the situation. 2. Formulate goals for resolution of the stressful situation. 3. Study the alternatives for dealing with the situation. 4. Determine the risks and benefits of each alternative. 5. Select an alternative. 6. Implement the alternative selected. 7. Evaluate the outcome fo the alternative implemented. 8. If the first choice is ineffective, select and implement a second option. Recent psychological studies have begun to uncover evidence that those who care for pets, especially dogs and cats are better able to cope with the stressors of life. They physical act of stroking or petting a dog or cat can be therapeutic. It gives the animal an intruitive sense of being cared for and at the same time give the individual the calming feeling of warmth, affection and interdependence with a reliable, trusting being. It is true that music can “soothe the savage beast.” Creating and listening to music stimulate motivation, enjoyment and relaxation. Music can reduce depression and bring about measurable changes in mood and general activity.

Stress Management Techniques By incorporating relaxation and stress reduction exercises into our daily lives, we help maintain our physical, mental and spiritual health. The techniques may include mental imagery, muscular stress reduction and mind-body harmony.

Apruebo, Roxel, A. The Science of Psychology 2009; 1st Edition. Philippines: Educational Publishing House Inc.
Ways of Coping with Stress Folkman et al defined coping as one’s cognitive and behavioral efforts to manage specific demands that are appraised as taxing one’s resources. It has two major approaches namely: 1. Problem-focused coping: altering or eliminating the source of stress such as confronting, seeking social support, and planful problem solving; and 2. Emotion-focused coping: Regulating the negative emotional consequences of stressors, such as self-controlling, distancing, positive appraisal, accepting responsibility, and escape/avoidance (wishful thinking).

Baron, Robert A. et al. Social Psychology, 2006; 11th Edition. USA: Pearson Education Inc.
Coping with Stress Because stress is an inescapable part of life, the key task we face is not trying to eliminate or avoid it, but that of learning to cope with it effectively – in ways that reduce its adverse effects while helping us deal with its cause. You are already familiar with several effective means of coping with stress, such as improving your physical fitness and eating a healthy diet, which can provide the added benefit of regulating your weight. Good weight regulation is very important outcome, and one to which we’ll return in a later section. Here, we focus on three major strategies; efforts to replace the negative emotions produced by stress with more positive ones (emotion-focused coping), efforts to alter situation itself – the cause of stress (problem-focused coping), and a technique suggested by the findings of social psychology – seeking social support – drawing in the emotional and task resources provided by others.

Drake, Robert E. Evidenced-Based Mental Health Practice, USA: W.W. Norton and Company Inc. 2005. Coping with stress involves helping consumers to recognize different types of stress and identify their own physical and emotional reactions to these stressors. Coping effectively with stress can decrease symptoms and distress, increase consumers’ ability to manage their illness, and improve their quality of life. Several different strategies for coping with stress are taught, such as relaxations and imagery techniques. For example, one consumer reported that she experienced stress at her job and found it difficult to relax at the end of the day. She explored several different ways of coping with stress, including taking a walk in the evening to help her unwind, and learning a muscle relaxation technique, which she practiced in the session and then later used at work when she felt tense. She said she found these strategies very helpful, and as a result, experienced less stress at work.

10 Surefire Ways to Beat Stress, June 2002.
By: Ee Lin Wan Stress has a way of sneaking up on us. Research show that overt stress, if untreated, can cause many health problems-insomnia, hypertension, peptic ulcers, heart attacks, decreased libido, to name just a few. Surveys and studies carried out over the past two decades reveal that 43% of all adults in the U.S. suffer adverse effects due to poorly managed stress. We are all affected by stress at one time or another and it may be tempting to turn to what we think will be a quick fix-alcohol, cigarettes, coffee, or sedatives. Unfortunately, these put more strain on our already strained body. Relieve your stress the right way. Here are 10 ways to do it. 1. Exercise even for at least 10 minutes, three times a week and get some fresh air as often as possible; 2. Go on a holiday to break the monotony of daily living; 3. Relax at the spa to improve skin texture and relax stiff muscles; 4. Catch up your friends to help the individual stay young and feel good; 5. Do something alone to reflect on life; 6. Volunteer which is always beneficial to one’s well-being; 7. Sing your blues away to allow the person vent one’s frustrations; 8. Pray to learn to let go and accept that some things are beyond our control; 9. Drink red wine, in moderation to reduce risk of cardiovascular disease; and 10. Gardening has always been a great stress reliever.

Santrock, John W. Psychology, 7th Edition. McGraw-Hill Companies, Inc. 2003.
Stress Management Skills. Client teaching is one of nurses’ most important functions. Knowledge of various stress management techniques will help provide a more comprehensive and holistic approach in caring for the client’s. Such techniques include the following: a.) sleep, b.) Progressive Muscle Relaxation, c.) Meditation, d.) Imagery, and e.) Music. Incorporating healthy lifestyle including good nutrition and exercise and avoiding alcohol and other drugs are other stress management suggestions. Other complementary therapies may include massage, biofeedback, acupuncture, healing touch, aromatherapy, and a pet therapy. Several interventions can be used simultaneously to enhance stress reduction and coping.

Cuevas, Frances Prescilla L. Public Helath Nursing in the Phiippines, 10th Edition. Philippines: National League of Philippine Government Nurses Inc. 2007.
9 stress management techniques This related literature aids in identifying some of the different stress management techniques that can be used to mange stress. These are: 1. Meditation – is a way of reaching beyond the senses. It is very effective method of relaxation. The idea of meditation is to focus one’s thoughts on one relaxing thing for a sustained period of time. It gives the body time to relax and recuperate and clear away toxins that may have build up through stress and mental or physical activity. Meditation may have the following effects: a) lowers blood pressure; b) slow breathing; c) gives the body time to eliminate lactic acid and other waste products; d) eliminates stressful thoughts; e) helps with clear thinking; f) helps with focus and concentration; g) reduces stress headache; 2. Self awareness – means knowing ones self, getting in touch with ones feelings, or being pen to experiences. It increases sensitivity to the inner self and relationship with the world around. Self awareness is important in evaluating ones abilities realistically, identifying the areas which needs to be improved, recognizing and building strengths, developing more effective interpersonal relationship, understanding the kind of motivations that are influencing such behavior, developing empathy and understanding to recognize both personal needs and the needs of other people. 3 .Scheduling: time management – time is a source. A source is something that lies ready for use, or something that can be drawn upon for aid. Time is a tool that can be drawn upon to help accomplish results, an aid that can take care of a need, assistance in solving problems. Managing time really refers to managing one’s self in such as a way as to optimize the time available in order to achieve gratifying results. 4. Siesta – mans taking a nap, short rest, a break or recharging of “battery” in order to improve productivity. It helps relax the mind and body muscles. It had been proven thru a study that siesta invigorates one’s body. Performance of an individual scored high when siesta is observed with a 15-30 minutes nap. It relieves stress tension and one wakes up invigorated and set for the next activity. 5. Stretching – are simple movements performed rhythmical and slow pace executed at the start of a demanding activity to loosen muscle, lubricate joints, and increase body’s oxygen supply. It requires no special equipment, no special clothes, and no special skills and it can be done anywhere and anytime. Frequent exercise is probably one of the best physical stress-reduction techniques available. Exercise not only improves health, it also relaxes tense muscles and induces sleep. 6. Sensation techniques – the sense of touch is highly a powerful and sensitive form of communication. It is a natural reaction to reach out and touch whether to feel the shape or texture of something or to response to another person, perhaps by comforting them. Massage helps to soothe away stress, unknotting tensed and aching muscles, relieving headaches and helping sleep problems. But massage is also invigorating; it improves the functioning of many of the body’s system, promotes healing and tones muscles, leaving with a feeling of renewed energy. 7. Sports – engaging in sports and physical activities like these have been known to relieve stress. It also gives the body exercise it badly needs. 8. Socials – a man is a social being who exist in a relationship with his physical environment and in relationship with people and society. Socialization plays a very important role in the development of interpersonal relationships. Through socialization life begins to be meaningful, happy and worthy. On the contrary without socialization life would be boring and unhappy. 9. Sounds and songs – music play is an important part in the everyday life of a person. It provides medium of expression for thoughts and emotions. It is also a way to relieve tension. Music adds to the quality of life of a person.

Rice, Philip F. The Adolescent: Development, Religion and Culture, 8th Edition. USA: Allyn & Bacon. 1996.
A model of spirituality for stress management In my efforts to integrate spiritual well being into the wellness paradigm of total well being for corporate health promotion, I created an integrative theoretical model to emphasize the dynamic relationship between stress and human personality. I synthesized this spiritual wellbeing model from the psychological theories of Jung, Maslow, Frankl, Peck, Fox, Selye, Schaef, and Borysenko, and several other influences from American Indian and Asian cultures. In this model, human spirituality is defined as the maturation process of our higher consciousness as developed through the integration of three facts: an insightful, nurturing relationship with oneself and others, the development of a strong personal value system, and a meaningful purpose in one’s life. These facets, each tightly integrated with the other two, constitute a dynamic configuration that, when attended to and nurtured, will advance him consciousness to a higher level of understanding- that is, seeing oneself as a part of a larger whole.

Rice, Philip F. The Adolescent: Development, Religion and Culture, 8th Edition. USA: Allyn & Bacon. 1996.
INTERNAL AND EXTERNAL RELATIONSHIPS Internal and external relationship involves a twofold process whereby one explores, confronts, and resolves one’s inner thoughts, feelings, and perceptions, as well as strengthens ties or connectedness with others in one’s environment. A weak domestic policy will carry over into a weak foreign policy. Human spirituality works the same way: a poor internal relationship carries over into a weak relationship with family, friends and other people with whom you come in contact. For optimal spiritual well being, there must be a healthy balance between internal and external relationships. In other words, love your neighbor as yourself.

White, Luise. Foundation of Basic Nursing, 2nd Edition. Australia: Thomson Delmar Learning. 2005.
Stress Management for the Nurse and Student Nurse There are many stressors in nursing. It is essential that nurses learn to cope successfully with the stressors. Nurses must cope successfully with stress to maintain their own wellness and to model healthy behaviors. Nurses must first be able to manage their own stress before helping clients learn to manage theirs. Nurses who cultivate the hardiness factor will likely be resilient to stress. Kobasa (1979) put forth the concept of hardiness in the late 1970’s. Hardiness consist of a set of attitudes, beliefs, and behaviors that make individuals more resilient (or hardy) to the negative effects of stress. The three components to stress hardiness are: Commitment become involved in what one is doing; Challenge perceive change as an opportunity for growth instead of an obstacle or threat; Control, believe that one is directing what happens to oneself rather than feeling victimized and helpless. According to studies (Kobasa, 1979; Kobasa, Maddi & Kahn, 1982), persons having higher degrees of hardiness are healthier than those with low degrees of hardiness. When experiencing multiple stressors, such people develop fewer illnesses. Many nurses must learn when to stop working and relearn the value of play. Nursing students, spending many hours working and studying, may need to schedule play time. The student nurse doing is making a start on managing stress.

Stress management programs Stress management programs teach individuals how to appraise stressful events, how to develop skills for coping with stress, in how to put these skills into use in their everyday lives. Some stress management programs are broad in scope, teaching a variety of techniques to handle stress; others may teach a specific technique, such as relaxation or assertiveness training. Colleges are also developing stress management programs for students. Some stress management programs are also taught to individuals who are experiencing similar kinds of problems—such as migraine headache sufferers or individuals which chronically high blood pressure. The following two techniques are often use in stress management programs. Meditation is the practice and system of thought that incorporates exercises that help the individual to attain bodily or mental control and well-being, as well as enlightenment (Gilliani & Smith, 2001; Tassi and Muzet, 2001). The strategies of meditation vary but usually take one of two forms: either cleansing the mind for new experiences increasing concentration. Researchers have found that the practice of meditation activate neural structures involve in attention and control of the autonomic nervous system (Lazar and Others, 2000). Transcendental meditation (TM) the most popular form of meditation in the United States, Is derived from an ancient Indian technique; it involves using a mantra, which is a resonant sound of phrase that is repeated mentally or aloud to focus attention Mindfulness meditation (also called awareness meditation) is another form of meditation. It involves maintaining a floating state of consciousness that encourages individuals to focus on whatever comes to mind—a sensation, a thought—at that particular moment (Bishop, 2002; Carlson and Others, 2001).

Pegues, Deborah Smith. 30 days in Taming your Stress. Philippines: OMF Literature Inc. 2007.
Sleep
Sleep is more important to our survival than water or food. Getting sufficient sleep to restore our bodies is a key factor in coping with day-to-day stress. Further, failure to get enough sleep also increases stress and can make us less able to handle stressful situations. Most adults, regardless of age, need the recommended eight hour us restful sleep a night. But sometimes stress can keep us awake, making matters worse as we find ourselves in a vicious cycle of stressful situation keeping us up and then a lack of sleep causing more stress. Sleeplessness then can be one of many signs that our body is under stress. What about your sleeping habits? Do you have a sleep routine in which you go to bed and get up about the same time, or do you allow events, people, deadlines or other circumstances dictate your sleep schedule? For those of you whose bedtime routine is rather extensive, do you start to wind down in plenty of time to allow yourself to complete it, or does the routine itself become stressor? Ever thought about completing it hours before your bedtime? Most of us think of sleep as some passive process in which we dreft off into oblivion and wake up several hours later well rested. The truth of the matter is that sleep is an active state. Many metabolic and other restorative processes occur during the various stages of sleep. Of we do not sleep long enough for our system to be rejuvenated, we will most likely find ourselves irritated by the smallest things and battling a whale of an appetite. The excess hunger is just our body’s cry for the energy that was supposed to be supplied by a good night’s sleep.
Nourish your body You will be able to manage your stress much more effectively if you know how the foods you consume affect your body’s ability to cope with daily pressures. Despite the many books on the market today that adequately explain how to properly fuel our bodies, nutritional ignorance seems to be the norm as the rate of obesity continues to rise. When the pressure is on, many find refuge and comfort in food. Nourishing our bodies properly is a lifelong endeavor and we would do well to become as nutrition-conscious as possible. If you have the physical stress symptoms of poor concentration, fatigue or a ferocious appetite, you may be tempted to get a quick fix by eating junk food. The items of choice usually contain caffeine, sugar or something salty with a crunch. Do your find it interesting that when spelled backwards, s-t-r-e-s-s-e-d is d-e-s-s-e-r-t-s? Have you noticed that you never tend to crave foods like carrots, apples, or lean meats, even though they may be better for you in the long run? But therein is the answer: the long run. It takes a healthy food choice longer to raise our blood sugar to the point where we feel satisfied, whereas the junk food delivers an immediate result because its refined ingredients are quickly assimilated. Further, they cause your brain to release serotonin, a hormone that helps you to relax – for a brief time. The time is so brief that you’ll need another hit of carbohydrates to recover from the precipitous drop in your blood sugar. This time you’ll probably have to consume even more carbohydrates because your blood sugar drops even lower than it was originally after the first carbohydrate fis, so your body is going to have to work harder to get your sugar level back to normal. Is this beginning to sound like a drug addiction scenario? Through all of this activity, there is a good chance that you are not really hungry but rather feeding whatever the emotion the stress generated. A 10 to 15 minute nap may be the best solution. Of course, if you were diligent to make sure that your ate the right foods frequently throughout the day, then your blood sugar would stay at a level that would eliminate those cravings. Nutritional and homeopathic supplements also play a vital role in helping us to cope with stress, tension or anxiety. However, before you begin a herbal program, you should at least make a call to your medical doctor to make sure that certain herbs do not interfere with your current medications. It is a known fact that during time of stress, more vitamin C is depleted from the body. Therefore, an extra dose to replenish it may be needed. Prolonged stress can cause our internal systems to breakdown. We need to keep our insides strong by selecting foods that nourish us rather than work against us.
Get Physical Physical activity is an excellent stress-buster and is critical to normalizing your body after a stressful event. When your brain senses a threat or danger, it quickly releases hormones carrying an urgent message via the bloodstream to the adrenal glands (which sit atop the kidneys). The message says, “Let’s prepare to resist or run now!” The adrenal glands produce excess stress chemicals, cortisol and adrenaline and rush them into the bloodstream, where they get delivered to various parts of the body via nerve fibers. The body responds with increased strength, raised blood pressure and other assistance needed to resist or run. There have been countless stories of people who exhibited unusual strength in a crisis. I heard of a petite young mother who actually lifted the back of a car under which her child had been trapped. Of course a crisis is not limited to threats of physical danger. The threat of losing a job or a loved one, or even the excitement of a happy occasion can cause the brain to put the body on high alert. The adrenal glands do not attempt to distinguish between negative or positive excitement. Once the crisis is over, the excess hormones need to be dissipated out of the bloodstream. This is where exercise plays a critical role. Regular physical activity help to burn these extra chemicals so your body can return to normal. Imagine their buildup if you tend to live in a period of stress day in and day out. In addition to its positive impact on stress, physical activity provides us with numerous other benefits, including better resistance to illness, stronger bones, more energy and stronger muscles. What activity is best? The best form of exercise is the one you enjoy and find the most convenient. These are the two biggest reasons why most of us fail to be consistent in following an exercise program. First, we either lose interest in the activity because we don’t really get a lot of satisfaction out of doing it. I have had beginning lessons in almost every sport – two or three times for some. Secondly, we tend to not be consistent in an activity if it requires too much time or effort to access. Whether a brisk walk or a high-energy fitness class almost any physical activity will help you let off steam, distract you from your source of stress and improve your mood. It also relaxes and reenergized your body. The duration of the exercise should be a minimum of 30 minutes of physical activity a day at least five days a week. Doing more is even better. Some fitness gurus suggest that if you cannot carve out 30 minutes at a time, grab 10 minute segments throughout the day. There are also other benefits to making exercise the center of your stress-busting program. People who are routinely active tend to eat better. In addition, physical activity can help you lose weight, keep it off and feel better about yourself. Feeling physically inadequate can be a stressor in itself. Stress can wear your body down mentally and physically; however, a healthy body can cope with stress better than an unhealthy one.
Schedule your day wisely Each new day presents us with 1440 minutes to use at our discretion. If we don’t consciously decide how we will spend them, we will look up and realize they passed us by without our ever starting the tasks we desired to complete. The best approach to manage stress is to prepare and follow a wisely prioritized to-do list. I should warn you up front that the list itself can become a source of stress if you include too many tasks. I use an electronic calendar and I categorize every activity by its importance. Every activity is not equally important. You really can put off until tomorrow those insignificant things that would stress you if you were to do them today. If you are not in the habit of developing a to-do list, you may wander aimlessly throughout the day without a sense of focus. A simple handwritten list will provide the same sense of accomplishment as you strike off the completed items. As you plan your schedule, do not plan on doing too many things at the same time. Studies have linked chronic, high-stress multitasking under intense pressure to short term- memory loss. Further, experts have concluded that multitasking actually makes a person more inefficient because it reduces the brain power needed to perform each task. If you feel you must be productive during all of your waking minutes, it’s time to redefine “productive”. Solitude is productive. Taking a mental time out while waiting in line is productive. Praying for each member of your family while sitting in traffic is productive.
Solidify your support system No man is an island. No man stands alone. Just as God created our physical bodies in such a way that our various internal systems support each other, so it is in our relationships. Everybody needs a support system.
Resolve Conflicts There are few things I find more stress generating than unresolved conflict. It keeps my adrenaline on high alert and consumes my thoughts until I have resolved it. Consequently, I try to confront offenses and misunderstandings right away. If we are going to manage the stress in our lives, we must develop the skills needed to address the conflicts which are sure to arise – for conflicts are inevitable. Further, the problem with failing to confront an issue is that it is likely to occur again. Strife is stressful and it is to our advantage to keep it at bay. We cannot eliminate conflicts from our lives because we are all unique individuals with different backgrounds, communications styles and preferences. However, we can confront the issues, resolve them and grow as a result.
Admit your mistakes and shortcomings “I’m sorry I was wrong.” “My mistake!” “I don’t know.” These are words that some people find hard to say. Staying blameless is a hard and stressful position to maintain. Everybody makes a mistake, misjudges an issue or otherwise messes up something at some point. It’s called being human. Oddly enough, mistakes are one of the major ways we learn. However, because of our fear of being judged negatively or losing face, we often try to coven up our mistakes – which opens the door wide for stress. On the other hand, admitting a mistake is a surefire stress-buster. It is a relief to yourself and an inspiration to others when you show the courage and the confidence to acknowledge you rmistakes without defining yourself by them. The only real tragedy about mistakes is if you don’t learn anything from them. Refusing to admit a mistake closes the door for growth. In addition to creating stress, there is another downside to an attempt to be blameless. When you deny your shortcomings and mistakes, people are likely to label you as arrogant and proud. The irony is that others connect with you better and will declare you humble when you admit your weaknesses. Humility is one of the traits that people admire most in others; pride is detested – even by other proud folks. Humans make mistakes. They have blind spots. Peace comes when we start confessing our faults to one another.

Taking a time-out Short breaks are essential in managing stress. Longer breaks are equally critical. You have to begin to deem your leisure time as important as any other commitment. Time-outs won’t happen without a firm resolve and careful planning.
Release your tension In addition to walking, running or other physical activities, we must practice ways to release the tension that builds up in us when we experience temporary stress. I have set forth a few strategies: Take a deep breath. Taking a deep breath can do wonders in diffusing the tension you may be feeling. Deep breathing relaxes you because it lowers your heart rate and circulates extra oxygen to various parts of the body. Squeeze an antistress ball or gadget. Simply squeezing it as tightly as you’d like relieves tension. Sing. Like in the Bible, when Paul and Silas were jailed for preaching the gospel, they chose to sing. I have found that a nice worship song ushers me into the presence of God and floods my soul with peace. Self-massage. Learn to massage you tense areas yourself.
Laugh
Humor has been a key stress reliever for me for as long as I can remember/ In fact, many people have told me they assumed I had no problems because I always seem so happy/ What they do not realize is that if I thought about it or more than a minute, I could find something to cry about each day. Rather than focusing on what isn’t I’ve made a conscious decision to maintain a merry heart. The impact of laughter on stress is well documented Studies show that laughter lowers blood pressure and reduces hypertension. It reduces stress hormones and cleanses the lungs and body tissues of accumulated stale air because laughter empties more air out than it takes in. It boosts immune functions in the body. In addition to all of the preceding benefits, laughter triggers the release of endorphins – those “feel good” chemicals in the brain that make you feel good and elated. Swap jokes with friends. Let people know you enjoy a good laugh. Don’t be shy about sharing your mot embarrassing moments. Laugh at your mistakes – especially on the job. Be a good sport. Laughter can also take your mind off what’s stressing you.
Maintain a positive outlook Maintaining appositive outlook requires not only faith but also mental discipline. While you may believe that God is in control of your life, oftentimes the reality of a situation can overwhelm your mind and threaten to negate your faith. As you arrest those negative thoughts, “fix your thoughts on what is true and honorable and right. Think about things that are pure and lovely and admirable. Think about things that are excellent and worthy of praise. The amount of stress you experience in a situation will be determined by your attitude toward what is happening. If you start confessing that you are overwhelmed, then you will experience what you have heard, for faith comes hearing. A positive attitude will not only minimize how much stress affects you but also has a direct correlation to how our bodies respond to diseases. Numerous studies have shown that optimistic people who are diagnosed with terminal illness tend to live way beyond the normal predicted life span “A relaxed attitude lengthens life.”
SYNTHESIS
Nursing school according to Dewitt is an exciting, challenging adventure that will demand much of nursing students in terms of time and energy, wherein the students experiences inevitable stress. To prove that assumption, Dewit stated that becoming a nursing student increases stress level because of the complexity of the information to be learned and applied, and because of new constraints on time. According to a study made by Vidana et al, most of the nursing students who experience a clinical duty with quizzes and individual conference are sleeping during duty breaks, had lacked interest in case discussions, had decreased concentration and difficulty in the retention of the lectures. To prevent these it is advisable for the students to apply stress management techniques in their daily routine. Awareness is the initial step in managing stress, wherein the individual becomes aware of the factors that create stress and the feelings associated with a stressful response. Stress can be controlled only when one recognizes that it is being experienced. There are lots of stress management techniques that can be used to minimize stress. Pegues has enumerated some stress techniques that can be used in daily life. These stress management techniques are as follows: Sleep, Nourish your body, Get Physical, Schedule your day wisely, Solidify your support system, Resolve Conflicts, Admit your mistakes and shortcomings, Taking a time-out, Release your tension, Laugh, and Maintain a positive outlook.

CONCEPTUAL FRAMEWORK

This study was based on Philip G. Zimbardo and Rosemarie Scully’s concept of stress. Zimbardo defined stress as the specific and non-specific (general) responses an organism make to stimulus events that disturbs its equilibrium and tax or exceeds its ability to cope. Stress Management Technique is the way we respond to change. An individual’s response to the need for change is made up of a diverse combination of reactions taking place on several levels, including physiological, behavioural, emotional and cognitive levels. In this study, stress refers to the physiological and psychological response of the nursing students to the stressors in the clinical area and stress management techniques are ways we maintain equilibrium despite the stressors present in our environment. The clinical practice or Related Learning Experience has been identified as one of the most stress producing component in the nursing field such as lack of experience, fear of making mistakes, being evaluated by the Clinical Instructor and paper works like case studies, concept maps and nursing care plan. The 4th year BSN students are one of the target population affected. It is essential that they learn to utilize successfully the Stress management techniques to cope with the stressors to maintain their wellness and to model a healthy behavior. In relation, the regular 4th year BSN students in their Related Learning Experience experiences different levels of stress in their RLE, the greater the stress, the greater the need for stress management techniques to be utilized.

CHAPTER 3
METHODOLOGY
This chapter will represent the researchers design, sampling design, instrumentation, data gathering procedures and statistical treatment that the researchers will apply in the particular study.

RESEARCH DESIGN The descriptive correlational method of research will be utilized in describing the relationship of level of stress and stress management techniques of Bachelor of Science in Nursing IV students as to their RLE in a selected college of nursing during the 1st semester of the SY 2009-2010. This design aims to examine relationship between two variables in a single group, also, the researchers will make no attempt to control or manipulate this situation.

SAMPLING DESIGN The respondents will be the all regular BSN 4th year students excluding the researchers enrolled during the first semester of SY 2009-2010 which is composed of 5 sections with the total population of 220 individuals.

Dummy Table 1
Total Population of BSN IV Students
|SECTIONS |REGULAR STUDENTS |
|A |45 |
|B |39 |
|C |45 |
|D |46 |
|E |45 |

INSTRUMENTATION In this study, the instrument that will be used in gathering data will be a modified questionnaire taken from the book “30 Days in Taming Your Stress” by Pegues, and “How To Use Relaxation for Health and Success” by Sheridan et al. Pegues book deals with enumerating and describing different stress management techniques being utilized. While Sheridan’s book talks about how to check the stress level of an individual. Before the gathering of data, the researchers will have an expert psychologist to validate the questionnaires as appropriate for use in the intended setting. The questionnaires will be divided into three divisions. The first divisions will contain the letter of the researchers to the respondents which seeks to ask consent and ensure the participants’ confidentiality; it also contains a control number specific to a respondent to ensure that no questionnaires will be lost.(Refer to Appendix A for Sample Questionnaire) The second division will ask for the demographic profile which is composed of Name (Initials), Age, Year & Section, Type of Residency (house/dorm), Marital Status, and current Clinical area of assignment . The third division will be divided into two parts. The first part consists of 5 columns, the first column pertains to the questions to determine the level of stress while the remaining 4 columns will refer to the Stress Level Scoring which the respondents will be asked to check. The Stress Level Scoring will have the following response options (qualitative interpretation) as follows: Stress Level Scoring
|Qualitative Interpretation |Score |
|Never |0 |
|At least for a few minutes during RLE |1 |
|Lasting for hours during RLE |2 |
|Lasting for few days during RLE |3 |

The second part of the third division will consist of six columns, it will aid in determining what are the stress management being utilized by BSN Level IV students. The first column will contain the lists of stress management techniques while the remaining five columns pertain to the five point scale. The five point scale will have the following response options as follows:
Five Point Scale
|Points |Interpretation |
|4 |Always |
|3 |Often |
|2 |Sometimes |
|1 |Rarely |
|0 |Never |

To test the validity of the instrument, the researchers will conduct a pre-testing of questionnaires to a total of 5 students taken from the 5 sections of BSN level IV. The participants will be asked to give their comments and suggestions regarding the contents of the modified questionnaires, which will be included in the revisions. During the pre-testing, the researchers will explain the purpose of the study and the mechanics in answering the questionnaires. The researchers will be available during the pre-testing to answer the respondents’ clarification and will ensure that all questions are understood.

DATA GATHERING PROCEDURES Before the actual data collection, the researchers will get permission through a letter from the Dean of College of Nursing to conduct the study in the school. Once the researchers receive the approval, a letter to the Registrar will be given to request for the total number of population of BSN 4th year students. Once the population is gathered, the researchers will send a letter to the Level Coordinator of the BSN level IV students to get an over-all schedule of the BSN IV students as basis for the scheduling for answering of the questionnaires. The researchers will then conduct a pre-testing which will subject the questionnaire into evaluation and revision. Data gathering will be done from August 3, 2009 – August 8, 2009. This will be done through the coordination of the Presidents of each section during their free time. The total number of questionnaires that will be distributed is 215 copies and all will be returned back immediately to the researchers. No questionnaires will be discarded since a control number will be placed to correspond to each participant. Moreover, the researchers will be the one distributing and collecting the questionnaires from each section. The researchers will ensure anonymity and confidentiality to the respondents by only asking their initials. A letter is attached to the questionnaires ensuring that all data gathered will stay only in the group and purely for the purpose of the study.

DATA ANALYSIS This section will discuss the statistical treatments that will be used to analyze the data that gathered, specifically looking into how to answer the questions presented in minor problems 1-3. To answer minor problem number 1, which is to determine the level of stress of BSN IV students, the researchers will add all the corresponding scores to each question in the first part of the questionnaire. Then the sum will be categorized according to the level of stress.
Stress Level Score Interpretation
|Level of Stress |Total Score |
|Acute Stress |1-11 |
|Moderate Stress |12-22 |
|Chronic Stress |23-33 |

To determine the specific stress level of each of the respondents, the data will be tabulated per section, an example of which is presented in this table.
Dummy Table 2
Level of Stress of BSN IV Students
Section A
|Participant Control Number |Stress Level Score |Interpretation |
|0001 |17 |Moderate |
|0002 |2 |Acute |
|0003 |13 |Moderate |

The dummy table shown above represents the stress level scores and its interpretations from each respondent organized according to sections. For minor problem number 2, which is to determine the stress management techniques utilized by the BSN IV students, the researchers will add up all the scores of stress management techniques of each respondent.
Dummy Table 3
Stress management Techniques
Section A
|Participant Control Number |Total # of Stress Management Techniques |
|0001 |58 |
|0002 |23 |
|0003 |16 |

The dummy table above will show the total number of stress management techniques utilized by each BSN IV students in each section. To answer minor problem number 3 which is to determine the extent of the relationship between the level of stress and stress management techniques, the researchers will use the Pearson product moment correlational coefficient. It measures the strength and the direction of a relationship between two variables. It has the formula of: N ∑xy – (∑x) (∑y) r = ([N (∑x²) – (∑x)²] [N (∑y²) – (∑y)²]

Where: x = observed data for independent variable y = observed data for dependent variable N = population size r = degree of relationship between x and y

Dummy Table 4 Level of Stress and the Stress Management Techniques
|Participant |Level of Stress |Stress Management |x2 |y2 |xy |
| |(x) |Techniques (y) | | | |
|0001 |17 |58 |289 |3364 |986 |
|0002 |2 |23 |4 |529 |46 |
|0003 |13 |16 |169 |256 |208 |
|Total |32 |97 |462 |4149 |1240 |

(3 x 1240) – (32 x 97) r = ([3 (462) – (32)²] [3 (4149) – (97)²] = +0.59

The dummy table and formula shown above is an example of how Pearson r is computed. The relationship will be shown further using a scatter plot graph. After attaining the value of r, it is then compared to the Correlation Interpretation Guide. Correlation Interpretation Guide
|r Range Interpretation |
|+ 1.00 perfect positive correlation |
|+ 0.76 – + 0.99 very high positive correlation |
|+0.51 - + 0.75 high positive correlation |
|+ 0.26 – + 0.50 moderately small positive correlation |
|+ 0.01 – + 0.25 very small positive correlation |
|0.00 no correlation |
|- 0.01 - -0.25 very small negative correlation |
|- 0.26 – -0.50 moderately small negative correlation |
|- 0.51 - - 0.75 high negative correlation |
|- 0.76 - -0.99 very high negative correlation |
|- 1.00 perfect negative correlation |

The value of r is such that -1 < r < +1. The + and – signs are used for positive linear correlations and negative linear correlations, respectively. Since the practice computation yielded a value of +0.59 and it falls on the range of 0.51 – 0.75, which is interpreted as having a high positive correlation, thus the stress level and the stress management techniques have a high positive correlation.

Decision Rule: The computed value will be significant when it is not equal to 0.00. Therefore, the null hypothesis will be rejected. Meanwhile the computed value will be insignificant if it is equal to 0.00. The null hypothesis then will be accepted.

BIBLIOGRAPHY
Book Sources:
Apruebo, Roxel, A. The Science of Psychology, 1st Edition. Philippines: Educational Publishing House Inc. 2009.
Baron, Robert A. et al. Social Psychology, 11th Edition. USA: Pearson Education Inc. 2006.
Borbowski, Nancy. Organizational Behavior in Health Care. Massachusetts: Jones and Barlett. 2005.
Calano, Roel B. et al. Statistics for the Health Profession Text-Workbook, 2006 Edition. Philippines: Giuani Print House.
Cuevas, Frances Prescilla L. Public Health Nursing in the Philippines, 10th Edition. Philippines: National League of Philippine Government Nurses Inc. 2007.
Dewit, Susan C. Student Nurse Planner, Version 3. USA: Elsevier Science. 2003.
Drake, Robert E. Evidenced-Based Mental Health Practice. USA: W.W. Norton and Company Inc. 2005.
Edlin, Gordon et al. Health and Wellness, 8th Edition. Massachusetts: Jones and Barlett. 2004.
Hegge, Marge et al. Stressors and Coping strategies of students in Accelerated Baccalaureate Nursing Programs, Volume 33, Number 1. January-February 2008. Lippincott William and Wilkins.
Henslin, James M. Life in Society, 2nd Edition. USA: Allyn and Bacon. 2007.
Kozier, Barbara et al. Fundamentals of Nursing, 7th Edition. Stress and Coping. Philippines Pearson Education South Asia PTE LTD. 2004.
Lazarus, Judith. Stress Relief & Relaxation Techniques. NTC/Contemporary Publishing Group, Inc., Lincolnwood, Illinois-USA. 2000.
Margnis, Bessie L. et al. Leadership Roles and Management Functions in Nursing Theory and Application, 5th Edition. Lippincott Williams and Wilkins. 2006.
Pegues, Deborah Smith. 30 Days in Taming your Stress. Philippines: OMF Literature Inc. 2007.
Potter, Patricia A. et al. Fundamentals of Nursing, 6th Edition. Stress and Coping, Philippines: Elsevier PTE LTD. 2005.
Rice, Philip F. The Adolescent: Development, Religion and Culture, 8th Edition. USA: Allyn & Bacon. 1996.
Santrock, John W. Psychology, 7th Edition. McGraw-Hill Companies, Inc. 2003.
Seaward, Brian Luke. Managing Stress: Principles & Strategies for Health and Well-being, 5th Edition. Massachusetts: Jones and Barlett Publisher. 2006.
Townsend, Mary. Psychiatric Mental Health Nursing, 5th Edition. Philadelphia: P.F.A. Davis. 2006.
White, Luise. Foundation of Basic Nursing, 2nd Edition. Australia: Thompson-Delmar Learning. 2005.

Thesis Sources:
Quality of Sleep and Academic Performance, A Correlational Study by Vidana, Lei Marie et al. 2005.
Nursing Student Stress Experience in Diffirent Clinical Areas as to the Selected College of Nursing by Fajardo, Goldiene Angeli et al. 2004.
Stressful Situation Experience by the Nursing Students in the Clinical Area by Sales, Georgina et al. 1995
Journal Sources:
Cheney, Daniel L. Nursing 2008. Getting a Grip on Stress. Wolter Kluwer: Lippincott Williams and Wilkins.

Magazine Sources:
Cosmopolitan, January 2009 Edition. Get a Life. Philippines: Cosmo Summit Media
Salazar, Rachel. Health Today, 10 Surefire Ways to Beat Stress. June 2002 Edition.

Internet Sources: http://www.ahna.org http://mathbits.com