Stress has a significant impact on student performance and is one of the top determinants of whether a student will stick it out throughout the program and matriculate. The nursing curriculum is known to be one of the most stressful programs, in part by the type of student that enrolls in these programs: individuals with families to support and limited hours for study.
Another stressor for nursing students over and above their academic load is the mandatory clinical experience, which has been reported by a significant majority of nursing students to exert the greatest stress. Thus, the clinical environment in which nursing students carry out their clinical studies plays a critical role in the learning experience. Nursing programs in large metropolitan areas tend to allocate students to more than one clinic setting during the course of their training and nursing students find it stressful to have to learn their way around a new setting and feel this detracts from the clinical learning experience. Some of these programs even call for nursing students to conduct their training in more than one clinical facility each semester.
It was the hypothesis of the authors of this study that assigning students to a single clinical setting throughout their studies would reduce the level of stress and that this would in turn improve their academic performance. To test their hypothesis, the authors conducted a study that allocated nursing students to either a single clinical experienced, which they termed a “home hospital experience” (n= 78) for the four semesters of the nursing program or to the traditional rotation of new clinical assignments per semester (n=79).
Stress was measured at the end of each semester using the Student Nurse Stress Index (SNSI) and Spielberger’s state anxiety scale. However, the authors failed to perform these tests at baseline so it is not clear what levels of stress the participants brought into the study.
Academic performance was evaluated using three separate and independent methods: tracking their nursing grade point average (GPA) throughout the nursing program; the students scores on a test based on the NCLEX, administered at the end of the program; and their success or lack of success in passing their first state nursing board licensure exam (NCLEX).
The results show that whereas nursing students tended to give different weight to stressors such as academic workload, clinical concerns, interface worries and state anxiety as the course progressed, there was no significant difference between the two groups in the way these stressors were perceived. There was also no statistical difference between the groups in regards to academic performance, results of the mock NCLEX and pass/fail rates.
Of interest, the home hospital group showed a decrease in anxiety as the course progressed but the difference was not significant. This is curious for one of the top stressors reported was poor relationships with clinical staff and one would think that this would present less of a problem for the home hospital group where the students would have the opportunities to develop closer relationships with the home staff. Another top stressor that should have presented less of a problem is the gap between theory and practice, again, it would seem that nursing students at a home hospital would be given more opportunities to interact with patients for they would have more time to gain the trust of the training home staff.
This was a quasi-experimental two-group design study because the students were not randomly assigned to the setting where their clinical training would take place. The students were apprised of the study prior to the start of the academic program during orientation. Data was collected at this point and throughout the duration of the nursing program and up until the results of the NCLEX were obtained.
All students enrolled in the nursing program for two consecutive academic years were recruited for this study. The students were divided into two groups. Nursing students in the home hospital group were assigned to one hospital for the duration of the nursing program, to there complete all clinical studies except for medical specialties for which the home hospital did not offer any training. The nursing students in the control group conducted their clinical training following the traditional curriculum of random assignation to a variety of clinical settings each semester.
One problem with the study is that a two-tailed test, p= .05 statistical analysis required 81 students per group for significant validity and, due to attrition, the home hospital group and traditional group ended up with 78 and 79 subjects, respectively. However, the authors of this study determined that repeated ANOVA testing would ensure the validity of the data.
A number of dependent variables were tested: (1) the Student Nurse Stress Index (SNSI) to determine stressors, (2) the Spielberger’s Trait Anxiety Inventory (STAI) to asses anxiety, (3) Nursing GPA, to determine academic performance throughout the program, (4) the Mock NCLEX-RN test to determine acquired knowledge at the end of the program, and (4) Pass/fail of the NCLEX-RN to determine success.
SNSI. The SNSI determines the sources of stress within four major categories including academic load, clinical concerns, personal problems and interface worries. Within each category there are various items that are evaluated. Within the academic load category there is the amount and difficulty of the classwork material to be learned. The clinical concerns category includes the client’s attitude towards the student and relationship with staff. Personal problems include the student’s fear of failing the course and the student’s relationship with parents. Interface worries include not having enough free time and school support.
STAI. The STAI evaluates how the students feel at any given moment and was administered once each semester.
Nursing GPA. The nursing GPA was based on the grades earned during the nursing program only.
Mock NCLEX-RN. This was an online test that paralleled the actual NCLEX-RN
NCLEX-RN. The results of this test were obtained from the National Council of State Boards of
All students admitted to the nursing program between the fall of 2005 and the fall of 2006 were recruited for this study. Demographic data was collected during orientation. All nursing students also took the Nursing Entrance Test (NET) at the time of orientation. The SNSI and the STAI were administered in the middle of each semester while the GPA was automatically tracked. Assigning each name an identification number during analysis and then having the names eliminated from the data protected the privacy of the students.
No statistical difference was found in the demographic parameters between the two groups nor in the NET tests results. There was also no difference in either SNSI or STAI test results between the two groups, although the SNSI test showed significant changes in student attitude for academic load, clinical concerns, interference worries and state anxiety from semester to semester. There was also significant and consistent correlation between the scores of the SNSI and the STAI throughout the study.
A statistical correlation was also found between academic load and state anxiety as a function of time for both groups, where a reduction of state anxiety was seen from semester to semester. However, whereas the home hospital group showed a higher correlation, the difference between the two groups was not significant.
Considering academic measures, there was no statistical difference between the two groups for any academic parameter tested. There was, however, the expected correlation between NET scores and Nursing GPA to NCLEX-RN passing rates. In addition, a negative correlation was found between nursing GPA and mean academic load and mean interface worries.
The results of this study show that a home hospital program can help reduce the level of subjective academic load and state anxiety perceived by nursing students, although this does not lead to improved academic performance. The authors hypothesize that this decrease in nursing student perception of academic load may be associated with a higher level of clinical consistency. It appears that closer collaboration engendered in the home hospital setting would help reduce the stress of nursing students.
Nevertheless, nursing students from either group had significantly higher state anxiety scores compared to non-nursing college students. In addition, although other studies have found gender associated differences in state anxiety, no such difference sex-dependent was found in this study. This high level of anxiety in nursing students correlates with levels found in other studies.
Of interest, state anxiety rose significantly in the non-home group during the second semester in which nursing students have to spread their training amongst three different units. This is also the same semester during which nursing students are expected to interact more with their patients and provide clinical care. Thus, the students had to deal both with adjusting to a new setting and to a new responsibility.
Another factor that may have impacted this study is that the researchers used a new group of clinical instructors than they were accustomed to, so they too had to make some significant adaptations during the course of the study, thus it is believed that future nursing students assigned to a home hospital program would be better served and show lower levels of stress and anxiety, and that these decreased levels would have a positive impact on academic performance.
One important point to consider is that nursing students assigned to the traditional rotations of clinical setting lose a minimum of two days devoted to orientation to a new setting. This means less time for the patient care experience. Furthermore, it takes a great amount of time and effort for administrators to coordinate the various rotations. Thus, switching over to a home hospital setting would benefit all shareholders in the nursing program.
Yucha C.B., Kowalski S. & Cross, C. L. (2009). Student stress and academic performance: Home hospital program. Faculty Publications (N). Paper 3.
Available at: http://digitalscholarship.unlv.edu/nursing_fac_articles/3