Academic Stress among Nursing Students in a Private University at Puerto Rico, and Its Association with Their Academic Performance

Background: Nursing programs have distinguished themselves for being rigorous. The college experience emerges with new challenges and demands that require adaptation in order to cope with academic stress. Situation that could lead to a non adaptive institutional environment. Objective: The purpose of this research was to determine and analyze possible repercussions of academic stress in nursing students in a Puerto Rican private university and how it affects academic performance in students. Materials and Methods: The selected methodology is a cross-sectional study. The simple random sample was comprised of 168 nursing students who were enrolled in associate degree (29.2%) and bachelor’s degree programs in nursing (70.8%). Data was collected through standardized Academic Stress (CEA, by its acronym in Spanish). Results: The study shows that academic stressors are correlated with the grade point average. In addition, correlation between academic stress and the performance rate was found, es pecially in terms of the difficulty to approve enrolled credits. Conclusions: Nursing students suffer from stress regardless their academic degree. Academic stress affects academic performance of students despite their use of management strategies.


Introduction
In recent years, there has been a growing interest in researching the implications Nursing students in Puerto Rico are not exempt from suffering academic stress. The nursing profession in the island of Puerto Rico faces constant challenges that stem, in part from state (Puerto Rico) and national (United States) requirements which regulate the nursing profession, a situation which entails significant curricular changes. The learning environment is a challenge that demands many hours of study and clinical practice since it is to be assessed by the United States national standards. Therefore, the required teaching standards are rigorous, plus the academic level of competitiveness required of the students is high. It is for this reason that nursing students in Puerto Rico become an academic stress risk prone population. Due to this fact, it is necessary to conduct research on this phenomenon.
According to the data obtained from the Consejo de Educacion Superior de Puerto Rico [10], less than 40% of the students obtain their degree, and over 50% drop out of college within the first year. As a preventive measure, in its assistance services, the Puerto Rican private university where the study was conducted, and from which the nursing students' sample was selected, includes a first-year supervision from the Dean of Student Affairs to help students cope within their first year of studies. The Nursing program that belongs to the university, reports a retention rate of 67% [11]. Nonetheless, the graduation rate reports a low percentage, under 27%, which supposes that a clear majority of students endure diverse personal and other types of situations that refrain them from completing their academic goals. This might be due to nursing student difficulties on managing academic stress [12] [13] [14] [15] [16], a reason by which it is necessary to conduct rigorous research on academic stress.
The purpose for conducting this research was to determine and analyze possible repercussions of academic stress in nursing students in a Puerto Rican private university and how it affects academic performance in students. Early detection of academic stress in nursing students is a priority endeavor, given the possibility to successfully confront it by using strategies that lessen or eradicate this factor. Therefore, the results of this study, besides filling a scientific and theoretical gap about managing academic stress, will create a foundation upon which academic stress managing techniques can be taught and learned effective-

Population and Sample
The population of the study was composed of nursing students enrolled to achieve an associate or baccalaureate degrees, and completing either their first, second, third or fourth year of studies, at a private university located in the Center-East zone of Puerto Rico. The students under study belonged to the School of Health Sciences of the mentioned institution. The sample was selected from this student population. A simple random sampling was used, from a population of 610 students at the university campus [11]. The sample, calculated by the Java operation system with a margin of error of 5% and a prevalence of 17%, resulted in a total sample of 170 individuals with a replacement rate of 50%. The following four inclusion criteria were established: 1) To be enrolled in the nursing program, 2) To be a full time or part time student in the nursing program, 3) To participate voluntarily in the study, and 4) to submit a written consent to gain access to their personal academic record.

Instrument
The instrument used to measure the variable academic stress was the questionnaire: Cuestionario de Estrés Académico (Academic Stress Questionnaire-CEA), originally developed by Cabanach, Valle, Rodríguez & Piñeiro [17]. The questionnaire was validated in a student population in Spain and contains three subscales: academic stressors subscale (E-CEA); stress response subscale (R-CEA); and coping strategies subscale (A-CEA). Responses to each item are registered in a five-point scale that ranges from: "Never" (1), to "Always" (5).

Subscale's Descriptions
A description of each CEA subscale is presented below: Academic stressors subscale (E-CEA)-Consists of 53 items that measure different situations and/or circumstances that belong to the academic context that, in some measure, can generate pressure in the student in a way that he or she perceives it as a danger or as a threat to his or her wellbeing.
Stress response subscale (R-CEA)-Consists of 22 items that pretend to measure symptoms related to physical, behavioral, and cognitive factors linked to academic stress.
Coping strategies subscale (A-CEA)-Consists of 23 items that pretend to measure behavioral and cognitive ways of coping with academic stress.

Instrument Translation, Transcultural Adaptation, and Validation
The Academic Stress Questionnaire (CEA) was modified and adapted to ensure it complies with reliability and validity criteria needed to assess academic stress in Puerto Rican nursing students. A α global of 0.80 and coefficients that fluctuate between 0.750 and 0.860 in the subscales were obtained. These coefficients were similar to the Alpha coefficients obtained in Cabanach study [17]. The Puerto Rican modified questionnaire also showed compliance with the reliability and validity requirements to be used in the assessment of academic stress in nursing students in Puerto Rico.
The academic performance of participating nursing students was measured in relation to their academic grade point average, and the number of enrolled and approved credits used to calculate the rate of return; for each participant in the study, using the equation: [(Credits Approved/Credits Enrolled) × 100]. For this sample, the rate of return average score was 83.89, which, by being near to the maximum score of 100, indicates a good rate of return. It indicates a high efficiency degree of the student and his or her academic activity within the institution.

Procedures
This research was approved and endorsed by the Board of Institutional Review (IRB), at the Ana G. Mendez University System (SUAGM). The researcher applied and obtained written permission from the Vice-chancellor and the Nursing Program Coordinator where the study took place. A teaching nursing program faculty meeting was arranged to present the intended study and its purpose.
Subsequently, the researcher visited each classroom to administer the questionnaire to the selected sample. Each completed questionnaire was put in an unidentified envelope and sealed by the participant, who proceeded him-/herself to place it inside an urn before exiting the classroom.

Statistical Analysis
The SPSS® 20 program was used to analyze the data input. An exploratory factorial analysis was performed, along with a reliability analysis to verify the validity of the instrument in terms of its adapted version to Puerto Rican nursing students taking part in the study. A descriptive analysis was also performed, using the averages from central tendency and dispersion measures, as well as frequencies and percentages. To correlate the variables involved, the Pearson correlation coefficient was used, considering a significance value of p < 0.05. A multivariate analysis (linear regression) was also performed.

Participant Description
From the 170 participants, only two questionnaires were excluded from the study database, since those two questionnaires left one of the subscales totally unanswered. The study sample was composed of 126 females (75%), and 42 males (25%). Regarding academic experience, 70.8% were nursing baccalaureate

Relation between Academic Stress Perception and Academic Performance
As part of the analysis, correlation matrices based on Pearson coefficients for CEA subscales and the variables of academic performance were computed and analyzed. Table 2  The Pearson correlation coefficients matrix between the global scores of the CEA subscales and the variables of academic performance (see Table 3), revealed that the Academic Stressors subscale (E-CEA) and the Stress Response subscale (R-CEA) correlated inverse and significantly with both performance variables (p < 0.05). This suggests that the more the perception of academic stressors and responses to stress with adverse symptoms contrary to physical, behavioral, and cognitive student wellbeing, the less will the student academic performance be.

Implications of Stress in the Academic Performance of Nursing Students
To explore the relationship between the academic stressor variables being studied and their repercussions, with the objective of predicting academic performance on nursing students, a multiple linear regression analysis was carried out.
The analysis revealed, as seen in Table 4 analysis (see Table 5) revealed significant relationship between academic stress among nursing students and their grade average. Specifically, the dimensions known as: Faculty methodological deficiencies, Public interventions, Low academic self-esteem, and Exams, were the academic stressors most significantly correlated (p < 0.05) to student academic performance based on academic grade point average.
With respect to the other variable, academic performance rate (Table 6), the analysis reflected a multiple correlation coefficient of 0.519, with 27.0% of the variability of this rate explained by the academic stressors used as predictive variables established in the model. It was also found that academic stressors replicate or, are correlated in a statistically significant manner, along with the academic performance rate (F = 6.478, p < 0.001).
The coefficients linked to this analysis (Table 7), showed significant relationship between nursing student academic stress and, the academic performance rate that showed the terms of either overcoming or approving enrolled credits.
The dimensions Poor social relations within the academic context, Lack of control over own academic performance, and Exams, were the academic stressors significantly correlated (p < 0.05) with the nursing students' achievement based in the registered academic performance rate. As previously mentioned, this rate is based on the attempted (enrolled)-approved credit proportion.

Discussion
The purpose of this research was to determine and analyze possible repercussions of academic stress in nursing students in a Puerto Rican private university and how it could affect academic performance in students. In this sense, one of the most important findings was an inverse and statistically significant relationship between the perception of academic stress upon considering the E-CEA stressors, and the academic performance in the nursing students' sample. The nine academic stressor dimensions correlated significantly with the academic grade point average and the academic performance rate. There is no doubt as to the relation that academic stress is related to the academic performance of nursing students. This is confirmed by Ponce Gomez et al. [18], at the mention of various studies in this field that find a similar relationship between academic performance and the stress situations generated by many academic factors, which will be mentioned further ahead. Nevertheless, not all the dimensions in the different research studies are the same or generate the most stress in the students [18]. Seron Cabezas [19], validated in his study the relationship between academic stress and the academic performance of nursing students. Nonetheless, according to MamaniConto [20], not all the studies related to academic stress and its relationship to academic performance coincide with the one conducted with Puerto Rican students. The MamaniConto [20] study, found the nursing students' academic performance to be fairly satisfactory (67.1%), and, in comparison to the statistical analysis, the relationship between the variable and the student academic performance and its personal, academic and institutional factors was not significant.
Conversely, weak correlations were found between the Faculty methodological deficiencies dimension with Academic grade point average, and between the Lack of content values dimension with the academic performance rate. Gonzalez Cabanach et al. [21], pointed out in their study that it is the nursing students who significantly perceive a major lack of learning and studying content values.
It is possible that the nursing plan of studies might not satisfy the nursing student initial expectations, or that the professional role models perceived might experience formative shortcomings. As a matter of analysis, the nursing faculty in Puerto Rico must reflect on the presented data, on the improvement of the nursing teaching methodology and, on the pertinence of the nursing course content.
The analysis of CEA global subscales and the variables of academic performance revealed that Academic Stressors (E-CEA) and Responses to Stress (R-CEA) were correlated inverse and significantly with performance variables.
This suggests that the bigger the perception of the presence of academic stressors and responses to stress with adverse symptoms contrary to student physical, behavioral and cognitive wellbeing, the lesser the student's academic performance.
This finding coincides with a study carried out by Mendoza et al. [8], which found that students who possess a negative perception about their academic  [28]. Other studies, in contrast with the one carried out in Puerto Rico, found that other different set of variables related with academic performance, such as the one that states that nursing students who adopt a daily study habit, turn out the best academic grade point averages [29], and the close relationship between psychological wellbeing and academic performance, which supposes a better academic grade point average [30].
With respect to the variable academic performance, the multiple regression analysis showed that the academic stressors are correlated in a statistically significant manner to the academic performance rate. Significant relationship between academic stress in students and the academic performance rate is evident.
Academic stress on nursing students and the academic performance rate, specially, showed that the difficulty to overcome or approve the attempted (enrolled) credits are related to academic stressors. The dimensions which refer to Poor social relations within the academic context, Lack of control over own academic performance, and Exams were the academic stressors most significantly related to the nursing student academic performance based on the proportion of attempted-approved credits. This finding coincides with studies which point to the fact that most students who control their academic stress and use managing strategies to face these situations, improve their academic performance [8].
There is a relationship between the management of the academic stress levels and the academic performance of nursing students. Also, it has been demonstrated that academic demands and academic stress considerably diminish student performance, thus producing low educational achievement, depressed or highly stressed students due to personal issues, a matter that also affects student academic performance [17]- [24]. Academic stress also affects attendance; since lack of attendance due to student maladaptation, causes poor academic performance that may result in academic failure on the part of the student, or even causing the student to drop out of the university [24]. Stress is known to be an adaptive phenomenon on human beings that, contributes, in good measure, to its survival, to adequate performance in their activities, and to the enrichment of life in general [24].
Despite the findings encountered in the Puerto Rican study, they are considered not sufficient by themselves to establish trend predictions applicable to other nursing students. Regardless to the subject of academic stress being a common health issue among nursing students at the university level, it has not been sufficiently studied [8]. Notwithstanding of the finding's analysis, conclusions and recommendations must be developed and implemented to further help students on coping with this academic disorder, and to motivate researchers to carry out further research on this topic.

Conclusion
It was found that academic stressors are correlated to the academic grade point average. It was also found that the academic stressors that affect nursing stu- These, in turn, also significantly are related to the academic performance of nursing students based on their academic grade averages. Considering the other academic variable, it was found that academic stressors are significantly correlated within the academic performance rate. It was also noted that significant relationship exists between academic stress among nursing students, and the academic performance rate. Findings showed, among students under study, that the capability of succeeding or approving the academic courses was related to academic stressors. Among them, emphasize must be paid to Bad social relations within the academic context, Lack of control over their own academic achievement and Exams. These being the academic stressors directly and significantly related to academic achievement of nursing students based on the academic performance rate, evidenced by the relationship among attempted-approved credits.