Balancing Nursing Studies and Life

Introduction

Students who are studying nursing deal with anxiety and high levels of stress throughout the learning process (Glazer et al., 2008). In substance, these students experience more stress than any other group of students in the healthcare domain (Higgins et al., 2010). Various factors contribute to the intensity of stress in nursing students due to the existence of competing priorities. Financial aid for University students such as the NHS Learning Support Fund is on the decline, and this factor implies that more nursing students have to get involved in income-generating activities to sustain themselves in college (Tagher & Robinson, 2016). Having to juggle academic courses, while also managing social, financial, and other life aspects raise the possibility of increased anxiety and stress levels. The rigorous nature of the nursing curriculum is also a cause of stress because failing the program or one of its courses translates to lost time and resources invested in student training. These challenges delay the realization of other outcomes in life, such as career life, and in an unfortunate turn of events, students drop out of the nursing degree program (Tagher & Robinson, 2016). Academic stress is a type of stress that nursing students experience encounter while they are in university. For instance, new nursing students struggle with learning how to tackle nursing examinations. Assessment tests in the program are seldom straightforward, and students must engage in critical thinking as opposed to ‘downloading’ memorized content. When students are handling examinations, especially multiple-choice questions, they always find themselves narrowing the answer pool down to two potentially correct answers (Thomas et al., 2016). Still, they choose the wrong one in the end, which implies that their learning techniques are not as effective as they should be. Research studies reveal that as students progress in their academic life, the material that requires to be learned increases in density and complexity (Larrabee & June 2008). As such, students undertaking their studies need to hone their academic capabilities if they stand any chance of passing evaluation tests in the last phase of nursing training. As such, students in the senior years of their training cycle experience more stress compared to their junior counterparts in the entry years (Semee, 2019). Numerous investigations about student retention and dropout rates in nursing schools in many places across the world indicate that the dropout rates among nursing students have increased significantly over the years. For instance, the United Kingdom recorded a massive nursing student dropout rate of about 20% in 2015. How significant is stress as a contributing factor to the damning statistics about the dropout rate among nursing students in Europe and the UK?

According to an article published by Sarah Marsh for The Guardian, ‘mental health problems’ are to blame for ‘the number of university dropouts.’ A report by the National Health Service shows that 1,180 students who were grappling with ‘mental health’ issues dropped out of university early between 2014 and 2015, representing a threefold increase from 380 between 2009 and 2010 (Marsh, 2017). Stress that is related to clinical practice is the other primary type of stress that nursing students encounter. Stressful events induce the body to engage a defence mechanism known as fight or flight (Robotham & David, 2008). The student nurse is required to decide on whether to deal with the situation or walk away from it. The latter option is the easiest way of stress management, as experienced by most students as an approach to coping with a stressful situation (Galbraith et al., 2011). For instance, when a student feels overwhelmed by activities such as meetings or conversations, they can excuse themselves. Stress has detrimental effects on the outcome of student nurses because it can precipitate, among other things, disease, a decline in health, deterioration of academic results, withdrawal from the learning program, and it can negatively impact the quality of care received by patients (Shaban et al., 2012). Primarily, dropping out of nursing school might be set up by the additive effect of both academic stresses as well as clinical stress. The competence of nurses is premised on the skills and knowledge they learn in school as well as the clinical setting. The clinical environment is the host of a large part of nursing training. Besides, this phase of nursing education plays an essential role when student nurses are deciding whether or not they will take up the nursing profession.

Background

As indicated in the introductory chapter, stress among nursing students has existed for as long as the nursing career has been in existence. As such, the curricula for nursing education contains sufficient material to guide students on how to alleviate stress, whether academic stress or stress encountered while on placement (Bindu & Munira, 2015).

Sources of stress

The thought of joining the University for Nursing Education is quite pleasing among students because they believe they are joining a great career, one that is rewarding and challenging (Higgins et al., 2010). However, nursing is notoriously difficult. Most universities require three A-levels or impressive scores in equivalent subjects, including one science such as biology, which are demanding subjects; therefore, the career is exceedingly fulfilling (Taylor &Vanessa et al., 2015). Various studies indicate that nursing students feel burnout at higher rates as compared with students pursuing other career paths. For example, Deary et al. (2003) found that nursing students in the UK encounter increasing levels of stress, prompting them to use harmful coping methods such as substance use. Pryjmachuket al. (2009) also finds that as the nursing programs become harder, students experience psychological morbidity due to stress. Besides, bachelor's students typically take longer to graduate than before, with many of the students taking more than four years to graduate. Since nursing programs tend to be more challenging in terms of credits, most students are forced to fast-track their degrees by doing several hard classes at once (Deary et al., 2003). Fast-tracking, in this case, means several most stressful mid-terms and finals at once. All these factors necessitate an all-night strategy to cover what is needed to pass the exams (Pryjmachuk et al., 2009). Staying up all night is not suitable for health; lacking proper sleep might affect one's memory, and thus losing focus (Labrague et al., 2014). For new nursing students, the main problems encountered, which cause academic stress, include inadequate information about the complexity of the program, inadequate knowledge on how to tackle nursing exam questions, financial difficulties, lack of exposure to deep studying techniques, among others (Higgins et al., 2010). To improve student outcomes in nursing, it is necessary to ensure that newly recruited students have slim chances of encountering stressors that have the potential to impact their academics significantly negatively. When new students can concentrate on their studies, they stand better chances of excelling in their academics as well as future practice. Students who excel in class are more likely to be confident than students who registered inferior grades when heading on to the clinical setting, which is the practical part (NHS, 2016). As such, the National Health Service Institute for Innovation and Improvement (2016) recommends that first-year nursing students should receive as much assistance as possible to get good grades from stakeholders such as senior students, universities, and the government. Further, the recommendation highlight that senior nursing students who are at most four semesters away from completing their courses are the central pillar in the plan of protecting new nursing students from stressors (NHS, 2016). Learners who are in their third or final year of the nursing program have amassed a wealth of experience, and they can share essential information on how to get through the program smoothly. For instance, they can help their juniors in the first year through various methods. First, they can help the newbies to process course questions and grasp critical material in the stem and understand question requirements (Galbraith et al., 2011). This undertaking can help curb some of the stress that is generated by course assessment tests, more so at the outset of the program (Jimenez et al., 2010). New students can also acquire deep learning skills to deter tendencies of studying by cramming and memorization. Deep learning is essential because a student maintains the knowledge gained throughout their nursing school (Gibbons et al., 2011). This will, in turn, help them in nursing practice or passing board exams. Other stakeholders, such as faculty, can protect first-year nursing students from stress through encouraging learning methods such as group work and encouraging mentorship among students (Jimenez et al., 2010). The government can also play a significant role by providing adequate student financing to discourage students from taking jobs to earn upkeep money (Galbraith et al., 2011). In substance, the battle to protect first-year nursing students from causes of stress ought to be fought from numerous fronts. With all these risks of burnout and stress, how do the students manage to stay positive? This is the type of question this submission tries to answer. Also, it aims to demonstrate how nursing students can have better outcomes through being protected from stressors from the onset of their training program. If nursing students experience fewer problems from the beginning of their learning period, they are more likely to register better academic results, which will, in turn, step down the intensity of academic stress. Academic stress plays a significant role in the build-up to clinical stress, which implies that less academic stress translates to less clinical stress. By protecting newly enrolled nursing students from the causes of stress, significant progress can be achieved on this issue and probably strip off this threat the identity of ‘major’ concern among nursing students.

Coping strategies

Even though solutions to the problem of stressors among nursing students are not limited, most scholarly sources recommend virtually identical techniques of pressure alleviation (Pourafzal et al., 2013; Bindu & Munira, 2015). The most popular methods for stress management include practising self-care, meticulous time management, keep track of goals and objectives to realize achievements or shortcomings, cultivate robust social interactions, practising meditation, engage in reflective practice, seeking professional advice from certified counsellors (NHS, 2016) among other techniques. These mechanisms are collectively referred to as stress coping mechanisms. Coping mechanisms can be defined as the combination of various elements such as thought, behaviour, and emotion relative to the stressor that an individual is facing. Coping techniques must not be mistaken for defence mechanisms. Defence mechanisms are involuntary, unique coping mechanisms whereby the subjects are purposeful and conscious (NHS, 2016). Coping mechanisms can be emotion-focused or problem-focused (also known as instrumental). Problems-focused strategies of stress management are typically associated with ways of modifying a problem to step down the stress intensity (Carroll, 2016). Emotion-focused methods of stress mitigation, on the other hand, help the victims of stress manage any feelings of discomfort associated that result from a problem. Besides, coping mechanisms can be characterized as avoidant or active. Active coping methods typically involve the acknowledgement of a stressor and resolute attempts to undermine the stressor, while avoidant methods of stress management include evading the stressor altogether (Carroll, 2016). Some coping mechanisms appear to accomplish de-stressing, but their efficiency is short-lived. The ineffective stress management methods are mostly counterproductive and exert negative impacts, hence the term 'maladaptive coping.' Adaptive coping mechanisms are those methods that ultimately yield a desirable outcome when applied (Adamgerbman, 2017). Emotion-focused coping comprises taking measures to counter the obstructive emotional responses that are associated with stressful situations such as anxiety, depression, fear, frustration, and embarrassment (Stress Management Techniques | Simply Psychology, 2019). Whenever a stressor is beyond the manipulation of an individual, this approach is more pragmatic. Drug therapy falls under this classification because it focuses on the stress-induced arousal and not the stress factor itself. Other emotion-focused stress management methods include distraction, whereby the individual engages in an activity that diverts their attention from the stressor. Emotional disclosure is another emotion-focused technique that involves the expression of intense feelings through writing about gloomy events that occasioned those negative feelings (Cheng, Tsui & Lam, 2015). It is imperative to state that emotional disclosure is an essential part of psychotherapy. Some nursing students turn to spiritual means such as meditation and prayer, which enhance mental calmness (Galbraith et al., 2011). Reflective practice and journaling are also examples of emotion-focused techniques alongside massive food intake, alcohol consumption, drug usage, suppression of negative emotions, and cognitive reappraisal (Stress Management Techniques | Simply Psychology, 2019). A rigorous analysis conducted by Lightsey et al., (2002) uncovers that emotion-based strategies of stress management mostly exhibit ineffectiveness as compared with problem-focused approaches considering the adverse health effects. Therefore, most emotion-focused strategies are maladaptive. Sarafino and colleagues also note that individuals who resorted to destructive techniques such as alcoholism, drug usage, and more food consumption reported adverse health outcomes (Sarafino, 2012). Such strategies are unsustainable because they disregard the root cause of the aetiology of the stress. Besides, other studies indicate that a person who applies avoidance as a way of dealing with stress is more likely to experience stress deterioration. Generally, the emotion-focused approach is discouraged unless the problem is beyond the control of an individual.

Problem-focused stress management strategy targets the stressor in pragmatic ways that neutralize the stress-causing factor, leading to mitigation stress. Examples of problem-focused techniques include time management, cultivating robust social interactions, and problem-solving (Simply Psychology, 2019). This approach is recommended because it tackles the cause of the stress, thereby dealing with the origin of the problem, presenting a reliable solution. Stress management techniques listed here have been proven to deal with high-impact stressors such as discrimination and low self-esteem, as documented by (Pascoe & Richman, 2009). Nonetheless, the problem-focused approach is not always applicable to all stressful situations. For instance, problem-focused techniques have a limited application depending on personalities. In this regard, not everyone can manage or take control of a situation or resolve controllable situations. Optimistic people tend to harbour positive expectations; hence they are more inclined to apply problem-focused stress management strategies, while pessimistic individuals are more likely to prefer emotion-based approaches. Since student nurses cannot avoid the causes of stress whenever they are studying theoretical material in college, they need to devise ways to cope with these causes. If they are unable to manage their stress, their performance, attitude, health, as well as role accomplishment as a nurse are adversely affected. When students are in the nursing university, they are taught about best practices, ethical behaviour, as well as the importance of selflessness to improve their efficiency and enable them to dispense the best service possible (Roxburgh and Michelle et al., 2008). As such, when the students are on placement, they are very eager to conduct themselves prudently, which makes it easy for them to get caught up in the simulation of professional life and neglect their personal needs (Boot et al., 2018). For the student nurses to remain healthy, they must not look at satisfying their needs as something they should engage in occasionally or as a luxury; Instead, they should perceive that taking care of one’s needs is essential, even in all settings. According to Carroll (2016), taking care of their personal needs is a prerequisite that students must implement routinely. The strategy has great potential to alleviate stress when fatigue is a causative factor (Cheng et al. 2015). In a stress-management plan, the ability of an individual to cope with stress is the imperative aspect. Feasible coping strategies limit the frequency of injuries related to stress (Shriver & Scott-Stiles, 2000). Cognitive and behavioural efforts are crucial in the regulation of external and internal pressure. Numerous strategies of coping with stress for nursing students have been proposed. Every student nurse employs either approach in considering the nature of the threat, beliefs, or temporary factors like shifting policy based on feedback type (Bargiel-Matusiewicz et al., 2005). Scientific studies have proven that nursing students employ various coping strategies such as; sharing their experiences with close friends, engaging in sporting activities, ignoring stressful situations, crying, feeling sad/miserable and using alcohol, which may improve their stress situation or exacerbate it (Reeve et al., 2013). Other studies have touted problem-solving as the strategy that most student nurses use while others cite emotion-focused coping methods.

Optimism, transference, and problem-solving are also among the most applied strategies among nursing students. It is imperative to note that the coping methods preferred by different student nurses affect their general health, as well as the quality of care provided they provide. As such, the ability to single out pragmatic coping strategies for nursing students is critical when it comes to early interventions (Chumping et al., 2012). Coping ought to be considered in the context of handling a particular type of stress (Glazer & Gyuark, 2008). Glazer and Gyuark advocate for qualitative studies as a utility to better understand coping strategies. It is undeniable that coping with stress is a phenomenon that depends on context; however, research on the topic in clinical settings has been mostly quantitative. Stress is one of the primary factors that impede any positive outcome for nursing students. The various approaches to countering this counterproductive phenomenon are probably not as effective as they ought to be, which necessitates research undertakings to come up with a more efficient means of countering stress in nursing students. Numerous sources cited in this plan implementation plan indicate that nursing students begin dealing with stress as soon as they are inducted into nursing school. This fact led me to realize there are very few studies, if any, that emphasizes the importance of mitigating stress among nursing students from as early as the first year of learning. During the initial stages of nursing training, most students are fresh from further education stage, and they hardly wield any substantial information about going through nursing, primarily academic wise. To realize this goal, the causes of stress among new students must be identified, and feasible ways to help these individuals subdue or manage the stress factors must be devised. Therefore this submission seeks to find better strategies for managing stress among nursing students. It will seek evidence from various works of literature and primary data from nursing students. The search strategy will include the use of the university's library search to identify works of literature from databases such as EMBASE and CINAHL to select the most recent primary journals. These databases will be selected as they form part sources of fundamental research; they will be ranked based on their originality and efficiency. Several subject titles related to the subject heading will be identified and used in the search process. For instance, the keywords will include; stress management, nursing students, nursing students in placement. It will also be essential to employ Boolean operators such as (and, in) to consolidate the keywords to enable the selection of relevant literature (Coughlan et al., 2013). Peer journals will be identified in the search process. According to Aveyard & Helen (2010), the most recent evidence can be found in journal articles.

Besides, the nursing and midwifery council requires that all nurses should have competence in appreciating the worth of evidence in practice, can understand and evaluate research, relate to appropriate models and results to their work, and ascertain areas that need further investigation (NMC, 2015).

Inclusion and exclusion criteria

The inclusion gauges for this submission include peer-reviewed articles in all forms, i.e., qualitative, quantitative, and mixed methods related to Stress Management among Nursing Students. The second criterion will be sourcing for all articles between the years 2010 to 2020, published in English. Newer sources will ensure that the evidence sourced is relevant and valid with the current times. On the other hand, the exclusion criteria will include abstracts and other pieces of literature that are not connected with the topic under research. This strategy will ensure that the study has logical precision, and also only vital evidence is used. This inclusion and exclusion criteria will be employed, as identified by Burns (2005), to reduce bias.

Main themes

The primary themes in this chapter will be stress in nursing students and stress management in novice and experienced nursing students. In the results, section terms associated with occupational and school settings, including job stress, workloads, among others, will be used. These terminologies are put in the perspective of students' clinical practice, discerning that nursing students maintain a working relationship with the centre.

Limitations of the search

It might not be possible to review all identified, valid literature connected to the topic under study, and this might limit the validity of the research. Besides, because UK research on this topic is limited, therefore various journal articles from other countries will be used, primarily Australian and Spanish since their healthcare is transferable to the UK's (Webb and Roe, 2007). Holland and Rees' (2010) structured critical model for articles will be used in the study. Besides, systematic analysis of meta-analysis studies will also be utilized to conclude the subject matter. According to Holland and Rees, the structured critical framework enables the researcher to identify the strength and weaknesses of a research article. Besides, this model suggests that the approach to appraising a research article for quality is to evaluate its research question as well as its aims and see whether they are stated clearly and also whether their research design is appropriate (Holland & Rees, 2010).

Improvement plan

This section tries to discuss various reasons for the need for interventions and also what will occur as a practice improvement plan progresses. Evidence suggests that most student nurses face academic stress while attending university, and there are no proper measures in place for these individuals to develop coping mechanisms. Some of the most common stressors among students are a feeling of being overwhelmed, time pressures, extreme class assignments, making life decisions, among many others (NHS, 2017). The effects of these stressors affect not only their academic performance but also their mental health (Labrague, 2014). Nursing students are advised to journal their experiences, thoughts, and concerns in an event where they, for instance, find themselves lying awake pondering on activities slated for the day ahead. Documentation of ideas in a journal is a way of getting clearer thinking of the stressors and finding solutions to solve them. Students can also eliminate stress by identifying what improves their mood. Even when students are faring well in nursing school, negative interactions in college have enormous potential to ruin their mood. Furthermore, since the field of nursing is people-centred, a student should understand the factors that contribute positively to their attitude, which is applicable even after graduation. Students are also advised to incorporate mood boosters in their daily routine, which include, doing many of the tasks in groups rather than solo, believe in what they do, among others, to increase optimism. (Robotham & David, 2008). Although stress is majorly retrogressive, it can be a utility if it prompts nursing students who are still in their early stages of training to evaluate how they might improve their situations. Practical stress management approaches are crucial for the nursing career in general. For instance, resilience is one of the attributes of a nursing leader, and it involves the ability to cope with stressors and challenges (Thomas et al., 2016). Therefore, educating and training student nurses on coping mechanisms for stress will enable them to build resilience even as they grow up to be caretakers of people's lives. The primary objective for this submission is to discuss various stressors among nursing student and provide an improvement plan to enable students to develop coping skills to stressors. It focuses majorly on two themes sources of stress and coping strategies. This plan is expected that the result of the implemented change will necessitate an improvement, with students getting the necessary support. It intends to engage approximately two hundred students from the University of Derby, getting their views about stressors and how they manage them.

Implementation

This section will discuss how the improvement plan will be implemented since its inception to culmination. The procedure involves applying a series of workshops with stress management as the subject, with the aim of heightening an individual’s ability to manage stress levels, identify stress symptoms, and coping with stress. This undertaking could assist them when they transition from students to registered nurses (Allen et al., 2017). This process will involve all students novel students (year one) because they are new to the system and haven’t yet familiarised with coping strategies for the various stressors. The first step will include recruiting participants for the study, who will later participate in the training exercise. In this exercise, the author plans on seeking approvals from the administration of the two universities to carry out the study. Upon approval, the author aims to liaise with the lead educators to help in recruiting the participants. The second step involves conducting a pre-analysis of various stress management needs with the identified participants. This step seeks to identify gaps in stress management among nursing students and try to develop strategies that will be taught during the workshops. Besides, information obtained will assist in developing objectives and aims of the entire training sessions. The third stage will involve a two by 2-hour workshops to be conducted by nursing tutors (See appendix for the stress management course). The Early Workshops will run from 1:00 pm - 3:00 pm, and the Late Workshops will run from 3:30 pm - 5:30 pm. The workshops will be interactive and engaging with sufficient time to workshop ideas and thoughts for the participants to learn a lot about stress coping skills. The fourth stage is to conduct a post-analysis by requesting the participants who underwent through the training to narrate their experiences in managing stress. The participants will be asked to fill a post-questionnaire to gather attitudes on their improvement in approaches to managing stress. This undertaking will be done after a semester. A comparison between the two sets of information will be undertaken. According to NICE guidelines, a questionnaire is an effective strategy of examining the knowledge and attitudes of a group of healthcare professionals that are geographically dispersed (NICE, 2014).

To ensure adequate training of the nursing students, the nursing tutors will ensure teamwork among students to support each other and to respect colleague's viewpoints. Ineffective of contributing to one another's progress will be identified as one of the barriers to change. Students who might not wish to participate could be demotivated or have a lack of interest in the process. But this barrier can be overcome by grouping them, making the session short and increasing visual presentations such as videos and questions (Larrabee, 2009). The students will have a feedback and suggestion segment at the end of every discussion, which can be incorporated into the next session. Besides, the sessions will include several themes and aspects to increase their resilience. For instance, new nursing students will be trained on how to formulate reliable study groups to extend their academic knowledge scope. The last stage will be reviewing the processes employed in the course training. The findings of the study stage will dictate the activities to be used in further exercises. Therefore, after examining the outcomes from the questionnaire, more recommendations on the stress management course will be made conditional to the results, whether negative or positive, from the previous cycle. If the students who took part in the training exercise can cope with stress and feel more supported, then the stress management training program will continue with other students. On the other hand, if the results turn to be negative, then further changes would be incorporated in the plan, especially new strategies that would result in positive outcomes.

According to Hallinan et al. (2016), constant reviewing of the implemented changes to acclimatize to the modifications and also to the feedback and involvement for the efficient functioning of the strategies employed.

Methods

The study will collect data from nursing students in the first year. This group will be appropriate because they are 'knowledgeable informants' (Creswell & John, 2011). The perceptions that these students have in their first year at college offer them a basis to compare their experiences in stress management to other students. The researcher will send letters to the facilities to ask permission to undertake the research. Upon approval, they will visit each of the facilities and inform every stakeholder who will be affected by the process of what they will expect. It is typically impractical to study the whole population, especially when using a questionnaire survey (Taherdoost, 2016). Sharma, (2017), describes sampling as an approach that allows researchers infer data about a population based on information of a proportion of the population without involving every character. Reducing the number of participants will save on cost and time, besides it will result in quality data, but needs to be balanced to have a sufficient proportion with sufficient influence to discern a real connection. There are various sampling techniques that can be employed in a study, and they can be divided into two; probability and non-probability sampling (Taherdoost, 2016). Probability sampling involves completing a sampling frame for all qualified participants from the whole population, and this gives each of the individuals an opportunity of being selected. In non-probability sampling, the researcher doesn't have to start with a complete sampling frame, and therefore some characters have no chance of being recruited. Probability sampling technique tends to be more time consuming and costly as compared to non-probability sampling. Consequently this study intends to use non-probability sampling technique more particularly convenience and purposive sampling. Purposive sampling relies on the judgement of the researcher on who should participate in the study, while convenience sampling relies on the convenience and availability of the participants to undertake the survey (Taherdoost, 2016). In this regard, the author will employ a purposive sampling technique first by indicating that only first-year nursing students are eligible to participate in the study. After which, convenience sampling will be applied in the recruitment process.

This submission plans to use quantitative to quantify student’s knowledge and feelings of competence in stress management. A quantitative research technique needs statistical analysis of data collected from the subject under investigation to improve on accurate outcomes and lessen the probability of error (Clay, 2014). Quantitative studies typically focus on subjects previously developed with an existing body of evidence (Shrma, 2017). The study will employ survey questionnaires for data collection from 100 first-year students from the University of Derby. The university is selected because it is one of the institutions known to the researcher which do not offer support programs for stress management.

Research Design

The lead lecturer at the university will be enlisted to assist in sample selection. These administrators are well conversant with the nursing students seeking placement at the institution or are already in deployment. The nursing students will be recruited voluntarily Upon invitation, the participants who will agree to participate will be contacted directly by the researcher. All participants agreeing to participate in the questionnaire will be briefed on details regarding the research's objectives, the needs of the researcher, and the confidentiality clause. For instance, the recruits will be informed that the information they would present will only be used for research purposes. They will again be reminded of the data collection procedure, the purpose of the research, and the anticipated advantages, their rights on withdrawing from the process at any moment. All these procedures are recommended by Creswell & John (2011) since they create a good rapport with the participants and show understanding of the subject under study. The research design intends to provide a suitable framework in a study, according to Leavy, (2017) the major decision in the research design process is the selection of the research approach because it determines how relevant and valid data for a research study will be obtained. This study represents quasi-experimental research because the independent variable –stress management, is manipulated before the dependent variables are measured (Leavy, 2017). Quasi-experimental study removes the directionality problem. However, since the participants in this study are not randomly designated, this design does not reduce the challenge of confounding variables. When it comes to internal validity, quasi-experiments lie between correlational and true experiments (Creswell, 2017). The recruited participants will be asked to fill the pre and post-training questionnaire. Questionnaires are the main tool for collecting primary information because the researcher can frame the kind of questions they want and sample they need. Besides, they are effective in measuring behaviour, perceptions, and intentions of a large population affordably and quickly than other methods (Schratz & Michael, 2019). The first-year students have been selected since it is a formative year with various challenges and stressors. Besides, the first years will be assumed not to have developed any skills for managing stressors. The questionnaire will help in understanding how the participants perceive the topic being studied. Besides, this model will generate outlines and create connections of meaning that will build new knowledge (Clark et al., 2008). Apart from being practical, questionnaire are also less expensive because they can be self-administered without hiring personnel to conduct the research. Moreover, results from a survey can be used to compare and contrast with other studies. Enhancing comparability infers minimising errors due to translation (Taherdoost, 2016). However, a questionnaire might not be valid because some questions might not be answered or ignored by respondents. Besides, too many open-ended questionnaires could result in too much data which can take long to analyse (Creswell, 2017).

The participants will be encouraged to answer as honestly as possible to increase the drawing of valid conclusions from the study (Choe et al., 2005). Every participant will be asked to reply to an identical list of questions of mixed questions to prevent biasness. The questionnaires will be based on a five-item Likert scale. The responses will be itemised using the five-point scale representing one = "strongly disagree" to 5 = "strongly agree." The answers will be summed to give the score of the measures. The recruited will be given a questionnaire protocol three days before answering the questionnaire; this approach will provide them with time to reflect on the answers they will contribute to the questions. Besides, providing the survey protocol ahead of time allows the participants to view the questionnaire and seek any clarification in parts where they seem ambiguous to them. The survey will begin with 'please describe your experience as a nursing student’; this structure will offer the participant the flexibility they need to give their experiences with stress and how they manage it. Most of the questions will be open-ended to allow the respondents to answer freely and openly (Krosnick, Jon, 2018). The questionnaire will be administered in several ways; for instance, for the first lot of recruits identified by the lead lecturer, the researchers will deliver the survey in paper form. This approach will increase engagement between the researchers and participants, including asking questions and receiving immediate feedback about the questionnaire (Choi et al., 2005). For individuals who will be fronted by the participants, the polls will be administered by mail. The respondent's answers will be examined in depth to improve the credibility of the research findings. The answers will be carefully read, and the conclusions tabled for logical analysis and interpretation of the information.

Pilot study

A small-scale pilot study will be done as an approach to developing relevant lines of questions for the research. Besides, the pilot study would help in the procedure of refining data collection procedures (Gentles & Stephen, 2015). According to Baskarada & Sasa (2014), one of the significant attributes of undertaking surveys and other data collection procedures is to ensure efficiency. Money time and efforts must be utilized in the most efficient way to attain success in data collection, especially those that entail a considerable sample. Therefore, conducting a pilot study promotes efficiency by offering an opportunity to identify possible undermining factors and dealing away with them. Specifically, a pilot survey tests the correctness of the instructions available in the document and whether the participants can follow the directions as specified. This process also offers improved information on if the employed type of survey is active in meeting the study’s objectives. The objective of the study was to determine stress management levels among nursing students. The pilot study will recruit ten participants for this study through convenience sampling. Convenience sampling is crucial since it is easy to use, and it allows the researcher to obtain necessary information without undergoing the difficulties of conducting a randomized sample. This technique is also essential in documenting the relationship between various phenomena (Sedgwick & Philip, 2013). The participants to be recruited in this process will be from any year at the university. Characterization of participants makes sure that the results obtained for the operation apply to the entire population that will participate in the actual study (Gentles & Stephen, 2015). The process will be divided into two processes participatory and undeclared studies. The process will opt for a participatory pilot survey first and then an undeclared pilot study later (Bjorner et al., 2010). A participatory research involves informing the participants that they are in a pre-test phase; on the other hand, an undeclared study consists of undertaking a full-scale survey as if it was a real one. Two of the participants will take a participatory study while the other three will take the undeclared pilot study process. In the participatory process, the participants will be asked what they perceive of the questionnaire; then, the researcher will document their comments, suggestions. For instance, one of the major questions will be: Do you think the questions are clear to you? They might also be asked to identify what among the questions are hard to answer. After undertaking a participatory process, then the remaining three participants will conduct the undeclared survey. The two operations will use paper questionnaires rather than online questionnaires because it is simple to administer and control the activities involved for actual results. After obtaining the results of the two surveys, the researcher will then solve the logistical, technical, and other concerns that will be identified after the process. For instance, the questionnaire format could be revised, or the form of the interview can be transformed into an appropriate one. If the errors were minor, then the researcher could execute the extensive scale survey. However, if the errors will be significant, then the researcher will conduct another pilot study to determine whether the errors have been effectively solved.

Notably, if the participants would be more difficult to recruit because of the several formal request procedures involved, then the small-scale pilot studies would not be conducted at all. Instead, some of the questions might be improved during the actual period of administering the questionnaires. For instance, the researcher would ask the participants to seek clarification in whichever questions they might feel are not clear to them.

Review of the survey protocol

Revision of the survey protocol will affect all the items of the questionnaire, such as the purpose of the study, the people who will have access to the information provided by the participants, the respondents' rights and risks, and the period taken to discard the data. Generally, whatever the respondents will perceive as vague and inconsistent with them will be subject to revision.

Data analysis

After the completion of the questionnaires, all questionnaires that will be presented physically to the participants will be collected and analysed in paper form. Online questionnaires will also be received and put ready for analysis. Answers submitted through online spreadsheets will be entered in a summary sheet, and scores will be computed and submitted electronically. For the questionnaires in paper form, the following steps will follow in the data analysis process. Preparation of a simple grid to collect and organize data delivered in the questionnaires. A simple coding system will be developed for questions and the model that answers take. This action will simplify the data analysis process greatly (Stuckey & Heather, 2014). Coding for closed questions will be easy since the answers will be ranked numerically, and the code will use the same scale. However, evaluating open-ended questions will require organizing them into a set of general classes, which can then be coded. In this regard, data will be entered on a grid; the percentage of the participants answering each category of every question will be calculated.

Preparation of a grid

Since there will be quite a large number of questionnaires, it will be easier to interpret the results of the survey when they are transferred into a single grid (Check table 1).

Coding data

All closed questions will contain answers on a scale of 1 to 5, and these are the numbers that will be entered directly into the grid. For the open-ended questions, they will need to be translated into a numerical scale, after which they can be entered into the grid as well. For instance, the first question will ask the students to note whether they are male or female. Value 1 will be ascribed to every male response and 0 for every female response. Ascribing values for every response helps in computing summary statistics and essential when trying to establish the relationship between variables (St. Pierre et al., 2014). Besides, making an entry for all questions data analysis will be easy, and the results will be accurate. All the answers will be read and will be grouped into meaningful categories. There will be a category known as 'other' for responses that the author cannot categorize implicitly.

Data evaluation

The proportion of respondents in every category will be calculated; the group for didn't know or didn't answer will be identified because it offers crucial information on the strength of feeling over a specific question. The results will then be used to compute mean scores for group questions. The mean score will then be used as the overall stress levels and management levels of students. This might not be a legitimate approach since it assumes that the author will be working on an evenly spaced scale; for instance, 'very poor' means twice as bad as 'poor' (Stuckey & Heather, 2015). Scores will be added for related questions to derive the index of stress management levels among nursing students. Caution will be taken in designing the questionnaires; otherwise, this approach will be inappropriate. In this regard, every question will be considered as relevant and of equal importance.

Establishing Trustworthiness

Any qualitative research is often criticized for its reliability; therefore, such studies should always be open for criticism and also further research. Generally, reliability refers to the level in which the research findings of a study can be replicated in other settings (Noble et al., 2015). According to Sarantakos & Sotirios (2012), two significant questions should be addressed in social research, and the first one is; is data valid? And the second, Are the research methods reliable? These are the fundamental questions that determine whether research is credible and reliable. In efforts to increase the trustworthiness of this study, the researcher will employ approaches as recommended by Williams et al. (2009). In this regard, the researcher will reduce threats to credibility by triangulating data. Triangulation, in this case, means using a cross-verification of two or more sources of data in a study (Noble et al., 2015). The main objective of this drive is to facilitate data validation. Therefore this study will use mixed research methods such as surveys and systematic reviews of peer-reviewed articles to collect data on the same topic. Another aspect that increases the study’s trustworthiness is dependability (also known as reliability). Dependability refers to the consistency of the research procedures and findings. Therefore, to improve the study's credibility, the researcher will provide an audit trail by outlining how data will be collected, how groupings will be done, and the procedure to be followed to arrive at conclusions (Williams et al., 2009). The research procedures will be properly documented to enable an outsider to develop an audit and critique the processes involved. There will be the usage of excellent, rich, and thick descriptions of findings to enable other researchers to make quick decisions regarding the transferability of this research. This aspect is referred to as external validity, whereby the research findings on the sample population can be applied to a population at large (Roberts et al., 2006). The researcher will try to reduce control for bias during the study to ensure objectivity. In this regard, constant comparison of data will be undertaken both through surveys and secondary sources, searching for works of literature for samples of the topic under discussion to get several viewpoints on the issue. Lastly, the researcher will be open to both negative and positive instances of the subject under discussion to reduce bias in the study. There will be continuous checking and rechecking of data collected, and this will ensure the conformability aspect of an investigation, as highlighted by Sarantakos & Sotirios, (2012). Data triangulation is of critical significance in ensuring the trustworthiness of a study. As the research unfolds and specific pieces of information become identified, appropriate steps will be taken to validate every piece of information against at least one other source — for instance, survey results (first source) and systematic review findings (second source). Employing a second source will guarantee a more precise, accurate, and wide-ranging and objective results (Noble et al., 2015). Therefore, for this research, a survey and review of secondary sources will be compared to ensure trustworthiness.

Ethics

Voluntary Participation and Consent

All participants should be willing to participate in a study voluntarily. Therefore, any need for persuasion or deception in efforts to achieve individual trust on the side of the researcher will not be acceptable. Recruitment for the participant will begin by asking the lead nurses to assist in enlisting potential participants for the study. Every invitation made will be accompanied by a consent form that will act as an agreement of trust between the researcher and the participants.

Sampling

This is the first step in the research design of a study. The researcher will explain why they have selected a specific group to participate in the study. Besides, they will also tell why they will leave out a specific group. In this case, all participants would be presumed to be adults (18 years and above), and so there will be no need for parental permission. However, in case of a participant who has special needs, permission from the guardian will be necessary along with consent from them.

Risk of Harm

The researcher will do everything in their power to protect the participants. Therefore, they will focus on the risk to benefit ratio before undertaking the study. If the conceived risks outweigh the benefits, then the study will be abandoned or redesigned. However, an evaluation of the risks will happen right from the start of the study until the end. Some of the possible risks of harm could include psychological, legal, and economical, among others.

Respect for anonymity and confidentiality

The aspect of privacy is one of the crucial elements of research. If a researcher cannot ensure confidentiality, then they can at least guarantee anonymity. Confidentiality refers to the management of private information by the researcher to protect the participant's identity. Besides, the participants have the freedom of withholding or providing as much information they wish to decide on (Kaiser & Karen, 2009). Therefore the researcher is supposed to maintain the confidentiality that exceeds loyalty. However, Wiles, Rose, et al. (2008) identifies an ethical dilemma where confidentiality could be broken to satisfy the moral obligation of protecting society. In this regard, the utilitarian theory focuses on the best interest of all stakeholders involved and the greater good of the society. The approach emphasizes that confidentiality could be broken when the happiness of society is of greater importance. Conversely, the deontological model argues that the moral obligation of ensuring confidentiality matters more than the happiness of society. However, when a researcher acts in line with the deontological arguments, then they have not protected society's interests. Another concern is when a researcher reports confidential information to courts, causing a moral dilemma. In this case, it is safe to assume that moral obligation and personal ethos supersede the legal requirement of the researcher. A researcher faces several challenges when it comes to maintaining confidentiality while researching because conduct is personal. In cases where the sample is small, and reports identify direct quotations of the participants, Kaiser & Karen, (2009) argue that it is wise for the researcher to use pseudonyms and distort categorizing of details participants in case of interviews during transcription of the tapes. However, Kaiser & Karen (2009) perceive that in cases where information is complex or extremely confidential, the researcher should seek a certificate from relevant authorities to ensure the privacy of the respondents, especially in researches where the researchers are compelled to disclose the information by legal jurisdiction. One of the Economic and Social Research Council's ethics principles during research is that the confidentiality of information provided by the respondents should be protected whatsoever (Fielding et al., 2008). Nevertheless, the principle highlights that sometimes confidentiality can be restricted. For instance, in situations where the participant is exposed to a risk of harm, then information can be disclosed to protect them. Therefore in this study, the researcher will always bear in mind all social and psychological implications that accrue to a breach of confidentiality might have on participants. The researcher will have to inform the participants of their rights and employ all possible coding mechanisms that could be appropriate to ensure confidentiality is maintained.

Skills of the researcher

According to Noble et al. (2015), there are three most fundamental aspects of research, which include the proficiency of the researcher, meticulous research design, and sensible findings. Therefore, the researcher will ensure that they possess the necessary skills and knowledge for a particular study. They will also make sure they are aware of the limits of individual competence in the study process. Any gap in knowledge will be clearly stated. In case the researcher meets an area where they don't understand, they will work under qualified personnel and later to be reviewed by the ethics committee. In the systematic review, the following ethical considerations will be implemented. Plagiarism- plagiarism is regarded as stealing and is unethical; it includes knowingly using a person's content without giving them credit. Therefore, the researcher will ensure that every material and ideas used in this study are cited and referenced accordingly. Fabrication- There will be no duplicate submissions nor even fabrication of content. For instance, the author will report results as they will be. This action aims at showing a representation of the original findings. The author will also make sure that past research is not suppressed to open a concept that they deem fit. Both negative and positive references will be used to ensure no bias. Unbiased pieces of literature- the author will ensure that they remain unbiased to gender, previous researches, among other factors. Any conflict of interest while undertaking the study will be addressed. Despite all these ethical concerns, what is superior is a careful selection of the method of data collection that ensures validity and dependability. These are the significant necessities that are needed in any type of research. The choice is contingent on the objective of the study. Besides, the research will involve humans, and all the above ethical considerations will be taken into account.

Dissemination

Dingli & Sandra (2013) describe the dissemination of research findings as a planned procedure of conveying the research findings to a target audience and even where appropriate communicating and engaging in a broader policy to facilitate research approval and implementation. In simple terms, this concept involves meticulously planning, thoughtful deliberation of the target audience, and interacting with the audiences. Before sharing the research, the author will ensure that the work has undergone review by experts to meet the standards and outlooks in the professional field. This action will seek to assess the work and ensure that the conclusions presented follow a logical deduction from the data presented. This process also identifies the threats to validity and determines whether the analysis of literature is realistic and systematic.

Key audiences

Successfully disseminating research findings needs identifying who are the right audiences, where the audience is located, and how to reach them (Titler & Marita, 2007). In considering the right audience, it is crucial to think about who might be interested in the research work. Also, the audience might include those who might not express enthusiastic interest but may still benefit from the information present in the research (Dingli & Sandra, 2013). Therefore, the research findings of this study are likely to benefit a lot of people, and they include.' The respondents and nursing students in universities – it will be essential to share the research findings to the participants and also other people who share similar characteristics or interests in the subject under research, including nursing teachers. The information will assist them in noting the changes they have made after undergoing an improvement plan. They will also identify areas that need improvement to ensure they manage stress effectively. Scholars and experts- other researchers studying similar topics would be another perfect audience for the research findings. By disseminating information to these audiences, it will assist them in developing their research works and also offering criticism that is healthy to research work. Organizations and policymakers- institutions that work in the nursing field, including hospitals where the nursing students are placed, nursing schools, and all engaged members of society, could represent a potential audience for the research findings. The general public- whereas there are several informal audiences for research findings, the general public is also a crucial audience for research findings. According to Dingli & Sandra (2013), research is an item under social work, and it involves working in capacities in the social world that the public might not wish to see. Part of the researcher's work is to shine a light on aspects that raise the consciousness of society as a whole. All the stakeholders mentioned above represent an audience that has an interest in the research work. However, it is essential to look outside the discipline and share it with everyone so that they can also use it in their fields where necessary (Titler & Marita, 2007).

Methods of Dissemination

The method of disseminating the research findings will depend on the audience. Therefore, the process will vary the means of spreading the information with keen consideration on the effectiveness of the method. According to Huberman & Michael (2012), the dissemination strategy should be in line with the norms and attitudes of the audience. For instance, in a scholarly journal, the author outlines submission guidelines that define the conditions for disseminating their work via a specified journal. Therefore, this research will employ various strategies to reach particular audiences. They include. Submission in an online journal database- this method will primarily target the scholars, experts, and all other audiences that might need the information for specific purposes. Providing the results both in print and electronically would meet the various demands of these audiences. It will also be crucial to subscribe to the websites to stay current on the literature on the subject topic. The research findings will be rephrased; such as 'Journal of Stress Management among Nursing Students and those in Placement' this way, the work will be shared widely among other scholars who might be interested in studying the topic. Formal presentations- another method to disseminate research findings will be formal presentations. This is a strategy aimed at creating an engaging, understandable interaction with the audience. In this regard, this approach seeks to inform people about information that is relevant to their lives and practice, which is why it is rigorous and follows a strict format. Therefore, the researcher will ensure the research findings are relevant to the practice, especially to the lives of the audience. And so, a formal presentation will be a perfect strategy to disseminate research findings to participants, nursing students, and those who are in placement. Since these audiences have an interest in the results, their most significant concern will be how they apply the information in their daily life and practice. The audience is also knowledgeable about the subject and so presenting conclusions with modesty needed by a social scientist will be essential.

Disseminating to the public

The author will disseminate information to the public using several mediums; however, the major ones include popular media outlets to reach a wider audience. The researcher will be cautious about overstating the extent of certainty they have in the conclusions. This approach aims at avoiding misleading the public audience on the result. Also, the author will review the journalistic standards of the media outlet by evaluating their previous work to determine the extent of control over the final product. Secondly, the author will inform the general public about the research findings using reports. However, the reports to be consumed by the public differ widely as compared with reports for scholarly consumption. Therefore, the author will tailor the information to suit the needs of the society, for instance, the public will want to hear about how the research findings will affect them rather than how it will affect other groups. Lastly, newspaper editorials will also be an excellent platform to share information with the general public.

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