ARTICLES

 

Coping Styles and Sources of Stress of Undergraduate Health Science Students: An Integrative Review

 

 

Robyn Marcella Henderson^{I, *, **}; Odell Chetty^{II, **}; Thavanesi Gurayah^III

^IB. OT (UKZN). https://orcid.org/0000-0003-0806-6541; Community service occupational therapist, Appelsbosch Hospital, KwaZulu-Natal, Durban, South Africa
^IIB. OT (UKZN). https://orcid.org/0000-0002-2594-3166; Community service occupational therapist, Addington Hospital, KwaZulu-Natal, Durban, South Africa
^IIIB. OT (UDW); M. OT (UDW). https://orcid.org/0000-0001-9005-6355; Lecturer, Occupational Therapy Department, School of Health Sciences, University of KwaZulu-Natal, Westville Campus, KwaZulu-Natal, Durban, South Africa

 

 

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ABSTRACT

METHOD: Background and aim: Tertiary education provides many personal and social benefits. However, students, particularly those from professional and health science disciplines are known to face significantly greater stress throughout their undergraduate degrees. In this integrative review sources of stress for students and the strategies they use to cope with the stress are explored. : Various databases were searched using common key phrases such as "stressors among undergraduate health science students" and "coping mechanisms utilised by undergraduate health science students". Thirty-three articles were selected based on predetermined inclusion and exclusion criteria. The content in the articles were analysed to identify themes
RESULTS: Academic stress was the primary source of stress for health science students. Other sources of stress included interpersonal interactions and clinical training. Students primarily used problem-focused strategies to cope with stress. Other strategies included avoidance and the use of social support networks
CONCLUSION: Health science students experience stress from academic tasks, interpersonal stress and stresses emanating from clinical training. They utilize problem-focused coping strategies, as well as avoidance and seeking social support when faced with stressful situations. Students would benefit from regular screening for stress-related conditions, and interventions to teach them more adaptive ways to deal with stress

Keywords: stressors, coping strategies, health science students, workload, student support.

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INTRODUCTION

Higher education is essential for both personal success and economic growth. Tertiary education provides social benefits such as the acquisition of advanced knowledge, increased employability and financial stability¹. However, successful graduation is a prerequisite for these benefits. Challenges to academic success include the complexity, number and timing of assessment tasks, and stress associated with intense studying at a higher education institution

Fears concerning the future, leaving behind friends and family, and having a poor work-life balance all take a toll on the mental health of university students². This was confirmed by Makoni³, who stated that mental health remains a global concern for university students, as psychological distress impacts negatively on academic performance. Stressful factors experienced by students include rigid course structures, insufficient support systems, inadequate finances and conflicting role demands, due to either childrearing, caring for an elderly family member or part-time employment². Moreover, many students are academically unprepared for higher education, as many are first generation students, who may lack the social capital to succeed⁴. This is reflected in their poor academic performance such as high failure and dropout rates, and lengthy throughput among others⁵.

This article is based on a review that was conducted by UKZN undergraduate students for the fulfilment of a bachelor's degree in Occupational Therapy. This review was underpinned by the following questions:

1. What are the sources of stress among undergraduate health science students?

2. What strategies do students use to cope with stress?

 

METHOD

An integrative review of the literature was conducted to understand the sources of stress, as well as the coping mechanisms utilised by undergraduate health science students. This method allowed for the inclusion of different types of studies for a holistic understanding of the research phenomenon⁶. This review was granted exemption from ethics, based on the pandemic, by the University of KwaZulu-Natal. The protocol reference number 00005806 was issued in response to the protocol submitted on 31 March 2020.

Inclusion criteria:

• Articles published between 2000-2020

• Articles on undergraduate health science students.

• All articles were published in English and had to be full text.

Exclusion criteria:

• Articles involving medical students were excluded from the review as they are exposed to different stressors, and the demands and duration of their degree was different to that of other health science disciplines.

• Articles on postgraduate health science students were excluded as they may be exposed to different stressors, and cope differently.

Review process

The review process was done in phases. The following health databases were searched: Microsoft academic, Refseek, Catalogue search, SagePub, SciELO, Semantic Scholar, Science Direct, Google Scholar, Pubmed, Ebscohost and Medline were used. Pubmed and Medline were searched separately. The following descriptors and Boolean phrases were used as key phrases:

• undergraduate health science students,

• undergraduate occupational therapy students,

• coping mechanisms utilised by undergraduate health science students, OR undergraduate occupational therapy students,

• stressors among undergraduate health science students, OR undergraduate occupational therapy students

• AND sources of stress in undergraduate health science students OR undergraduate occupational therapy students.

The initial searches yielded 60 studies, and the title and abstracts were read in July 2020. The final sample consisted of 33 articles that met the inclusion criteria. The information to be extracted from the studies were defined and categorized, and the full-text articles were read. Data analysis entailed creating a table and extracting the information from all articles into sources of stress and coping strategies. Information was further broken down into themes such as academic, personal, environmental factors and other stressors, as well as adaptive and maladaptive coping strategies. Once all the information was extracted, the themes were constituted, reviewed, and refined, and a flow chart created. The review process is illustrated in Figure 1 (below).

 

 

RESULTS

Twenty five of the 33 studies were quantitative, six were qualitative, and two were systemic reviews. The studies were conducted in various countries including South Africa, Nigeria, Saudi Arabia, the United Kingdom, the United States of America, and Australia. The studies were focused on the perspectives of occupational therapy, physiotherapy, dental therapy, speech pathology, pharmacy, and nursing students. The articles included in this review are presented in Table I (p31), which are organized according to the numerical order of references.

The findings are presented according to the sources of stress and coping strategies utilized by students.

Sources of stress

Three major sources of stress were identified, which included academic activities, interpersonal/social interactions, and clinical training. Several studies identified academic demands as the most significant source of stress for health science students^7-9. Students described examinations and a high workload as the major factors contributing to academic stress^10-12. Interpersonal or social stressors with family and peers were cited in 15 studies^7,11,13-25. In another study conducted in Saudi Arabia, nursing students identified relationships with hospital staff to be a source of stress²⁶.

Stress from clinical training was emphasised by 13 out of the 33 studies^{7,13,17,18,20,25-32}. Poorly staffed clinical departments, fast-paced wards and initial clinical placements were all factors contributing towards the stress of students²⁸. High level patient care was also a prevalent stress factor amongst nursing students^13,17,20. Other stressors that were reported less frequently included personal issues, financial concerns, environmental factors, psychosocial issues, and lack of students' professional skills. Personal stressors consisted primarily of students being stressed about their personal health-related conditions and illnesses⁷.

Financial issues were cited in a study by Gibbons, Dempster and Moutray²⁸, where students revealed that they had to work part-time during their undergraduate studies to support themselves. Environmental factors cited as stress inducing included noisy living environments¹³. In terms of psychosocial stressors, final year physiotherapy students described the suffering and death of their patients as a traumatic experience³⁹. Another study revealed that high parental expectations and decreased time to participate in leisure activities contributed to the students' psychosocial stress¹⁰.

Lack of professional knowledge was reported as a source of stress in six out of the 33 studies^{13,17,20,23,25,27}. Students felt that they lacked the necessary skills, and that clinical training was not always sufficient⁴⁰. Other stressors identified in this review were concerns about postgraduate opportunities and career choices⁷. The frequency with which the stressors were identified in the reviewed studies is illustrated in Figure 2.

 

 

Strategies used by students to cope with stress

Students used a variety of strategies to help them cope with stress. Problem-focused coping was identified as one of the most used coping strategies^14,20,25. Avoidance was another commonly used strategy, which involved students waiting for others to solve their problems, or avoiding teachers, but this approach led to difficulties in clinical training³³. Other negative coping strategies that were not health promoting was avoidance (17%), transference (11%) and substance use by 2% of the sample.

Students used social support networks as a strategy for coping, as indicated in eight of the 33 studies^{14,16,18,21,24,29,33,39}. The frequency with which various coping strategies were used by students in the reviewed studies can be seen in Figure 3.

 

 

DISCUSSION

Health science students experience significantly higher levels of stress as compared to students in other disciplines⁴¹. Academic related stress was most prevalent amongst health science students^7-9 and appeared to increase over the four-year occupational therapy course, with final year students perceiving it to be the greatest source of stress¹². Examinations and an increased workload were most significant^10-12, which was attributed to students' poor time management³⁴. This was reiterated by Mohamadkhani et al ⁴²who stated that efficient time management skills were an important predictor for academic performance, reduced stress levels and increased productivity⁴².

Clinical training was also identified as a source of stress²⁸; due to understaffed clinical settings, high turnover in wards and problematic clinical placements. Garber et al.⁷described fieldwork rotations to be stressful for pharmacy students, who were concerned about their performance in these experiential rotations. Negative relationships with faculty members were identified as one of the key social stressors⁷. A poor relationship with staff can result in decreased academic performance, as students find it difficult to approach lecturers or clinical supervisors. Social stress was cited in Gomathi et al.³⁴, who reported that competitive relationships amongst peers was stressful. These competitive interpersonal relationships have been found to negatively impact on students' available support systems. Family conflicts were also found to compound the stress experienced by students, due to a negative impact on the students' available support networks²¹.

Gomathi et al.³⁴, reported that the main psychosocial stressors experienced by students were high parental expectations, lack of adequate leisure time, and anxiety about the future, which centred about future unemployment. Psychosocial stresses of students included difficulties in processing the death or suffering of their patients³⁹. Peters et al⁴³, suggested that health providers are constantly exposed to the death and suffering of their clients, which can serve as a subconscious reminder of their own mortality. Students' health-related conditions were also stress inducing^7,13. Students with chronic illnesses, or those who had surgeries found it difficult to manage these additional stressors⁷. Binge eating disorders and obesity were prevalent in first generation students⁴⁴. These findings were in stark contrast to what has been reported in developing countries, such as South Africa, where many students presented with food insecurity and malnutrition⁴⁵. Dominguez-Whitehead⁴⁵ highlighted that South African university students were subjected to food insecurity because of limited funds.

Environmental factors such as noisy environments and the climate within the university and clinical settings were also stress inducing. Servilha and Delatti⁴⁶, reported that increased noise levels were a major stressor for undergraduate health science students, which impacted their studies negatively. Financial stress was another source of stress identified within this integrative review. In one of the studies, it was found that students needed to secure part-time employment to alleviate their financial burdens²⁸. University students with financial stress were likely to present with decreased academic performance, as they struggled to balance work and completing academic tasks⁴⁷. This continues to be a problem particularly in developing countries, including South Africa, with many students on financial aid. A lack of professional knowledge was the least reported stressor within this integrative review. These students felt that clinical training was inadequate, and that they continued to lack the necessary clinical skills²³.

Coping strategies of health science students

Students used a variety of coping strategies, including problem focused coping and emotion focused coping. It was found that students with high levels of resilience and optimism tended to respond to stress with adaptive coping strategies, such as task-oriented and active coping, whilst those with high levels of pessimism were likely to use maladaptive strategies, such as disengagement, denial, and venting of emotions. Some of the adaptive strategies included remaining positive and using social support. Other negative coping strategies included avoidance, transference, and substance use to cope with stress.

As can be seen in Figure 3, health science students were more likely to utilize problem-focused coping (20%)^{14,17,20,24-27,34,35,36,41}, in contrast to emotional-focused coping (13%)^{14,16,24,34,35,37,39}. Problem focused coping involves taking control of the stressor by either seeking information or assistance in handling the situation, whereas emotional focused coping included avoidance(l7%)^{17,24,25,27,29,33,34,35,36} and seeking social support^{14,16,18,21,24,29,33,35} (15%). Govender et al¹⁴ found that only 2% of occupational therapy students at the University of KwaZulu-Natal between the first and fourth year of study used problem-focused coping¹³. This strategy consisted of identifying, planning, analysing potential solutions and taking the necessary actions to solve the problem⁴⁸. Other studies revealed that health science students employed a range of problem-focused coping strategies such as "managing their time, seeking information and sport and recreational activities, or they employ emotion-focused strategies such as tension reduction strategies, such as exercising, balanced diet, getting enough sleep, and engaging in constructive leisure activities"¹⁴.

Adaptive coping strategies

Remaining positive was cited in 11 out of the 33 studies included in this integrative review1^{4,17,20,24-27,34,35,36,39}. Students were found to adopt a positive attitude and mind-set in response to stressful events, confirming the use of hopefulness and optimism as a coping style³⁶. A positive mind-set is likely to prevent students from resorting to helpless coping styles. Students were reported to be engaged in problem-focused methods of coping where they actively sought ways to cope with different stressors. Coping approaches included the development of solutions to their problems, and the seeking of assistance from student support services²⁶. Another adaptive coping style identified was seeking social support. Support from family and friends is crucial in enabling a student to successfully integrate into university life, and a poor support network is a strong predictor of mental distress³⁸. This approach entailed students talking about their problems with family and friends⁴⁸. One study identified 61.7% of nursing students from a cohort of 1324 students who used social support as a means of coping¹⁷.

Emotion-focused coping was cited in seven out of the 33 articles^{14,16,24,34,35,37,39}, where the individual tried to minimise the stressor, and they felt better, but the problem remained unsolved. Other strategies used by students included remaining positive, transference, and other non-specific methods, such as remaining positive or optimistic,^17,27 and substance use.

Maladaptive coping strategies

Students who engaged in avoidance behaviours often participated in activities such as procrastination, substance use and playing video games. These students were unlikely to identify the positive aspects of a situation²⁴, which indicated a negative worldview and tendency to utilise avoidant coping styles. McCombie et al²¹postulated that some students used substance use as a coping strategy. Problematic family relationships resulted in a lack of social support, resulting in the increased tendency to use substances. With emotion-focused coping, the stressor is not analysed or resolved, but rather indirectly managed, and may include maladaptive coping strategies, such as substance use, avoidance, or transference, self-blame, denial, minimisation, sleeping, eating, wishful thinking and keeping to oneself.

 

LIMITATIONS

The limitation in this study was that the researchers were undergraduate students and novice researchers. This could have affected the analysis and information extracted during the integrative review. However, having the project supervised by a more experienced researcher mitigated this limitation.

 

RECOMMENDATIONS

Based on the researchers' analysis, the following recommendations are made:

• Health science and other professional degrees are associated with an increased academic workload, due to the clinical training component. Therefore, there is a need for health science disciplines to review their course structures, and the number and timing of assessments, to reduce the stress on students.

• Interventions to support students should be emphasised for first year orientation programmes. Thereafter student support services could send out electronic stress questionnaires to students, which could be conducted biannually, at the beginning and end of the academic year, allowing support services to screen for any students who may be struggling, and ensure timely support, nuanced to the students' needs³⁹. Students who experienced the death of a patient can be referred to a psychologist or student counsellor to assist them in coping with this loss. Research has shown that students do experience stress because of their patients' suffering and death⁴⁹.

Some believe that academic support should be compulsory for health science students, who are often reluctant to attend sessions voluntarily⁵⁰. Moreover, it is recommended that student support services must address the academic and emotional needs of students, and support must be nuanced to the students' needs.

• Workshops aimed at addressing budgeting skills would be useful in assisting students to better manage their finances and reduce financial stress.

• The clinical supervisor-student bond may be strengthened during annual workshops for supervisors to ensure students are well supported during their fieldwork blocks. King, Edlington and Williams⁵¹, suggested that both the student and the clinical supervisor require training to ensure effective clinical supervision.

 

CONCLUSION

The purpose of this integrative review was to determine the sources of stress for health science students in undergraduate programmes, and strategies that they used to cope with stress as reported in international published peer reviewed articles. The sources of stress included academic demands, social and personal factors, financial worries, and stress as a result of clinical training. Other stress-inducing factors included environmental influences, psychosocial factors, and feelings of inadequacy in relation to professional knowledge. Most students reported the use of problem-focused coping in response to increased stress, while others used maladaptive coping styles, such as substance use and other avoidant behaviours. The multitude of stressors and maladaptive coping necessitates the need for support to be timeously accessed by students. The implementation of online semester check-ins would be beneficial in allowing support services to identify students requiring additional support. Students' mental health are predictors for how well they will cope in tertiary education, and specifically with the demands of the health science programmes. It is imperative they access timely support, nuanced to their academic and personal needs.

 

AUTHOR CONTRIBUTIONS

Odell Chetty and Robyn Henderson conducted the initial article search, information extraction, data analysis, writing, editing and submission of the article. Thavanesi Gurayah conceptualised and supervised the project and edited the final manuscript.

Acknowledgements

The authors wish to acknowledge the other members of their research team Lerato Xulu, Nelly Zulu, Zama Mzobe and Nqobile Mhlope who assisted in conducting the review.

 

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* Corresponding Author: Robyn Henderson. Email address: robynhenderson1404@gmail.com
** Undergraduate students at the time of the study