Clinical Stress among Bachelor Nursing Students: A Qualitative Inquiry

Background: Stress has been linked to different life stages. One of those stages is the transition during the college period. Nursing has been identified as one of the challenges that face student, as its deals with human life. In addition, high levels of stress may lead to health problems and academic dissatis-faction. Objective: To explore clinical stressors among nursing students in Saudi Arabia. Methods: This study employed a qualitative study design; therefore, the collection of data was employed using semi-structured face-to-face interviews with nursing students. Data were analyzed through the use of content analysis. Results: Analysis of the data identified three categories of students’ stressors during clinical training: the urge to learn, how to learn communication, and the nature of the hospital environment. Conclusion: As this study highlighted the clinical stressors facing nursing students, recommendations for nursing education and clinical environments are mentioned in order to ease the stressors.


Introduction
Students pass through a normal developmental phase characterizes by tension and anxiety as they try to achieve their goals. The objectives of this developmental phase are to develop autonomy and self-government [1]. Difficulty in achieving these objectives leads to maladaptation in the form of feeling stressed, depressed, and anxious. Therefore, it has been recommended to improve college students' attentiveness and teach them healthy coping mechanisms through on-campus training [2]. Worldwide, students enrolled in health colleges reported high levels of academic stress, resulting in social, mental, and emotional distress. Therefore, vels of stress were explored among different levels and academic years of nursing students. The highest level of stress was reported by the fifth and sixth levels of nursing. The most-reported stressors were course requirements [7]. In Jordan, the stress among nursing students was measured and 52% of respondents reported high levels of stress [8]. In Nepal, academic stress was found among 20.9% of medical students [9]. In addition, a study was undertaken in Pakistan and found that 90% of medical students have stress [10]. Furthermore, some studies have gone beyond academic stress and found that 2.7% of students in Sweden who had enrolled in a medical college attempted suicide due to stress [11]. In Jizan city in Saudi Arabia, the prevalence of stress was studied among 385 medical students. The results showed that 71.9% of participants reported having stress. High reported stress levels were found among females and among those in the first year of study. They reported the greatest stressor was the prolonged study schedule [12]. At Majmaah University, 105 male medical students were examined for levels of stress, and it was found they had high levels (88.5%) [13]. In addition, at the University of Dammam, stress levels were found among 71.7% of medical students [14]. In Ireland, a cross-sectional study was undertaken among medial undergraduate students, and stress was found among 71.9% of the study sample [15]. In addition, in the Karachi Ziauddin College of Medicine, 125 Pakistani medical students were screened for stress and the majority (80.3%) reported having stress [16]. In a study of 387 Iranian medical students, 76.1% of students complained of having stress during their academic lives [17].
Furthermore, in Ethiopia, 47.7% of nursing students at Jimma University reported having stress [18].
Students' stresses were classified into three main groups: stressors related to academic requirements, for example, exams and evaluation and long hours of studying [9] [19] [20] [21]; stressors related to clinical training, for example, making mistakes, relationships with patients, and fears of death [19] [20] [21]; and stressors related to personal and social life, for example, lack of live entertainment and poor family relationships due to staying in university accommodations [7] [9] [22]. Therefore, nursing students are required to be competent physically, emotionally, and logically in order to face academic, clinical, and personal stressors [23] [24]. Out of the previously mentioned stressors, academic  [25]. In Pakistan, the factors that may lead to stress among nursing students were classified as 75% related to clinical settings, 70% related to academics, and 60% related to environmental factors [26]. On the other hand, students who pass through individual, emotional, family, and social problems were found to have low academic performances compared to stable students [27]. In addition, the focus was moved and the stress was found to be highest among newly enrolled nursing students, as a result of the need to transition between high school and college life [28]. Moreover, other studies reported the students' classes and courses had a great impact on the stress levels among nursing students [29] [30] [31].

Study Aim
The aim of this study is to explore nursing students' stressors related to clinical training.

Methodology
Research Design: This study employed a qualitative research design. Participants and Data Collection: The research data was collected from Imam Abdulrahman Bin Faisal University, College of Nursing. Fourteen nursing students who were enrolled in the second, third, and fourth years of the bachelor's program and had current clinical training were involved in the study. To ensure the variety of the sample, students were chosen from different study levels, genders, ages, places of living, and marital statuses. Data were collected until data saturation was reached so there was no new information obtained from interviews.
Therefore, the sample size was 14 nursing students' were eight females and six males; 30% were married; 70% were living with their families; 20% were living in the university compound, and 10% were living with their friends. Among the participants, 30% were in their second year, and 40% were in their third year, while the remaining 40% were in the last year of the study.
Research data were collected through semi-structured face-to-face interviews with 14 nursing students. Participants were asked the following initial questions: "How do you perceive clinical training?", "What are the barriers to the clinical training" and "What are the motivators for clinical training?" More questions were added during the interviews that were relevant to the focus and evolution of each one-to-one interview in order to gain in-depth additional clarification and information. The interviews last for about 45 minutes and were recorded on a digital voice recorder under agreement from each participant. Interview recording is essential for assessing qualitative research as it helps the person to record data accurately. Content analysis is used as a qualitative descriptive research approach to condense and strip a large amount of text data in order to gain new insights into the phenomenon of the study.
Data Analysis: Interviews were transcribed and content analysis was used for qualitative analysis. The manuscript of the interviews was read numerous times Ethical Consideration: Ethical approval was sought and granted from the Institutional Review Board at Abdulrahman Bin Faisal University. After obtaining ethical approval, the students were contacted through their course coordinators.
The objective, nature, and significance of this study were explained orally and enforced in writing by obtaining the consent forms. Students were assured their participation was voluntary, and they had the right to cancel their participation.
In addition, no identifying personal information was used. Moreover, students were assured their participation would not affect their college enrollment status, grades, or any services they received.

Results
Nursing students reported four main categories and related themes that affected their clinical training. Those themes and sub-themes are summarized in Table 1.

Urge to Learn
• Lack of knowledge The majority of respondents 10 out of 14reported a lack of clinical knowledge as a vital stressor at the beginning of each clinical training. They reported that, although they understand the theoretical part of different diseases, they feel stressed when facing real patients for the first time, and it is totally different in regard to doing assessments and applying nursing care. The students reported that worrying about how to deal with patients, give medication, write notes, and performs the nursing assessment. In addition, being asked by the patients and their families about the diseases and prognoses make them feel shy because they lack the exact answers, knowledge, and experience. For example, one student stated, "My biggest concern was being asked a question about my patient that I don't have the answer for" [ In addition, four nursing students claimed some patients become very sensitive when they know procedures will be done by nursing students. Students reported feeling hopeless if they didn't have the chance to observe, help, or do some of the procedures. This made students feel stressed and unconfident, and the students needed to be patient, take deep breaths, and study hard in order to assure the clinical patients that they were self-confident and able to help and carry out the procedure. As one of the students claimed, "My clinical instructor expected that I would be able to do all the procedures as I had learned in the laboratory; however, it was hard for me to retain all the information that I learned in the quite assuring laboratory in comparison to the very busy hospital floor" [Participant no. 12].
Another student reported, "My first clinical rotation was very hard for me, as my clinical instructor asked me to help the nurse during intravenous insertion; unfortunately, I didn't read the producer to refresh my information and I put myself in a big struggle, especially when the patient noticed that I was not confident in what I was doing" [Participant no. 14].
Therefore, in order for students to pass through the problem of a lack of knowledge, they found that preparing themselves with the type of training for each clinical area was the best way to feel at ease and comfortable.
"I learned that before each new clinical rotation I needed to prepare myself very well by reading and knowing the type of nursing works expected in this unit, the main procedure done, and the type of patient diagnosis that I would deal with" [Participant no. 3].
• Being tested by staff and patients A number of nursing students (four) reported that they felt stressed when the nursing staff started to test their knowledge and skills. The students felt each time they visited the clinical area they were tested not only by their clinical instructor but also by staff, physicians, and even the patients. One participant reported, "When I started to observe the nurse preparing medication for an injection, she gave me a huge number of questions as if I was in a final clinical exam; I did not really expect to be tested by the nursing staff" [Participant no. 6].
In addition, participants stated patients became very concerned when they knew students were dealing with them in providing care or even when only ob-

How to Learn Communication
• Trust relationship Building a trust relationship was perceived by all participants as a major issue in regard to clinical stressors. The trust relationship was viewed as the pathway for dealing with patients and, therefore, was a perfect chance for effective clinical training. All participants emphasized that before starting the clinical training there were taught that the first step in dealing with clinical staff and patients was to build a strong relationship. One of the students stated, "I didn't understand that in order to work with the patient that needed to build a trust relationship until I found myself assigned to a patient; I was so anxious about how I would provide for her full care without a trust relationship" [Participant no. 13].
Another student claimed, "Since the introductory lecture about the nurse-patient relationship, I noticed that it was the hardest part for any nurse, if this stage passes" [Participant no. 14].

• Feeling inadequate
The lack of ability to communicate with staff nurses and physicians and understand physicians' orders made students feel inadequate and unsatisfied. This was viewed as a strong factor that played a role in increasing the stress level of students. The nursing students reported they were impressed by the way the nursing staff had very good relationships and excellent communication skills, even with other healthcare providers, in each clinical area through which they passed. Therefore, this made the students feel unsatisfied regarding their communication skills and abilities and left them feeling inadequate at starting and maintaining relationships because they needed to pass through many clinical areas within three months. For instance, one participant stated, "I saw how in each clinical area the nursing staff dealt like a family. They had a very smooth communication and understanding, and, as I was going to spend only four days in each ward, I felt unsatisfied regarding my ability to gain their communication techniques" [Participant no. 4]. unexpected and dangerous events compared to their skills as students. Some students reported they were assigned to patients who had been called for cardiopulmonary resuscitations and passed away. These events were rated as highly stressful for students because they primarily dealt with them based on emotion and not as a professional staff nurses who could differentiate between emotions and could act appropriately based on the event and hospital policy.

Nature of the Hospital Environment
"The only event that really affected me and I couldn't forget until now is when I heard the Blue Code announcement in the Emergency Room" [

Discussion
This study investigated related clinical training stressors of nursing students at one university in the Eastern Region of Saudi Arabia. Students identified a number of themes related to clinical training stressors. Those themes were lack of knowledge, poor communication skills, and hospital environment. These results are consistent with previous studies [31] [32] [33] [34]. Students' lack of knowledge was identified as the most common stressful issue reported, besides the nursing skills [35]. The lack of knowledge led students to be terrified of their patients [36], and it led students to not be able to control their emotions when giving nursing care [37]. Moreover, fear of clinical structures and nursing staff and being asked by patients has been noted in other studies, as these are a part of academic and clinical stressors [21] [31]. Therefore, those stressors caused students to be afraid of making mistakes, which in turn led students to be judgmental about themselves and feel negative about their achievements, generating student disappointment and loss of self-confidence [20]. Consequently, it has been recommended that linking theory to clinical practice, besides establishing an effective learning atmosphere in conjunction with social construction, helps students to obtain a professional demeanor [38].
Lack of communication skills with patients and healthcare providers has been identified as a stressor perceived by students. This finding is consistent with previous studies [39] [40]. A vigorous professional relationship between the clinical instructors, staff nurses, and students by applying effective communication skills, for example verbal and nonverbal communication, active listening, self-control, and the aptitude to communicate assertively, enables students to effectively connect with each other [20]. In addition, it improves the ability to build trust with patients and increases self-confidence, respect, and understanding [32]. In return, improving communication skills facilitate a high quality of care for patients and the quality of relationships among health care professionals.
The nature of the hospital environment was found to be stressful for students, Nursing students reported they were extra burdened as a result of the healthcare provider hierarchy between students and doctors [30]. In addition, students were found to feel disappointed by the inability to make professional relationships with the patients as a result of insufficient clinical training [41]. Furthermore, the fear of making mistakes during doing a professional procedure and being assigned to a patient with complicated conditions was found to be stressor among nursing students [24]. Most importantly, the death of a signed patient or performing after-death care was related to student distress during clinical training [20]. Therefore, it is very important to establish an environment where students can feel welcome and their achievements are praised in order to build self-respect, confidence, and empowerment [20] [42].

Recommendations
The results show students experience personal and environmental stressors; therefore, they require improvement of their personal, social, professional, and coping skills. It is suggested this situation be deliberated during curriculum development and evaluation. In addition, the organization of social and professional skills training sessions will help students be more powerful. Nurse educators are responsible for implementing the intervention to reduce stress among students, which is not only important for the students' well-being but also significant for preparing nursing professionals who can deliver a high quality of care for patients [35] [43].

Limitation of the Study
The limitations of the study were the sample size of nursing students and the fact the study was undertaken at only one university in the Eastern Region of Saudi Arabia. Consequently, it is not recommended to generalize the study findings.
Accordingly, the recommendation for forthcoming studies is to increase the sample size and cover a number of universities in different regions in Saudi Arabia.

Conclusion
The aim of this study was to explore stressors facing nursing students during clinical training in one university in the Eastern Region of Saudi Arabia. Students identified three categories of clinical stressors. Therefore, focusing on improving nursing education and clinical environments will enhance students' clinical training.