Pre-registration nursing students’ experiences of stress

This research study aimed to explore stress among pre-registration nursing students in the United Kingdom. The specific objectives of the study were: To explore the experience of stress among pre-registration nursing students; to determine the type of stress and sources of stress in pre-registration nursing field; to investigate the perceptions of pre-registration nursing students on stress and anxiety in pre-registration nursing programme; and to identify suitable measures that can be implemented to help the pre-registration nursing students to cope with stress. Qualitative research method and phenomenological approach was used in this study and the data was collected with the help of face-to-face semi-structured interviews. The setting for the current study was a higher education institution (HEI) that delivers pre-registration nurse education in the UK. The study sample was six pre-registration nursing students from the East Midlands who were in the first, second, and in final year of the study program leading to BSc (Hons) Nursing with NMC Registration. A thematic analysis of the data was conducted which led to four emergent themes: Pre-registration nursing students’ experiences of stress; re-registration nursing students’ perceptions of stress and anxiety; sources of stress in the nursing field; and measures for coping with stress. The findings revealed that the pre-registration nursing students in this study perceived stress as a problem associated with human health that basically is caused by academic pressure presented by either theoretical assignments, projects, and examinations and placement demands such as while caring for patients. Moreover, stress among pre-registration nursing students was found to be a problem embedded in their lifestyle that impacts their wellbeing. Further findings showed that the study participants perceived that stress and anxiety are interrelated; anxiety takes place in response to stress resulting from academic and clinical placement pressure; and anxiety has a strong relationship with stress and is a contributor to depression too. The study participants also perceived that the major causes of stress include social distress, financial problems, academic pressure, demands of clinical placement, and family expectations. Academic pressure was found to be the most common cause of stress among the pre-registration nursing students in this study. Lastly, the findings revealed that the coping strategies that can help pre-registration nursing students to manage stress are adopting social support mechanisms, encouraging physical activities, and spiritual support. students’ perceptions of stress and anxiety, sources of stress in the nursing field, and measure to be adopted for helping pre-registration nursing students facing stress. A critical literature review was taken up prior to the research for the purpose of exploring the existing studies and knowledge on the research problem. The critical literature review offered the researcher a basis for conducting a critical discussion of the findings in line with the research questions. This study used the interpretivist phenomenological


Introduction
The current research study explored stress among pre-registration nurses in the United Kingdom (UK). The notion "pre-registration nursing education" used in the current study depicts "the programme that a nursing student in the UK undertakes in order to acquire the competencies needed to meet the criteria for registration with the Nursing and Midwifery Council (NMC)" (NMC, 2010:4). In the UK, there exists a standard for pre-registration nursing education which stipulates all the protocols and guidelines of nursing. Wright and Wray (2012) argue that because of these protocols and guidelines, pre-registration nursing programmes are renowned to be stressful and demanding and this stress is associated with nursing student attrition and a subsequent increase in the drop-out rate.
the individual appraises an event as threatening and lacks the appropriate coping resources to deal with it. High levels of stress can impact on learning and memory, affect concentration and cause deficits in problem-solving abilities" (p. 161). McVicar (2003) argue that stress perception is subjective in nature and the complexity of nursing practice can potentially result in variation between nurses' identification of sources of stress phenomenon. Similarly, stress among pre-registration nursing students can lead to a number of challenges and problems during the theoretical and placement endeavors. It is therefore important to explore and understand the phenomenon of stress among pre-registration nursing students in the UK. This study into the stress experience of the preregistration nursing students can potentially help address their level of stress. This is supported by McVicar (2003) who state that stress intervention strategies need to be focused on stress prevention for individuals while tackling broader organizational issues.

Nursing students' experiences of stress
Pre-registration nursing students perceived stress as a problem associated with human health that basically is caused by academic pressure presented by either theoretical assignments, projects, and examinations and placement demands such as while caring for patients. Moreover, stress among pre-registration nursing students in the UK is a problem embedded in their lifestyle that impacts their wellbeing. Academic workload increases the stress levels among nursing students as also evidenced by Orton (2011). However, contradictory findings were reported by Murphy et al. (2012) and Shivers et al. (2017) who contended that pre-registration nursing students in the UK undergo positive experiences in their clinical placement. Murphy et al. (2012) in particular noted that students find sufficient support from their colleagues which helps them in coping with and reducing the workload. Shivers et al. (2017) highlighted that there are beneficial impacts of clinical placement and clinical learning environment on the pre-registration nursing students as these have a positive contribution towards the preregistration nursing students' increased satisfaction because of enhanced support. However, the negative experiences were faced by the pre-registration nursing students in the current study with regard to academic and clinical placement, which in turn lead to stress among these nursing students. The reason for this difference in the findings can be attributed to the individual perceptions of the participants rooted in their personal life, background and setting where the study was conducted. Another reason for different findings could be associated with the research methods used in the respective studies. In this regard the current study adopted a qualitative method and used qualitative semi-structured face-to-face interviews for data collection, On the other hand, Orton conducted a literature review, whereas Murphy et al. (2012) and Shivers et al. (2017) collected data through quantitative survey questionnaires. The current findings thus add another angle to the existing findings by revealing that despite the support systems, some students undergo negative experiences during academic work and clinical placements because of their personal and family responsibilities and issues which lead to stress among these pre-registration nursing students. However, the methodological limitations of the current study, such as utilization of only qualitative approach and data collection through a single tool of semi-structured interview limited the scope of the study. Moreover, the small sample (6 pre-registration nursing students) limited the ability to generalise the results of this study to a wider population of pre-registration nursing students.

Nursing students' perceptions of stress and anxiety
Stress and anxiety were found to be interrelated. Participants perceived that anxiety takes place in response to stress resulting from academic and clinical placement pressure. Moreover, the participants perceived that anxiety has a strong relationship with stress and is a contributor to depression too. Higgins et al. (2010) and Jack (2017) contended that the academic and placement demands make the pre-registration nursing students experience anxiety. Higgins et al. (2010) in addition found that the anxiety among the nursing students is associated with the fear that they might fail in meeting and acquiring the required academic and placement knowledge and skills for becoming a proficient nurse. A similar reason for anxiety was noted in the present study too where the participants feared that they might not succeed in performing their academic and clinical responsibilities in a successful manner.
Some of the possible reasons for increase in the levels of stress, anxiety, uncertainty, and fear among the preregistration nursing students in the UK were pointed out by Higgins et al. (2010). Higgins et al. (2010) concluded that the most common and highly stressful experience for the pre-registration nursing students in the UK was the shifting or moving of pre-registration nursing education from apprentice style training to the modern higher education evidence-based practice training because changes of this type bring about academic issues and inadequacy of support. Galvin et al. (2015) reported that undergoing placements in the NHS may be an innately challenging aspect of training for the nurses, as this working environment is famous for being stressful. In the UK, nursing has moved to an all-graduate profession recently. This move has ensued in conjunction with widening participation where students are coming onto degree level nursing programs from non-traditional backgrounds (Gale et al., 2015) which could also be a background cause of stress among pre-registration nursing students. Similar background reasons could be the cause of stress, fear, uncertainty and anxiety among the current study 91 participants who reported that they felt stressed due to the academic and placement demands and the challenges faced in the attempt to balance these demands.

Sources of stress in the nursing field
The study pre-registration nursing students perceived that the major causes of stress include social distress, financial problems, academic pressure, demands of clinical placement, and family expectations. Academic pressure was found to be the most common cause of stress among the pre-registration nursing students in this study. Galvin et al. (2015) also concluded that academic workload such as assignments and struggling to create a balance with the clinical placement activities are the major causes of stress among pre-registration nursing students. The large amount of academic and clinical placement work was found to increase the pre-registration nursing students' stress levels, and reduce their enthusiasm and engagement in this study. However, Thomas et al. (2012) arrived at contradictory results and noted that some of the nursing students have high level of satisfaction owing to the caring, supporting and nurturing nursing environment. Nursing and Midwifery Council (NMC) (2010) also reports that pre-registration nursing students undergo higher degrees of stress due to workload and the need to attain NMC standards during clinical placement. Poultney et al. (2014) also found that stress among pre-registration nursing students resulting from the workload and clinical activities.
The pre-registration nursing students perceived that social distress and family expectations also lead to stress. They found it challenging to balance family responsibilities with academic demands and placement responsibilities. Single mothers or married pre-registration nursing students and those who had children experienced stress in terms of an effort to balance family responsibilities, education, and work responsibilities. Orton (2011) also concluded that family and financial demands often lead to senior registered nurses hanging on to their positions for longer time than expected, thus influencing new job openings and opportunities for fresh graduates.

Measures for coping with stress
The coping strategies that can help pre-registration nurses for stress management are adopting social support mechanisms, encouraging physical activities, and spiritual support. Several existing studies have also supported the positive role played by the supporting strategies in helping pre-registration nurses to manage stress. For example, according to Wood (2010), since the social support strategy conforms to the NMC standards, the mentors in the pre-registration nursing programme ought to deliver support to students for reducing academic workload and demands. It was also reported by Galvin et al. (2015) that since it is quite challenging to provide counselling services to pre-registration nursing students due to the clash between the timing (hours) of the provision of these services and the students' academic hours. Hence, in order to make sure that the students make use of social support service, it is essential that these services be offered beyond the normal working hours so as to help them in finding an easier access to these services ( 2011) noted that implementing the social support mechanism, for instance providing mentoring and preceptorship support within pre-registration nursing programme helps in promoting nursing students' retention in the study programme and improves their learning practices.
The pre-registration nursing students reported that physical exercise also helps them to cope with stress. In this regard, engagement in physical exercise like going for a walk and playing with children, and recreational activities like watching television are helpful in decreasing the feeling of stress among the pre-registration nursing students. Milligan et al. (2016) also found that adaptive or positive coping processes acknowledged by students in their study comprised a period of reflection and engagement in a physical activity along with the decision to carry on with the study program. The pre-registration nursing students believed that spiritual support can also help them in coping with stress. This finding showed that involvement in physical exercise and seeking help from cultural and spiritual support, such as praying and taking assistance from church advisors was reported by the study participants to be useful in coping with stress and to be an effective means for them to share their experiences of stress, relate to each other and get develop support networks.

Conclusion
The aim of this study was to investigate pre-registration nursing students' experiences of stress and to find out the measures which can be adopted to minimize stress levels among pre-registration nursing students. The current study centred on the pre-registration nursing students' perceptions of stress and anxiety, sources of stress in the nursing field, and measure to be adopted for helping pre-registration nursing students facing stress. A critical literature review was taken up prior to the research for the purpose of exploring the existing studies and knowledge on the research problem. The critical literature review offered the researcher a basis for conducting a critical discussion of the findings in line with the research questions. This study used the interpretivist phenomenological Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.85, 2021 92 approach. Semi-structured face-to-face interviews were conducted with six pre-registration nursing students for data collection. Semi-structures interviews were considered a suitable data collection technique based on the research questions that required in-depth and rich information based on the participants' lived experiences for addressing the research questions. The study population was pre-registration nursing students enrolled in a UK university. The prospective sample size was 10 participants but only six participants who showed consent to participate in the study were interviewed. The participants' responses to the interview were analysed for identifying the emergent themes for addressing the research questions. The study used thematic analysis for identifying the emergent themes. For this purpose, the individual transcripts were read and reread for identifying the emergent themes which were then arranged, presented and discussed under the sections based on the research questions.
The study findings evidence that stress is a problem associated with human health that the nursing students face during the pre-registration nursing stage. The stress levels among pre-registration nursing student are an outcome of the demands of their academic and placement environments. The findings showed that a significant increase in the stress levels is associated with anxiety. In addition, increased stress among nursing students has also been ascribed to heavy academic workload and demanding clinical placement. The findings revealed that the need for the pre-registration students to dispense quality services to patients in clinical placement and social distress increases their levels of stress. The findings further revealed that balancing academic work such as assignments and sitting the exams and meeting deadlines, along with placement and family responsibilities add to the stress among the nursing students. The adoption of effective coping strategies assist in decreasing the stress levels. In this regard, social support mechanism helps nursing students in coping with stress and anxiety. Moreover, getting help from family members, relatives or even colleagues may help the pre-registration nursing students in coping with stress. Furthermore, engaging in physical exercise and getting spiritual and religious support may also help in reducing stress. With regard to physical exercises, playing or taking a walk; recreational activities like watching TV may also be of help to prevent engaging in negative thoughts regarding stressful experiences in the nursing field. Spiritual and cultural support such as praying or getting help from church members on ways for coping with stress can also be helpful for pre-registration nursing students in coping with stress. Nonetheless, there is the need to conduct more research for exploring the effectiveness of the aforesaid two coping strategies.
Most significantly, this study laid down the foundation for future researches into pre-registration nursing students experiences of stress along with providing these students a platform for expressing their experiences of stress, and for suggesting possible solutions to help such students to adjust to the pre-registration nursing environment and conditions. The pre-registration nursing students in this study had the feeling of incompetence, and being overburdened with the workload and demands of academic and clinical placement responsibilities and duties. Subsequently, the current study helps in exploring the stress experiences of per-registration nursing students and recommends suitable procedures that may help them in accomplishing pre-registration nursing programme in a successful manner.
This study brings to light the significance of giving value to pre-registration nursing students in their learning environment and clinical placements. The findings of this study imply that pre-registration nursing students need to have a sense of self-wroth in both their academic and clinical placements because it is crucial for their success. Bringing down the stress levels and motivating nursing students helps them in meeting the NMC nursing standards so as to become competent and proficient nurses in the actual clinical environment.

Recommendations
The research findings of this study support the majority of the previous research reviewed in the critical literature review. However, with regard to the emergent theme three, there were some new and contradictory findings, such as financial problems as a cause of stress among the pre-registration nursing students. This, thus, shapes significant concerns for future research needed for establishing the possibility of financial constraints and challenges as a cause of stress among per-registration nursing students in the UK. This notion thus need to be investigated further. Regarding the emergent theme four, it was also found that physical exercises and spiritual and cultural support are the major steps that can be taken for assisting the nursing students facing stress which were unique to this study and have not been found in any earlier study. Thus, it is suggested that further research may be taken up with enhanced focus on physical exercise and religious and spiritual support to ascertain the usefulness and effectiveness of these strategies in helping nursing students to cope with the stressful experiences. It may also be possible in future research to extend the current research by keeping focus not only on pre-registration nursing students in the UK but also globally for further exploring the stressful experiences in the nursing field. Future research study can use a large sample of pre-registration nursing students as interviewees which can help further deeper insights into the pre-registration nursing students' experiences of stress. This can also enable generalisation of research findings arising from the study.