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Clinical Instructor Social Support and Nursing Student Stress in Clinical

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 International Journal of Advanced Biotechnology and Research (IJBR)
ISSN 0976-2612, Online ISSN 2278–599X,
Vol-8, Issue-1, 2017, 182-188
http://www.bipublication.com

Research Article

Clinical Instructor Social Support and Nursing Student Stress

in Clinical Environments

Marzieh shayesteh far1, Hojat Zareh Houshyari Khah2, Khadijeh Moradbeigi3,

Nasim Hatefi_Moadab4, marzieh ghassemi3,
Bahman Cheraghian5 and Saeedeh Elhami*6
1
Shiraz University of medical sciences, Shiraz,
IRAN and Abadan school of medical sciences, Abadan, Iran
2
Abadan School of medical sciences, Abadan, Iran
and guilan university of medical sciences, guilan, Iran
3
Abadan school of Medical Sciences, Abadan, Iran
4
Student Research Committee, Kermanshah university of medical sciences,
Kermanshah, Iran
5
Ahvaz University of Medical Sciences, Ahvaz, Iran
6
Abadan School of medical sciences, Abadan, Iran (Corresponding Author)

ABSTRACT
Background and purpose: Clinical Environment is Essential to The Nurse Education. Physical Structure And
Social Aspects of Clinical Environment is Associated With Nursing Education.The Idea of Social Support is one
of the Basic Needs in Clinical Education. Social Support of Students In The Clinical Environment Impact on
Student's Stress Level. The Purpose of the Study Was to Investigate The Social Support Nursing Student Obtain
from Clinical Instructors and its Relation With Clinical Stress in the Clinical Environment
Materials and methods:A Descriptive Correlational Design Was Utilized. Sample Size Consists of 238
Baccalaureate Nursing Students. Three Instrument an Included Demographic Data Sheet, Revised Inventory
Socially Behavior (Rissb) and Student Nursing Stress Index Snsi. Statistical Analysis Was Conducted Using
Descriptive Analysis.
Results: according to the Result, Perceived Social Support 76.5% of Nursing Study is Intermediated. Clinical
Stress In 65.5 % Of Nursing Student Is Intermediation. There Was a Significant Correlation between Perceived
Social Support and Age, Course Degree, Stress Of Nursing Students(P<0.001).
Conclusion: With to this, It’s Necessary for the Nursing Faculty to Focus on Social Support, also Faculty Should
Plan Session Where Perceived Social Support ability Student Can Nurturance. Active Training Program for
Teachers to Promote Professional Competence, Professional Socialization of Nursing Students is Recommended.
Keywords: Social Support, Clinical Instructors, Nursing Students, Stress

INTRODUCTION:
Nursing is a practice-based profession (1), thus issues, mutual respect and honest
clinical learning environment is the foundation communication between educator and students
of nursing education (2). Nursing education in in treatment centers. Social climate dominating
the clinical learning environment is related to treatment centers affects individuals' behavior,
physical and social structure. The physical emotions and growth. According Mouse, social
structure of the environment refersto (classroom, atmosphere or clinical learning environment in
room temperature, position of chair, paint, etc.) the treatment centers will have a significant
(3). The social aspect of clinical learning impact on individuals' occupational and
environmentincludes every detail of human, workplace choices in the future (4).Other
physical and organizational and interpersonal researchers stated that social climate in clinical
 Clinical Instructor Social Support and Nursing Student Stress in Clinical Environments

environments, includes interactions between should be assessed. Undesirable level of such

nurses, patients, educators, nursing students and support in the clinical environment can lead to
other health care providers that encompasses stress in students, which in turn affects the
social support (4). The social support is an quality of learning in the clinical setting (12, 4).
interpersonal supportive process, the main core Clinical training process is always associated
of which is information exchange. This with stress factors (15). Most studies have
information includes facts, advice, reassuring shown that nursing students' stress is associated
words, positive confirmation, communion or with factors such as personal and family
similar supportive terminologies exchanged problems and economic issues. Also, the results
through verbal or non-verbal communication of the studies on nursing students revealed that
(5). Considering that the clinical setting is the clinical and academic stressors are considered
basis of the nursing education and nursing together. Clinical environment stressors include
students spend major part of their training time various educational tasks, lack of necessary
in the clinical setting, therefore, the social experience to perform assigned duties, lack of
support system (social interaction) in the clinical knowledge about the clinical setting,
setting is of much higher importance than the responsibility and possibility of making
classroom. One of the components of the social mistakes while performing procedures for the
support system in the clinical learning patient, fear of causing harm to the patient,
environment is nursing educators who guide interaction with patients and relatives ,
clinical experiences as learning facilitators and interaction with instructors and other members
can guide students to achieve learning objectives of care team, clinical performance evaluation by
by making changes in the learning environment. the instructor, fear of lack of proper
They also play the role of supporters so that communication with the patient, in effective
students are able to gain experience in the communication with the clinical instructor, non-
clinical setting (6,5). So without social support, availability in an emergency and etc.(15, 16). It
learning will not be effective in the clinical should be noted that students' clinical stress,
setting. The results of the study conducted by affects not only the educational purposes but
Alavi (2007) showed that, from the perspective also increases the likelihood of errors and
of students, those educators that could provide jeopardizes the patient safety (13 , 17).In his
additional support for students in the clinical researches, Eric Johnson (2007) showed a
setting are more effective. (7) . After arrival at negative relationship between social support and
the hospital and interacting with their educators, stress among nursing students (17). Moreover,
students can judge about their behavior and they psychological variables have shown that high
will experience the presence or absence of level of social support can have neutralizing
supporters based on their reactions (8-11). effect on the clinical stress (4, 18, 19).
Social support in a positive clinical environment Therefore, the role of instructors as social
leads to increased level of creativity, self- supporters of students is part of the expected
confidence, confidence, motivation in learning tasks, which has a significant effect in reducing
and professional growth (12 and 4). On the other student's level of stress and enhancing their
hand, weak social support aspects in the learning quality (20).According to the results of
educators' performance such as, poor past researches, measuring the level of social
communication, ignoring students, tarnishing support of nursing educators is considered as a
their honor, will have a negative impact on quality index of clinical learning environment
motivation in clinical training (13). The results (4). By reviewing past studies, it can be inferred
of the study conducted by Ebrahimi (1994) that there few studies in the field of social
showed that undesirable level of social support support and its effects on stress levels among
is provided for students in the clinical nursing students and there is also no
environment (14). So, in order to assess the comprehensive and specific research on social
social support, the received social support support of nursing students in Iran. On the other

Marzieh shayesteh far, et al. 183

 Clinical Instructor Social Support and Nursing Student Stress in Clinical Environments

hand, social support, along with other factors in support (22 questions), guided support (8
a clinical setting has not been studied. The questions) and tangible support (6 questions)
researchers conducted their study to evaluate based on 5 Likert scale. The behavioral scale in
social support provided to the nursing students each part is based on 5 Likert scale.To calculate
by their clinical instructors. Outcomes of level the social support received for each item, the
of social support on the students' stress are very following scores wereassigned to each option.
important. Thus, the present study aimed to (Never) 1 , (Rarely) 2 , (Several times) 3, (often)
evaluate nursing educators' social support and its 4, (always) 5.The minimum and maximum
effect on students' stress in the clinical setting so social support scores were 36 and 180,
that in addition to studying the status quoand by respectively so that scores of 83- 36, 84-132 and
reflecting the results to the relevant authorities, 133-180 respectively indicate low, average and
necessary strategies are adopted to enhance high social support. This instrument was used in
clinical learning environment and quality of similar research and had high reliability validity.
clinical education process. (Alpha coefficient of 66% -94% and content
validity of 0.718) (4).C) Nursing Student Stress
MATERIALS AND METHODS: Index Questionnaire (SNSI), this contains 22
This is a cross-sectional study. The study questions and was used to investigate the
population included all nursing undergraduates nursing students' perception of stress. The Self-
studying at two Schools of Nursing of the report instrument measures nursing students'
University of Medical Sciences. The sample size stress level (Pulido 2012). This instrument is
was 238 participants, including all used in three areas: academic workload, clinical
undergraduate nursing students who participated concerns, personal problems and other concerns
during all the semester. Inclusion criterion scored based on 5 Likert scale, in which Score=
included completing at least one internship in 1and Score=5 denote ''not stressful'' and
the last semester and the exclusion criteria ''Extremely stressful'', respectively. Thus, the
included having a mental crisis during the past minimum and maximum score is between 22-
one month (students who have been suffering 110 and score between 22-51,52-80 and 81-110
from mental problems in the screening by respectively shows mild, moderate and severe
University of Medical Sciences, crises such as stress. The validity and reliability score of
marriage and the death of loved ones) and English version of the questionnaire is (0.70)
students who have clinical experience at the and Cronbach's of (0.88), respectively(17).It
paramedic level and those who are currently should be noted that the questionnaires were
studying. This study was approved by the Ethics simultaneously translated into Persian by two
Committee of Ahwaz University of Medical people in order to use social support and clinical
Sciences. The data collection tool included a stress questionnaires in the present research and
questionnaire consisted of three parts: a) finally, a questionnaire was prepared. Then, it
demographic questionnaire b) Revised inventory was again reviewed by an expert fluent in
social support behavior questionnaire (RISSB) English and the final questionnaire was
with 40 items, which was developed by Orly for prepared. In order to determine the content
the first time to evaluate social support in validity, the questionnaire was given to 10
nursing students was used and After the initial experts to comment on the statements. After
review, the 40-item questionnaire was converted considering the views, the content validity
to 38-item questionnaire (4). Two items of the of0.71 and 0.70 was obtained for Social Support
questionnaire was removed by the Research Questionnaire and students Stress Index
Committee of the School of Nursing due to their Questionnaire, respectively. Also, to evaluate
heterogeneity with cultural issues and the 36- the reliability, after guided a pilot study on 30
item questionnaire was used to assess students' students, a Cronbach's alpha coefficient 0.87%
level of social support. The questionnaire was and 0.85% was calculated for Social Support
designed in 3 domains, including unguided Questionnaire and students Stress Index

Marzieh shayesteh far, et al. 184

 Clinical Instructor Social Support and Nursing Student Stress in Clinical Environments

Questionnaire. In this research, data were support medium 123(49/8)

high 18(7/3)
collected during one step after visiting two
119/05
nursing universities. After the necessary The findings also showed that the perceived
coordination with Education Unit of colleges, stress level of 65.5% of nursing students was at
the time to complete questionnaires for each the medium level.The results showed that the
course was considered according to the perceived stress level of 65.5%,47% and 52.6%
pedagogy of theoretical and practical courses in of nursing students within domains of academic
the free time of training programs. Then Social work, clinical concern and individual problems
Support Questionnaire and Clinical Stress was at the moderate levels (Table 2).
Assessment Instrument were completed and Table 2 - Frequency the perceived stress of nursing
collected in a one step after explaining the goals students at academic selected centers
of the study to the students, obtaining their the perceived stress of Frequency
mean (SD)
nursing students (percent)
informed consent and assuring them regarding low 62(25/1)
the confidentiality of information.To analyze the academic work medium 162 (65/6) 41/69(1/059)
data, SPSS(ver.16) was used.First, studied high 23(9/3)
low 87(35/2)
variables were described using descriptive clinical concern medium 116(47) 27/23(2/86)
statistics methods such as frequency tables, high 44(17/8)
graphs and indicators of central tendency and low 77(31/2)
individual medium 130(52/6) 8/35(3/036)
dispersion.Then, chi-square test, T- test and problems high 0(16/2)
analysis of variance, Pearson correlation 60/91(14/47)
coefficient and nonparametric equivalents were The present study showed that the relationship
used to perform statistics analysis and to between social support behavior and the age of
investigate the relationship among variables. students was assessed using Pearson's
Findings correlation coefficient, which showed no
In the present study, since researchers attended statistically significant difference(rho=0.52 and
at the time of data collection, all questionnaires (P <0.001). Also, the relationship between
have been returned. The average age of nursing students' level of social support and semester
students was (21.26 ± 1.579). Female, single, were examined using Spearman correlation
junior participants and nursing students from coefficient correlation, which showed no
two university centers accounted for 70.97%, statistically significant difference (rho=0. 046
90.7%, 30.8% and 53.4%, respectively. Based and (P <0.001). The relationship between the
on the results, 76.5% and 12.1% of students level of social support and school location was
evaluated the received social support at medium examined using t- test, which showed
and high levels. Results on social support in statistically significant difference (t=3.029 and
each domain showed that a total of 68.4%, df=245 and (p <0.001). Also, the relationship
62.8% and 49.8% of the students evaluated between perceived social support and stress
social support at the medium level, respectively levels in nursing students was assessed using
in the unguided, guided and intangible domains. Pearson's correlation coefficient. This
The frequency distribution of social support relationship was statistically significant to
behavior is elaborated in Table 1. (rho=0.047, (P <0.001).In other words, with
Table 1 - Frequency of social support in nursing increasing social support given to students by
students at academic selected centers the teachers, the level of stress among the
Frequency students decreases.
received Social support mean (SD)
(percent)
low 28 (11/3) DISCUSSION AND CONCLUSION:
unguided
medium 169(68/4) 75/06(14/63)
support The present study aimed to determine nursing
high 50 (20/2)
low 21(8/5) students' perception of social support received
guided support medium 155(62/8) 26/26(5/61) from clinical instructors and its relationship with
high 71(28/7)
tangible low 106(42/9) 17/75(5/22) level of stress among nursing students. The

Marzieh shayesteh far, et al. 185

 Clinical Instructor Social Support and Nursing Student Stress in Clinical Environments

findings showed that (76.5%) of students materials to students that should be done by
evaluated the social support at the medium level, instructors. In this regard, instructors should
which was consistent with the results obtained give students a list of resources such as books
by Montalvo (4) and Orly (22).Considering that and articles, thereby giving the opportunity to
clinical instructors have not received academic the student to acquire desired skills in the
training in the field of clinical education in most clinical field and accept the instructor as a
universities, except in some cases of workshop- competent and wise guide trying to advance
based clinical training and self-learning, on the their professional development, therefore,
one hand, and most clinical instructors are learners will put more effort in the professional
inexperienced and do not have the right skills socialization and learning process (25).This
and efficient clinical training, on the other hand; study showed that there was a significant
and therefore, their teaching methods and correlation between the level of social support
student assessment is also based on students' received by nursing students and their age (p
theoretical knowledge;(23) so, we can't expect <0.001). In other words, younger nursing
to have higher social support and professional students had higher perception of social support.
clinical education behavior. To achieve this Perhaps, it can be said that younger students are
goal, attempts should be made to increase the more inclined to receive the social support due
ability of clinical instructors in different ways. to having little experience and that is why they
The results of this study also showed that had higher level of perception of the social
unguided and guided supports were at the support. In a study, Stewart also implies this
moderate level from the viewpoint of nursing result (20), but there was no relationship
students. Unguided support includes measures between age and perceived social support in the
such as active listening and understanding etc. study conducted by Montalvo (4).The results of
This area covers on of the important skills in the thepresent study also showed that students'
effective communication that emphasizes stress level was moderate.Clinical training
students' role from the stage of learning to work process is always associated with stress factor
in the clinical setting. So, it reduces stress in the and students' clinical experience can cause such
workplace and strengthens students' level of stress in them (7).Students' clinical stress not
self-confidence in doing work independently only affects the educational purposes but also
without instructors' assistance. Guided support is increases the likelihood of errors and
one of the basic needs of the qualified clinical jeopardizes the patient safety (9,10). Stress is a
instructor that should be considered by them and multiple domain phenomenon that always
universities.Guided support also includes happens between the individual and the
aspects such as advice and gives feedback to the environment (17).If the level of stress increases
students.Feedback is one of the fundamental in the clinical learning environment, students
ways in the clinical positions.In fact, it is a kind will not be able to adapt themselves with its
of structured and goal-oriented interaction to triggers (25 and 17). Therefore, nursing
better learning and gives the opportunity to the instructors must identify the stress phenomenon
learner to think deeply about his/her in the learners and reduce distress in them by
performance.The feedback aims to transfer a manipulating the learning environment.The
clear concept of the problem to learners clinical environment cannot always be
thatmakes them aware of their shortcomings and controlled and the student may suffer from an
eventually provides suggestions on how to unexpected disaster at any moment (17).The
correct the defect (writing a list of clinical clinical instructor should create a positive
problems, prioritizing them by importance and clinical learning environment and relieve
resubmitting them to the instructor) (24). students' stress experience. The clinical
Students also evaluated the non-tangible instructor must have the ability to recognize and
assistance at the medium level.By non-tangible interpret stressful experiences and the reduce the
assistance, we mean providing educational complexity of the stressful environment by

Marzieh shayesteh far, et al. 186

 Clinical Instructor Social Support and Nursing Student Stress in Clinical Environments

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