Nurse Media Journal of Nursing
e-ISSN: 2406-8799, p-ISSN: 2087-7811
https://medianers.undip.ac.id
14(1):1-15, April 2024
https://doi.org/10.14710/nmjn.v14i1.53987
ORIGINAL RESEARCH

Stressors and Coping Strategies as Perceived
among Nursing Students during Related Learning
Experience (RLE)
Geraldine S. Ridad1, Haniya S. Angintaopan1, Princess Haniefa Mae K. Ayunan1, Saipoden M. Manalocon1
1College of Health Sciences, Mindanao State University (MSU) - Iligan Institute of Technology, Iligan City,

Philippines

Article Info

Abstract

Article History:
Received: 29 April 2023
Revised: 13 March 2024
Accepted: 19 March 2024
Online: 30 April 2024
Keywords: Curriculum; nurses;
nursing students; psychological
adaptation
Corresponding Author:
Geraldine S. Ridad
College of Health Sciences,
Mindanao State University (MSU)
- Iligan Institute of Technology,
Iligan City, Philippines
Email:
geraldine.ridad@g.msuiit.edu.ph

Background: Stress in relation to academic studies is identified to be one of the
reasons behind suicide cases in higher education institutions around the world.
Locally, there is none to less studies that explored this area among nursing students.
As stress is inevitable in nursing students’ Related Learning Experience (RLE),
recognizing the stressors that affect their quality of RLE is necessary.
Purpose: This study aimed to investigate the stressors and coping strategies that
nursing students commonly use in managing stress during their RLE and their
relationship to each other.
Methods: A descriptive correlational research design with total enumeration
sampling was employed. A pilot-tested questionnaire was used to gather data from
191 junior and senior nursing students from two nursing schools in Iligan City.
Weighted mean, standard deviation, percentages, and Spearman rho were used to
analyze the data.
Results: The findings show that the "Clinical Instructor" (Mean=3.01) is perceived
to cause higher stress among all the intrapersonal and interpersonal stressors
identified. Students highly utilize both intrapersonal (Self-Concept Mean=3.75) and
interpersonal strategies (Role Function Mean=4.13, Interdependence Mean=3.46)
to cope with stress. When students’ clinical “skill confusion” increases, they tend to
work less with others (r=-0.259, p=0.000). When “staff nurses” cause them less
stress, their use of positive “self-concept” decreases as well (r=0.152, p=0.035).
Furthermore, when students are stressed with their “Duty-mates,” they rely more
on “physiological” coping mechanisms (r=0.160, p=0.027). When their “clinical
instructor” causes them stress, they cope less with “physiological” (r=-0.237,
p=0.001) and “interdependence” strategies (r=-0.317, p=0.000).
Conclusion: Among all the stressors, clinical instructor causes more stress to the
students. The students’ perceived stressors affect their effective use of intra and
interpersonal coping strategies. Nurse educators, nursing schools and regulating
bodies can consider these results in designing a holistic curriculum and helping
students manage stress healthily.

How to cite: Ridad, G. S., Angintaopan, H. S., Ayunan, P. H. M. K., & Manalocon, S. M. (2024). Stressors and coping
strategies as perceived among nursing students during related learning experience (RLE). Nurse Media Journal of
Nursing, 14(1), 1-15. https://doi.org/10.14710/nmjn.v14i1.53987
Copyright © 2024 by the Authors, Published by Department of Nursing, Faculty of Medicine, Universitas Diponegoro.
This is an open access article under the CC BY-SA License (http://creativecommons.org/licenses/by-sa/4.0/).

1.

Introduction
The rate and level of stress and depression among students in different academic fields is
alarming (El Ansari et al., 2014; Monteiro et al., 2014). For the past two years, there were
approximately three completed suicide cases in a higher education institution in Southern
Philippines, with one of the primary causes identified to be stress in relation to their academic
studies (Mindanao State University-Iligan Institute of Technology Clinic, 2018). At present,
World Health Organization (WHO) claims that more than 700,000 adolescents die to suicide
yearly. For many years, it has become a serious public health concern (World Health
Organization, 2023). In India, academic stress is identified to be one of the reasons behind suicide
cases among students in higher education institutions (Hindustan Times, 2023). In fact, many
studies associate stress to increased adolescents’ risk for suicidal behavior. In the presence of
stress, factors that are biologic and cognitive in nature, including personality factors, such as
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Nurse Media Journal of Nursing, 14(1), 2024, 2
being perfectionist, increase suicidal ideation and behavior (O’Connor et al., 2020; Stewart et al.,
2019).
Stress is defined as a particular relationship between the person and the environment
appraised by the person as taxing or exceeding his or her resources and endangering his or her
well-being (Hutmacher, 2021). However, it may be defined differently by people depending on
the situation they are in (Fink, 2016). In the life of nursing students, juggling academic classes,
clinical and community duties, and other responsibilities or workload, stress is inevitable. In fact,
globally, nursing is considered the most challenging and stress-provoking among all other
professions (Ching et al., 2020; Rayan, 2019). Many studies claimed that nursing students endure
more stress from various sources than other non-nursing students (Ching et al., 2020; Tharani et
al., 2017).
Several studies identified various sources of stress for students under the nursing program
(Alghamdi et al., 2019; Lavoie-Tremblay et al., 2022; Milton-Wildey et al., 2014). They are
summarized into academic, clinical, social, and personal stressors. Some of them claimed that
academic stressors cause higher stress than all other sources which involves large bulk of
workload, demanding schedules for different course subjects, exhausting course requirements
that entail long hours of studying (Alghamdi et al., 2019; Lavoie-Tremblay et al., 2022; MiltonWildey et al., 2014). Other studies include the lack of time for rest and leisure, tests, or exams in
varying mode, low or failing grades, meeting deadlines and expectations (Chaabane et al., 2021;
McCarthy et al., 2018).
On the contrary, several studies also claimed that students’ clinical training is the highest
source of stress among students (Admi et al., 2018; Ching et al., 2020; Aljohani et al., 2021;
Chaabane et al., 2021). The students’ clinical training or Related Learning Experience (RLE) is
the core component of nursing education, as it is basically skills or practice-based, which makes
nursing unique among all other professions. In the Philippines, according to the Commission on
Higher Education Memorandum Order No. 14, 2009, a nursing student is required to complete
2,346 hours of RLE. This is composed of teaching-learning opportunities designed to develop the
competencies of students utilizing processes in various health situations (Commission on Higher
Education, 2009). However, this requirement can be stressful to the students. Their clinical
training might even impact how they perceive stress on their future nursing career (Aljohani et
al., 2021; Chaabane et al., 2021; Lavoie-Tremblay et al., 2022). Clinical stressors include lack of
confidence in one’s skills, unfamiliarity with the clinical setting, technology or equipment, fear of
committing errors, patient care itself and harming the patients (Admi et al., 2018; Aljohani et al.,
2021; Chaabane et al., 2021; Ching et al., 2020). Other studies include witnessing death and
suffering of patients, negative relationships with clinical instructor and hospital staff,
disconnection of theory from actual clinical practice, as well as the noise, smell, and crowdedness
of hospitals (Al‐Gamal et al., 2018; Bam et al., 2014).
Regrettably, stress can have numerous negative effects on student nurses. Stress can affect
health and memory, decrease concentration or ability to focus and motivation leading to poor
academic performance. Successively, decreased academic performance can lead to higher stress
levels, catching the student in an unhealthy cycle of distress. It adversely affects the students’ wellbeing and quality of life (Ching et al., 2020; Durgun Ozan et al., 2020; Lavoie-Tremblay et al.,
2022; Ribeiro et al., 2018). As increased stress in the clinical area affects memory and attention,
it also increases the risk of committing errors especially in drug administration, as well as
decreases one’s capacity to promptly recognize and address critical needs of the patients (Alvarez
et al., 2019).
In general, students cannot eradicate stress, but they can reduce it, and so coping strategies
is an element that helps to preserve their psychosocial well-being. It is the deliberate use of
cognitive and behavioral strategies to manage internal or external demands or any stressful
events. It aimed to preserve mental health by overcoming stress instead of avoiding it. These
coping strategies could either be helpful or less helpful. It could bring out good results when used
successfully, and psychological distress when used unsuccessfully (Lavoie-Tremblay et al., 2022;
Mahomed et al., 2019).
Indeed, stress is recognized to affect the physical and psychological well-being and quality of
life of nursing students. Current studies that explore stressors among nursing students were of
international origin which involve diverse social, cultural, and environmental factors (Aljohani et
al., 2021; Alvarez et al., 2019; Cheng et al., 2023). Internationally, a lot of studies (Admi et al.,
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Nurse Media Journal of Nursing, 14(1), 2024, 3
2018; Aedh et al., 2015; Alghamdi et al., 2019; Bam et al., 2014; Ching et al., 2020; Hirsch et al.,
2018; Ismaile, 2017; Lavoie-Tremblay et al., 2022; Msiska et al., 2019; Shdaifat et al., 2018; Toqan
et al., 2023) and systematic reviews (Chaabane et al., 2021; Labrague et al., 2017; McCarthy et al.,
2018; Ribeiro et al., 2018) explore the various sources and levels of stress and coping mechanisms
among nursing students in the many facets of their nursing education, especially in their academic
and clinical trainings. Locally, only one study (Labrague et al., 2018) was found that explored
stressors and coping strategies among 153 nursing students in the Northern Philippines but none
in the Southern Philippines. Two other studies (Labrague, 2021; Labrague, 2022) from the same
author explore stress and nursing students’ coping skills during the Covid-19 pandemic in the
Central Philippines. Moreover, most of the studies (Monteiro et al., 2014; Rayan, 2019) explored
the influence of various factors such as demographics (age, gender, and emotion), mindfulness
and self-efficacy on students’ coping and stress, but none explores how stressors influence their
utilization of coping strategies. Lastly, there is an increased need and urgency to conduct the
study, as stress was being identified as one of the causes of completed suicides in a university in
Southern Philippines. Hence, this study aimed to investigate the stressors and coping strategies
that nursing students commonly used during their RLE and their relationship to each other.
2. Methods
2.1. Research design
This study used a descriptive correlational research design to describe the common clinical
stressors of the selected nursing students during their RLE and their coping strategies. It is
deemed to be the most appropriate design (Polit & Beck, 2022) to determine any significant
relationship between the independent variable, stressors and the dependent, students’ coping
strategies.
2.2. Setting and samples
This study employed total enumeration sampling with a total of one hundred ninety-one (191)
junior and senior nursing students. Two out of the four nursing schools in Iligan City, Southern
Philippines, consented to participate in the study. One school is a government institution, while
the other is a private one. The names of the participating schools would not be divulged to uphold
confidentiality as per their request. The return rate was 100% from the two selected schools. The
transition of the new educational system which is the K-12 curriculum resulted to the lack of
second year college students. Thus, the selection of the respondents was delimited to the thirdand fourth-year nursing students who were known to already have clinical exposures. They were
officially enrolled during the second semester of school year 2019. These nursing students were
exposed to related learning experience for an estimated 153 hours for the whole semester having
four rotations each for three weeks and eight hours per day of duty. They were also at least 18
years old. First year students were excluded from the study. Students who did not complete at
least four clinical rotations during the second semester of school year 2019 were also excluded.
2.3. Data collection
The researchers categorized the stressors into interpersonal and intrapersonal based on Betty
Neuman’s System Model (McEwen & Wills, 2019). Coping strategies were also categorized into
self-concept, physiological, role function, and interdependence according to Roy’s Adaptation
Model (Roy, 2009). However, existing research instruments do not gather the data necessary to
address the objectives of the study, which are the stressors and coping strategies of nursing
students during RLE based on the two models. Hence, a researcher-made questionnaire, a Likert
scale type questionnaire was used. Questions were constructed from related literatures, various
books, journals, and personal experience of the authors themselves. The crafted instrument was
checked by seven experts in the field for content validity. Selected subject matter experts (SMEs)
in the field of study were three guidance counsellors and four nurses. The three guidance
counselors have worked in the university for at least 15 years. They have conducted several studies
related to stress and coping strategies of university students in general. Two nurses were Clinical
Instructors and two were staff nurses who have also worked for at least 15 years in their respective
fields. All of them have conducted studies related to stress and coping. The seven SMEs evaluated
each item of the constructed questionnaire with content validity ratio that ranges from 0.84 to 1.
Five items that did not reach at least 0.99 or above the critical value were removed. The final
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Nurse Media Journal of Nursing, 14(1), 2024, 4
questionnaire has 55 items with two parts: the first part is the identified clinical stressors, which
is divided into two subsections: interpersonal and intrapersonal; and the second part is the
identified coping strategies, which is also divided in another two subsections: interpersonal and
intrapersonal. The students’ perceived interpersonal and intrapersonal stressors and effective
coping strategies were determined using a 5-point Likert Scale; 1-Never, 2-Almost Never, 3Sometimes, 4-Most of the time, 5-Always. The respondents’ answers relating to their perceptions
regarding the stressors were scored as: Highly Stressor (4.25-5.00), Quite a bit of Stressor (3.434.24), Moderately Stressor (2.82-3.42), Some Stressor (1.81-2.81), and Low Stressor (1.00-1.80).
Whereas responses regarding the coping strategies utilized by the respondents were interpreted
as: Very High Coping Strategy (4.25-5.00), High Coping Strategy (3.43-4.24), Moderate Coping
Strategy (2.82-3.42), Low Coping Strategy (1.81-2.81), Poor Coping Strategy (1.00-1.80). The
instrument was also pilot tested to determine the questionnaire’s reliability. The Cronbach’s
Alpha of .854 with 35 items for the clinical stressors and .840 with 20 items for coping strategies
indicated that the instrument had high reliability. Demographic data on age and sex were also
obtained using the instrument. Data were gathered for three months from February 18 to May 18,
2019.
2.4. Data analysis
The researchers tallied, organized, and analyzed the actual data from the respondents using
the SPSS software version 19. Weighted mean, standard deviation, and percentages were used to
describe the clinical stressors and coping strategies of the selected nursing students. Spearman
correlation coefficient was used to determine the degree of correlation between the two variables,
the stressors, and coping strategies. P-value was used to determine the significance of
relationships between the independent variable and the dependent variable.
2.5. Ethical considerations
Permission was sought from the College of Nursing Research Ethics Committee to conduct
the study. This is to ensure that the study was conducted as thoroughly and ethically as possible.
This study was granted ethical clearance and approved by the College of Nursing Research Ethics
Committee, MSU-IIT (02/16/2019). Proper communication and coordination were done with and
through the Deans of the selected Nursing Schools in Iligan City, the Clinical Coordinators, and
College Evaluators. After the study was approved, the respondents were informed about the study
in complete detail before obtaining their consent. They were assured that they would have full
confidentiality throughout the study and data obtained would not be disclosed elsewhere, except
for the intended study and certainly would not be used against them. The respondents were
provided an opportunity and enough time to ask questions, which have been answered to the best
of the researchers’ ability. Therefore, the individuals have not been forced to give consent. It was
freely given by the students who volunteered to participate in the study.
3. Results
3.1. Demographic characteristics of the respondents
A total of 191 nursing students completed the questionnaire with 100% return rate. As
portrayed on Table 1, the majority of them are females, which accounts 76%, while males comprise
only 24%. The respondents were at least 19 years of age; more than half (61%) of them were 2122 years old while the rest (39%) were 19-20 years old.
Table 1. Frequency distribution of the respondents according to age and gender
Characteristics
Gender
Female
Male
Age (year)
19-20
21-22

Frequency (f)

Percentage (%)

146
45

76.4
23.56

70
121

36.65
63.35

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Nurse Media Journal of Nursing, 14(1), 2024, 5
3.2. Perceived intrapersonal stressors of nursing students during RLE
Table 2 portrays the intrapersonal stressors that commonly caused or increased nursing
students’ stress level during their RLE subcategorized into knowledge insufficiency, fear of clinical
area, and skills confusion. As depicted in the table, intrapersonal stressors are considered by the
respondents as some stressor or rarely caused them stress. Most students revealed that being not
certain with the protocols in the clinical area and the etiology and disease condition of the patient
causes them some stress under Knowledge Insufficiency category. Under Fear of the Clinical Area,
the handwritings in the patient’s chart that are difficult to read and understand give them
moderate stress. Being unable to systematically perform a certain procedure as presented in the
book or following the procedures manual also give them moderate stress, under Skills Confusion.
Table 2. Perceived intrapersonal stressors of nursing students during RLE
Stressors
Intrapersonal
Knowledge Insufficiency
Not certain with the protocols in the clinical area.
Not certain with the procedures I’ll be performing to my patient.
Not certain with the etiology and disease condition of my patient.
Not certain with the drugs of my patient
Not certain with my general and specific objectives before going
to duty
Fear of Clinical Area
Worried with certain protocols of the hospital
Worried with the location of equipment and drugs in the clinical
setting
Worried with the location of the respective wards or departments
of the hospital
Worried that the institution is not conducive for learning.
Worried that the handwritings in the patient’s chart are difficult
to read and understand
Skills Confusion
Not able to systematically perform a certain procedure as
presented in the book or manual.
Not able to follow the prioritization of the problems identified in
my nursing care plans.
Not able to apply and perform all the interventions listed on my
nursing care plans.
Not able to check and evaluate my patient’s condition adequately
after doing nursing interventions and medications are given.
Not able to anticipate the need of my patient in accordance with
his/her situation

Mean

(SD)

Interpretation

2.43
2.57
2.53
2.57
2.52
1.97

.846
.830
.839
.764
.863
.934

Some Stressor
Some Stressor
Some Stressor
Some Stressor
Some Stressor
Some Stressor

2.73
2.79
2.69

0.984
1.055
.965

Some Stressor
Some Stressor
Some Stressor

2.39

.898

Some Stressor

2.37
3.41

.953
1.047

Some Stressor
Moderately Stressor

2.66
2.91

0.902
.907

Some Stressor
Moderately Stressor

2.77

.888

Some Stressor

2.57

.797

Some Stressor

2.50

.945

Some Stressor

2.54

.972

Some Stressor

3.3. Perceived interpersonal stressors of nursing students during RLE
Table 3 shows the interpersonal stressors that caused or increased students’ stress level
during their clinical exposure subdivided into staff nurses, duty-mates, clinical instructor,
patients, and significant other/s. Similar with intrapersonal, these interpersonal stressors caused
students some stress. It can also be noted that the Clinical Instructor factor is considered a
moderately stressor, which causes students higher stress among all the other identified stressors
with the highest mean of 3.01. One of the circumstances that very often gives them stress is when
their clinical instructor converse or scolds them in a loud tone of voice. Under Staff Nurses factor,
students identified that situations like when the staff nurses offer them an opportunity to perform
a procedure without their clinical instructor knowing it give them moderate stress. Likewise,
unable to answer or satisfy patient and/ or their SOs on any of their queries caused moderate
stress.
3.4. Perceived intrapersonal and interpersonal coping strategies during RLE
Table 4 depicts the coping strategies that the respondents commonly used to manage stress
during their clinical exposures, categorized into intra- and interpersonal. Students recognized
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Nurse Media Journal of Nursing, 14(1), 2024, 6
coping strategies involving Self-Concept, Physiological care, Role Function, and Interdependence
to be effective and helpful in managing and dealing stress during their RLE. They very often
employ all the identified strategies or consider them High Coping strategy, except for
Physiological which they only consider a Moderate Coping strategy.
Table 3. Perceived interpersonal stressors of nursing students during RLE
Stressors
Interpersonal
Staff Nurses
To establish rapport to the staff nurses
To approach the staff nurses
When my concerns and queries are not entertained by the staff
nurses
When I do not know who the staff nurses on-duty during my
shift are
When the nurses offer me an opportunity to perform a
procedure without my clinical instructor knowing it
Duty-Mates
To establish rapport with my duty mates
To coordinate and/or collaborate with my duty mates.
When I do not know who my duty mates are
When I cannot accomplish any task(s) with my duty mates
When I cannot gain knowledge and skills from my duty mates
Clinical Instructor
When my clinical instructor is present during a procedure I am
performing
When my clinical instructor converse with me in a loud tone of
voice
When my clinical instructor has high expectation of me
When I cannot gain knowledge and skills from my clinical
instructor
To approach my clinical instructor
Patients and significant other/s
To build rapport with my patients and their significant others
To approach my patient(s) and/or their significant other(s)
If whether my patient and their significant others accept me as
their primary care provider
When I am not able to provide comfort to my patient(s) and/or
their significant other(s) just when they needed most
When I am not able to satisfy the queries related to their
situation by the patient(s) and/or significant other(s)

Mean

(SD)

Interpretation

2.70
2.59
2.51
2.77

0.941
.859
.876
.917

Some Stressor
Some Stressor
Some Stressor
Some Stressor

2.79

.974

Some Stressor

2.85

1.078

Moderately Stressor

2.33
2.10
2.09
2.27
2.55
2.63
3.01
2.85

1.049
1.161
1.022
1.095
1.034
.930
1.090
1.116

Some Stressor
Some Stressor
Some Stressor
Some Stressor
Some Stressor
Some Stressor
Moderately Stressor
Moderately Stressor

3.39

1.225

Moderately Stressor

3.24
2.85

1.102
.942

Moderately Stressor
Moderately Stressor

2.74
2.79
2.63
2.60
2.86

1.064
1.056
1.072
1.114
1.059

Some Stressor
Some Stressor
Some Stressor
Some Stressor
Some Stressor

2.79

.990

Some Stressor

3.06

1.047

Moderately Stressor

Most of the students prefer to take a break on their vacant time during RLE to manage stress.
They expressed that praying before starting their day and sleeping, as well as crying when they
feel tired or burned-out from stress highly helped them intra-personally. They are less likely to
take vitamins and other supplements, as well as do not have enough time for exercise as other
means to manage stress. In terms of interpersonal coping, most of them conveyed (1) listening
attentively during hospital orientation, (2) reviewing the concepts and practice the procedures
learned before reporting to duty, and (3) expressing or sharing their concerns to their families,
friends, and duty-mates to be of great help to them.
3.5. Relationship between stressors and coping strategies (both intrapersonal and
interpersonal)
As illustrated on Table 5, among all the Intrapersonal stressors only Skill Confusion has
significant relationship with interdependence under Interpersonal Coping strategy, since its pvalue of 0.000 is less than 0.01 level of significance. Furthermore, the Spearman’s correlation
coefficient r of -0.259 indicates a low degree of correlation. This means a significant negative
relationship between Skill Confusion and Interdependence of Interpersonal coping strategy.
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During student nurses’ RLE, increased Skill confusion (interpersonal stressor) lead to decreased
Interdependence (interpersonal coping).
Table 4. Perceived intrapersonal and interpersonal coping strategies of nursing students
during RLE
Coping Strategies
Intrapersonal
Self-Concept
Pray before starting my day and before going to sleep.
Engage in recreational activities.
Cry whenever I feel burned out/tired due to stress.
Self-talking, reinforcing positive feedback.
Self-awareness exercises and over-come my weaknesses
by means of meditation.
Physiological
Sleep adequately and take nap(s) daily
Take a break during my vacant time
Eat my meals three times a day and eat snacks
Take vitamin supplements every day
Do exercise at least 30 minutes a day
Interpersonal
Role Function
Collaborate with my duty mates and refer endorsements
accordingly.
Listen attentively during hospital orientation.
Review the concepts and practice the procedures learned
Before reporting duty.
Formulate a plan of care for my patient and anticipate
any possible events during my care.
Evaluate patient’s condition after the nursing
interventions and medication administration
Interdependence
Express/ share my concerns to my duty mates
Express/ share my concerns to my Clinical Instructor
Express/ share my concerns to the staff nurses
Express/ share my concerns to my friends
Express/share my concerns to my family

Mean

SD

Interpretation

3.75
4.15
3.61
3.50
3.71
3.80

1.128
1.170
1.123
1.289
1.008
1.049

High Coping Strategy
High Coping Strategy
High Coping Strategy
High Coping Strategy
High Coping Strategy
High Coping Strategy

3.39
3.58
3.89
3.59
2.95
2.94

1.219
1.107
1.028
1.228
1.348
1.386

Moderate Coping Strategy
High Coping Strategy
High Coping Strategy
High Coping Strategy
Moderate Coping Strategy
Moderate Coping Strategy

4.13
4.19

0.855
.917

High Coping Strategy
High Coping Strategy

4.42
3.97

.734
.900

Very High Coping Strategy
High Coping Strategy

3.99

.888

High Coping Strategy

4.07

.834

High Coping Strategy

3.46
3.66
3.30
2.92
3.71
3.72

1.230
1.038
1.290
1.427
1.154
1.241

High Coping Strategy
High Coping Strategy
Moderate Coping Strategy
Moderate Coping Strategy
High Coping Strategy
High Coping Strategy

Table 5 also summarizes the Spearman’s Correlation test results between Interpersonal
Stressors’ variables on Staff Nurses, Duty-Mates, Clinical Instructor and Patients and Significant
others, and the respondents’ identified Coping Strategies. The results portray that in all the factors
under interpersonal stressor, Staff Nurses has a significant relationship with Self-Concept
(intrapersonal coping); with r=0.152 and p=.035 tested at 0.05 confidence level. This implies a
weak positive correlation between staff nurses and self-concept.
Also, Duty-mates with r=0.160 and p=0.027 tested at 0.05 confidence level and Clinical
Instructor with r=-0.237 and p=0.001 tested at 0.01 confidence level, were both significantly
correlated with Physiological coping strategy (intrapersonal). This indicates that Duty-mates, an
interpersonal stressor, is positively correlated to Physiological coping strategy, an intrapersonal
coping, while, the interpersonal stressor, Clinical Instructor, has a negative relationship with
Physiological coping strategy of nursing students.
Clinical Instructor also has a significant moderate negative correlation with Interdependence,
an interpersonal coping, with r=-0.317 and p=.000 tested at 0.01 confidence level, as perceived
by the respondents during their RLE duty in the hospitals.

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Nurse Media Journal of Nursing, 14(1), 2024, 8
Table 5. Relationship between stressors and coping strategies (both intrapersonal and
interpersonal)
Stressors
Intrapersonal
Knowledge
Insufficiency

Correlation
Coefficient
Sig. (2-tailed)
Fear of Clinical Area Correlation
Coefficient
Sig. (2-tailed)
Skill Confusion
Correlation
Coefficient
Sig. (2-tailed)
Interpersonal
Staff Nurses
Correlation
Coefficient
Sig. (2-tailed)
Duty-Mates
Correlation
Coefficient
Sig. (2-tailed)
Clinical Instructor
Correlation
Coefficient
Sig. (2-tailed)
Patients and
Correlation
Significant Others
Coefficient
Sig. (2-tailed)

Self-Concept

Coping Strategies
Role
Physiological
Function

Interdependence

-.108

.084

-.083

-.127

.136
-.037

.246
.012

.255
-.071

.081
-.134

.607
-.070

.872
-.007

.328
-.110

.064
-.259

.339

.927

.130

.000*

.152

.016

-.070

-.015

.035**
-.030

.826
.160

.334
-.077

.832
-.110

.679
.074

.027**
-.237

.290
-.055

.128
-.317

.312
.023

.001*
-.027

.450
-.108

.000*
-.117

.757

.712

.136

.106

*Correlation is significant at the 0.01 level (2-tailed).
**Correlation is significant at the 0.05 level (2-tailed).

4. Discussion
This study aimed to investigate the stressors and coping strategies that nursing students
commonly used in managing stress and their relationship to each other. It has been portrayed
that all the identified intrapersonal and interpersonal stressors were perceived to be “some
stressor” by the respondents, except for the interpersonal stressor Clinical Instructor, which is
perceived to be “moderately stressor”. This implies that this interpersonal stressor caused more
stress than all the other stressors identified by nursing students. Similar findings of Shdaifat et al.
(2018) point out that nursing students experience a moderate level of stress because of their
teacher and nursing staff, peers, daily life, and taking care of patients. Moreover, a study in the
Arab American University yielded the same results that identify teachers and nursing staff as the
main stressors of nursing students in their first clinical training (Toqan et al., 2023). A
phenomenological study among Malawian nursing students revealed that a lecturer who interacts
in a “policing manner” induces more stress (Msiska et al., 2019). These students shared that the
intimidating and unfriendly way of supervising them arouses stress, which causes them to commit
mistakes more. They feel threatened whenever their teacher approach them and starts asking
questions or shouts at them when doing procedures or committing errors. Because of the way
their lecturers approach them, they feel nervous and avoids them. This poor lecturer-student
relationship affects the clinical experience and learning of the students (Msiska et al., 2019).
Students who experienced stress in the practice settings because of their teachers felt
embarrassed, belittled, and stupid (Al-Qerem et al., 2021).
The instructor’s role in assisting student nurses to reach professional excellence is very
important. In the same study conducted at Shiraz University of Medical Sciences (Shiraz, Iran)
most of the students had the perception that their instructors have a more evaluative role than a
teaching role. The clinical instructor or mentors can play an important role in student nurses' selfconfidence, promote role socialization, and encourage independence which leads to clinical
competency. A supportive and socializing role was identified by the students as the recommended
function of a mentor. Nursing faculties can also help meet student needs by acknowledging their
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Nurse Media Journal of Nursing, 14(1), 2024, 9
complaints of heavy workloads and extra assignments, offering supportive services. The results of
this study highlight the necessity of building a more connected, healthy, and positive teacherlearner relationship especially in the clinical setting. This entails the need for continuing
professional education among educators that enhances their relational competence as well as
effective supervision of students in the clinical practice setting (Msiska et al., 2019).
As to the utilization of coping strategies, results revealed a “High Coping Strategy” utilization
of both the intrapersonal and interpersonal strategies, except for Physiological, an intrapersonal
coping strategy. According to Roy (2009), Physiological coping strategy pertains to the way a
person responds as a physical being to the stimuli from the environment. The goal of this coping
strategy is primarily geared towards physiological integrity. It basically means that one must
attend to his physical bodily needs to establish individual coping against stressors. Students may
be able to benefit from this coping strategy through activities that facilitate proper physiological
functioning such as eating healthy foods and instituting adequate rest and sleep patterns. Similar
results were observed in the study of Toqan et al. (2023), that revealed a combination of problemsolving and avoidance, both of which are interpersonal, as well as optimism which is an
intrapersonal coping strategy were occasionally utilized by students to manage stressors. While
transference behaviors like feasting a deep sleep, relaxing by watching TV, taking a shower,
exercise, etc. have low impact on their stressors. However, a study among nursing students in
Najran University in Saudi Arabia yielded a contradicting result such that transference or shifting
stress to leisure activities like sleeping, listening to music, watching movies, or sports was the
most frequently employed coping strategy (Aedh et al., 2015).
Furthermore, among all the coping strategies identified in this study, role function was found
to be utilized the most. It is defined by Roy (2009) as the primary, secondary, or tertiary roles that
a person performs in the society. Being aware of one’s role enables an individual to accomplish
tasks effectively. Students establish role function coping by being thoroughly competent in their
role as a care provider. Attentively listening to nursing endorsements, participating in hospital
orientations, reviewing concepts and procedures before going to duties, and the like increase
student’s sense of preparedness and confidence to attend clinical duties and do their role as care
giver. Bodys-Cupak et al. (2016) affirms that students feel less stressed when they are more
confident and better prepared to perform procedures to their patients. Several studies (Ab Latif
& Nor, 2019; Baluwa et al., 2021; Nebhinani et al., 2020) yield somewhat similar results that
active coping skills and planning are the commonly used coping strategies among nursing
students. A qualitative study also claims that actively confronting stressful situations by
developing one’s professional competence, reflection, observation, and learning from the
experience of others, and previous mistakes helped them control stress (Rafati et al., 2017).
It was also disclosed in this study that among all the Intrapersonal stressors, Skill confusion
has significant inverse relationship with interdependence under Interpersonal Coping strategy.
Skill confusion can be rooted down from the lack of knowledge and professional abilities coupled
with the responsibilities of patient care. A study in Saudi Arabia expressed that the lack of
knowledge and skill proficiency is perceived to be the topmost stressor by students. This happens
when they are not familiar with the medical terms, patient history, diagnosis, and treatment
regimen (Aedh et al., 2015). The students experience more stress when they lack confidence and
do not feel ready or prepared to perform a procedure towards their patients (Bodys-Cupak et al.,
2016). Interdependence as defined by Callista Roy (2009), pertains to the coping strategy from
forming close relationship to foster collaboration and coordination.
The results of this study imply that in the clinical setting, when the student nurse has
increased stress from Skill confusion (interpersonal stressor) it can lead to decreased utilization
of Interdependence (interpersonal coping). This means that when students are stressed due to
poor performance during RLE, wrong intervention, or was not able to prioritize and implement
nursing care plans accordingly, they work and talk less with others. On another note, when the
Interdependence coping strategy is increased, it promotes collaboration and therefore decreases
the Skill confusion as a stressor. This means that they collaborate and talk more with their others,
their duty-mates, and assigned clinical instructor when students perform well and are less
stressed. A longitudinal study among nursing students in Hong Kong shared similar findings. The
lack of knowledge and lost confidence causes them frustrations, self-doubt, and heightened
anxiety. The overwhelming stress from the clinical placement keeps them from working
effectively with their peers. This often caused them to struggle in keeping up with their fellow
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Nurse Media Journal of Nursing, 14(1), 2024, 10
duty-mates (Cheng et al., 2023). However, these are contrary to the results of a cross-sectional
study in Kelantan, Malaysia which found significant positive correlation of “stress from lack of
professional knowledge and skills and ward staff” with emotional and instrumental supports as
coping (Ab Latif & Nor, 2019). The contrasting results could be attributed to the differing
demographics of the sample of this study and that of the study in Malaysia. Moreover, the
instruments and methodologies used in the two studies were also different. This could be explored
more on further studies.
Also, in all the factors under interpersonal stressor, Staff Nurses has a positive significant
relationship with students’ Self-Concept under intrapersonal coping. When the nursing student
has a higher self-concept, it can be said that he or she will be likely to perform better; as he or she
perceives himself or herself as a person who is able to provide quality care to the patients in the
hospital and able to perform certain procedures and tasks (Duraku & Hoxha, 2018). Additionally,
when the staff nurses have higher confidence on students performing procedures on patient care,
this causes decreased stress on students. Decreased stress implies a lesser need for the selfconcept coping strategy, since the students will be able to carry out responsibilities given to them
by the staff nurses without fear or anxiety. The results somehow correspond with the study of
Grobecker (2016), that claims that good relationships with the healthcare team, especially the
staff nurses, and students’ sense of belongingness in the clinical environment positively impacts
students’ self-concept, motivation, confidence, leading to a maximized learning. On the other
hand, an unwelcoming or intimidating practice setting caused by an unapproachable, ignoring
nursing staff can decrease students’ sense of belongingness. This is strongly associated with
increased distress among nursing students (Admi et al., 2018; Labrague et al., 2017; McCloughen
et al., 2020).
Staff nurses are an integral piece of the nursing students’ education process. Due to the
nursing shortage, fewer staff is available to assist in the educational process. Faculty depends on
staff nurses to assist them in clinical education of nursing students and often staff nurses are not
given any direction on how to provide this assistance to both faculty and nursing students
(Gorton, & Foss, 2017). Establishing proper communication to staff nurses aids the student nurses
to perform properly in rendering care to the patient. The result of this study is somewhat in
congruence with the study of Ismaile (2017), as well as the study of Al‐Zayyat & Al‐Gamal (2014),
that staff nurses cause high level of stress among undergraduate student nurses during their
clinical exposures. The lack of support and uncooperative nursing staff are the commonly
identified great source of stress among the student nurses. They highlighted the need to employ
appropriate strategies to improve this student-staff nurse relationship such as improving clear
communication between the nursing school and affiliated hospital on students’ preceptorship
programs especially before the start of the students’ exposure, as well as an integral part of the
clinical instructors in the process.
As to the duty-mates stressor and physiological coping strategy having a positive significant
relationship, when the stressor, duty mates, is increased, there will be a higher need for the
physiologic coping strategies. For the student nurse to combat the stress brought about by their
duty mates, the student nurses usually attend to his or her physical bodily needs. This facilitates
proper physiological functioning; by this the student nurses can perform their duties well, with
the ample hours of rest, balanced diet, and exercise. A healthy student nurse can provide their
competent skills during their duties. The results of this study imply that an increased stressor on
duty-mates necessitates an increased physiologic coping strategy. Several studies also report that
problems in communication and interactions among student nurses and their groupmates during
their supervised clinical or practical trainings to be a significant root of academic stress (Hirsch
et al., 2018).
Lastly, the clinical instructor as a stressor has a negative significant relationship with both
the physiological and interdependence coping strategies. During the clinical exposure of the
student nurses, the clinical instructor has their own expectations and requirements to be
complied with, therefore causes increased stress to the students on duty. In this study, the more
the Clinical Instructor becomes a stressor, the lesser is the utilization of physiologic coping
strategy by the student nurses. This is because the time that should be spent for eating, sleeping,
taking a break and the like will be more likely spent on completing requirements and improving
patient care to meet the instructor’s expectations (Guro & Buenavidez, 2023).
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Nurse Media Journal of Nursing, 14(1), 2024, 11
When the interpersonal stressor, clinical instructors, causes students more stress, they utilize
Interdependence coping strategy less. This means that they share concerns less with each other
when they are stressed by their instructor. When the instructor’s approach or expectation/s cause
them stress or pressure, it can lead them to focus their full attention on their individual patients
to meet deadlines and these expectations. When the stress brought upon by the Clinical Instructor
increases, the team dynamics is also affected as well as the ability of the group to perform their
nursing responsibilities efficiently and effectively as a team (Delawala, 2020). Various studies
affirm these results such that over dedication to academic studies and inefficient management of
stress adversely affect their quality of life, social and family relationships (Quah, 2014). It also
harmfully impacts the student nurses’ sleep, mood, affinity, and ability to perform some physical
exercise, their over-all physiological and mental health (Hirsch et al., 2018). Ismaile (2017) also
attributes the stress brought about by their teachers to unclear or undefined expectations from
both sides. Setting of clear learning objectives and outcomes for each clinical duties will help
resolve and prevent instructors from having unrealistic and unconstructive expectations from
their students.
5.

Implications and limitations
The findings of this study imply the need for the nursing educators to reflect on what role and
attitude they have when supervising students during their RLE, whether more of the strict, nonapproachable, non-accommodating or the other way around. A balance of imposing appropriate
discipline in the right tone and timing in the clinical area and the provision of the much-needed
support, and a clinical environment conducive for learning will better help students manage stress
during the RLE. As stress is known to have various impact on the academic performance and
quality of life of the students, this result highlights the importance for the nursing administrators
to consider and regularly monitor student feedback when it comes to what causes them stress.
This study also has implications also for nursing administrators as well as nursing regulating
bodies to review the current curriculum and consider the inclusion of programs and strategies
that help students manage stress more efficiently especially in their RLE. Effective curriculum
should offer students quality nursing education but should not cause them stress that could
compromise their academic performance as well as over-all quality of life.
This study has limitations. It is purely descriptive and correlational; hence no direct causal
relationships can be drawn from the findings. Great insights on nursing students’ stressors and
coping during their RLE can be derived from the study, nonetheless. Also, the instrument used
was a researcher-crafted one which has only undergone content validity. Appropriate
psychometric tests of construct validity should be done for it to be widely used for future studies.
Lastly, although the study employed total enumeration sampling, data were gathered from only
two out of three schools in Iligan City who gave consent. Upscaling the sample size could enhance
generalizability.
6. Conclusion
This study concludes that stressors are inevitable and integral in nursing students’ related
learning experience. All intrapersonal and interpersonal stressors experienced by the nursing
students rarely cause them stress except for the Clinical Instructor. The impact of Clinical
instructor causes more stress to the students among all other stressors. Responding to and
confronting these stressors resulted to high intrapersonal and interpersonal adaptive coping
utilization among these students. The current study only describes the common stressors and
coping strategies of nursing students as well as its significant relationship. Further studies on
other factors such as demographic data, effectiveness of various coping techniques and existing
stress management programs are recommended.
Acknowledgment
The researchers personally funded this research study. However, the authors would like to
extend gratitude to all the nursing schools, administration, and students who in one way or
another made contributions in the completion of the study.

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Nurse Media Journal of Nursing, 14(1), 2024, 12
Author contribution
All the authors contributed in the conceptualization, review of related literature, data
collection and analysis, writing of the manuscript and approved the final output. GSR repackaged
the manuscript for publication approved by the rest of the authors.
Conflict of interest
There is no conflict of interest for all the authors of this study.
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