Stress, physiopsychosocial status and coping behaviors of nursing students in clinical practice

The aims of this research was to understand the stress, physiopsychosocial status and coping behaviors of nursing students in clinical practice, the differences in stress, physiopsychosocial status and coping behaviors among nursing students of different demographic factor, exploring the relationship between students stress, physiopsychosocial status and coping behavior.

輔 英 科 技 大 學 護 理 系 碩 士 在 職 專 班

碩 士 論 文

Department of Nursing Fooyin University Master Thesis

Recommendation Letter from the Thesis Advisor

Thesis/Dissertation Oral Defense Committee Certification

ACKNOWLEDGEMENTS

It has been a challenged period for pursuing master program but I overcome and complete my master degree now My achievement would not have been possible without encouragement from some special people

Firstly, I would like to deeply express my sincere gratitude to my advisor, Assistant Professor Yi-Chuan Chang She is always willing to listen

to my idea, comments, attention and understanding I could not finish this study without her help I had many difficulties when I researched this issue However, she encouraged and gave me the strength to continue my study Secondly, I would like to thank my family for their love and support to

me They are always besides me when I feel disappointed

Thirdly, I would like to thank my co-workers in Nursing Department who shared works at the Duy Tan University while I studied the master's program and thank respondents who are willing to fill in my questionnaire With my best regards!

Ho Thi Lan Vi

臨床實習護生的壓力、身心社會狀態和因應行為

中文摘要

背景

護理學生在臨床實習過程的壓力大，沒有積極處理壓力，可能導致許多身體、心理和社會問題。有效的因應策略可以加速學生恢復平衡並減少壓力的負面影響。

目的

本研究的目的是探討護生在臨床實習中的壓力程度、生理-心理-社會狀態、因應行為及其相關性。

度不同，其感知壓力（t = - 5.46, p = 0.000），生理、心理、社會狀態

（t = -6.66, p = 0.000）和因應行為（t = -2.13, p = 0.034）呈現顯著差異。 學生的學習程度不同，其感知壓力（F = 3.04, p = 0.049），生理、心理、 社會狀態（F = 3.57, p = 0.029）和問題解決（ F = 3.74, p = 0.025）呈現

顯著差異。且感知壓力，生理、心理、社會狀態和因應行為呈現正相關。 “逃避”與整生理、心理、社會狀態間呈現中度正相關（r = 0.51,

p = 0.000）。 “保持樂觀”和“社會行為症狀”間呈現中度負相關（r

= 0.12, p = 0.026）。 “轉移”與整體生理、心理、社會狀態（r = 0.11, p = 0.039）;“身體症狀”（r = -0.10，p = 0.043）;“社會行為症 狀”（r = -0.15, p = 0.004）間呈現中度負相關。如果學生避免，解決問

-題或試圖保持樂觀以減輕壓力，學生會有更高的壓力。但如果他們使用轉移，教師和護理人員的壓力就會減少。

結論

對於臨床實習的護理教育，提供有益的環境以減少護理學生的壓力是重要的，需要臨床護理教師和護理人員共同擬訂有效的計劃和策略，減少或預防護理教育和培訓過程中的壓力。

關鍵詞：護生、壓力、因應行為、臨床實習

Stress, physio-psycho-social status and coping

behaviors of nursing students in clinical practice

ENGLISH ABSTRACT

Background

According to a report, nursing students have high levels of stress, in some cases higher than those of other medical practitioners If the stress is not dealt with it could cause many physical, psychological and social problems Efficient coping strategies expedite the student's return to equilibrium and reduce the negative effects of stress

Aim

The aims of this research was to understand the stress, social status and coping behaviors of nursing students in clinical practice, the differences in stress, physio-psycho-social status and coping behaviors among nursing students of different demographic factor, exploring the relationship between students' stress, physio-psycho-social status and coping behavior

physio-psycho-Methods

Using a descriptive, cross - sectional design The subjects were 378 nursing students who had finalized their clinical practice at Duy Tan University for the semester Three standardized instruments were used, the Perceived Stress Scale (PSS), the Physio-Psycho-Social Response Scale (PPSRS) and the Coping Behavior Inventory (CBI)

Results

Results showed that “assignments and workload” (M = 1.80 ± 0.68) and

“taking care of patients” (M = 1.70 ± 0.60) were the highest sources of stress

in clinical practice The highest symptom response to stress was emotional symptoms (M = 1.60 ± 0.89) The main coping behaviors were

“Transference” (M = 2.55 ± 0.84) and “Staying optimistic” (M = 2.18 ± 0.69)

Among students in regards to their level of interest in Nursing, there was a

significant difference in perceived stress (t = - 5.46, p = 0.000), psycho-social status (t = -6.66, p = 0.000) and coping behaviors (t = -2.13, p =

physio-0.034) There were statistically significant differences between their level of

study and perceived stress (F = 3.04; df = 2; p = 0.049), physio-psycho-social status (F = 3.57 , df = 2, p = 0.029), problem solving (F = 3.74, df = 2, p =

0.025) Significant positive correlations between perceived stress, psycho-social status, coping behavior were found There was a positive moderate correlation between “Avoidance” and overall PPSRS scale (r = 0.51,

physio-p = 0.000) There was a negative moderate correlation between “Staying

optimistic” and “Social-behavioral symptoms” (r = -0.12, p = 0.026) There

was a negative moderate relationship between “Transference” and all the

PPSRS scale (r = -0.11, p = 0.039), with “Physical symptoms” (r = -0.10, p = 0.043), “Social-behavioral symptoms” (r = -0.15, p = 0.004) If students

avoid, problem-solve or try to stay optimistic to reduce stress, students get a higher level of stress But if they use transference, stress from teachers and nursing staff was reduced

Conclusion

These results are imperative for supporting nursing education in clinical practice to take methods to supply a helpful environment in order to decrease nursing students‟ stress, warrants further interventions from both clinical teachers and clinical staff Effective intervention planning and strategies are needed to decrease or prevent stress in nursing education and training

Keywords: nursing students, stress, coping behavior, clinical practice.

TABLE OF CONTENTS

Recommendation letter from the thesis advisor i

Thesis/dissertation oral defense committee certification ii

Acknowledgements iii

中文摘要 iv

English abstract vi

Table of contents viii

List of tables xi

List of figures xiii

Chapter 1: Introduction 1

1.1 Statement of the Problem 1

1.2 Prevalence of Stress 5

1.3 Purpose of the study 8

1.4 Research Questions 9

1.5 Conceptual definitions 9

1.6 Significance of the study 10

Chapter 2: Literature review 11

2.1 Clinical Practice 12

2.2 Perceived stress 14

2.3 Coping behaviors 19

2.4 Effect of stress on student's physio-psycho-social status 23

Chapter 3: Methodology 30

3.1 Research design 30

3.2 Conceptual Framework 30

3.3 Sampling & Setting 31

3.4 Instruments 34

3.5 Process of Questionnaire Translation 41

3.6 Data Collection 42

3.7 Data Analysis 44

3.8 Ethical consideration 44

3.9 Research process 45

3.10 Summary 45

Chapter 4 Results 46

4.1 Demographic data 46

4.2 Percieved stress, physio-psycho-social status and coping behaviors of nursing students stress 47

4.3 The differences in stress, physio-psycho-social status and coping behaviors among nursing students of different demographic factors 54

4.4 The relationship between students' stress, physio-psycho-social status and coping behavior 60

Chapter 5 Discussion 65

5.1 Demographic 65

5.2 Perceived stress, physio-psycho-social status and coping behaviors of nursing students stress 66

5.3 The differences in stress, physio-psycho-social status and coping behaviors among nursing students of different demographic factor 71

5.4 The relationship between students' stress, physio-psycho-social status and coping behavior 76

Chapter 6 Conclusion 81

6.1 Conclusion 81

6.2 Limitation 82

6.3 Implementation 82

Refenrences 85

Appendix 98

Appendix A: Agreement Form 98

(English version) 98

Appendix B: Questionaire 100 (English version) 100 Appendix C: IRB 110

LIST OF TABLES

Table 1 Literatura review 27

Table 2 Fictitious Ratings on a PSS Scale by Three Experts 37

Table 3 Fictitious Ratings on a PPSRS Scale by Three Experts 38

Table 4 Fictitious Ratings on a CBI Scale by Three Experts 39

Table 5 Summary of research instruments 40

Table 6 Research process 45

Table 7 Demographics data 46

Table 8 Descriptive statistics for all factors of the PSS 47

Table 9 Perceived stress by nursing students in clinical practice 48

Table 10 Descriptive statistics for all factors of the PPSRS 50

Table 11 Physio-psycho-social symptoms occurred during clinical practice 51

Table 12 Descriptive statistics for all factors of the CBI 52

Table 13 Coping behaviors utilized by nursing students 53

Table 14 Analysis of differences in the subscales and over all PSS scores by interest in Nursing 55

Table 15 Analysis of differences in the subscales and over all PSS scores by grade 56

Table 16 Analysis of differences in the subscales and overall PPSRS scores by interest in Nursing 57

Table 17 Analysis of differences in the subscales and overall PPSRS scores by grade 58

Table 18 Analysis of differences in the subscales and over all CBI scores by interest in Nursing 59

Table 19 Analysis of differences in the subscales and over all CBI scores by grade 59

Table 20 Correlation coefficients of PSS, PPSRS and CBI 60

Table 21 Correlation coefficients of PSS and PPSRS 61

Table 22 Correlation coefficients of CBI and PPSRS 62

Table 23 Correlation coefficients of PSS and CBI 64

LIST OF FIGURES

Figure 1 Conceptual Framework 30

Figure 2 Sample size determination 33

Figure 3 Data collection process 43

Figure 4 Perceived stress by nursing students in clinical practice 50

Figure 5 Physio-psycho-social symptoms occurred during clinical practice 52 Figure 6 Coping behaviors utilized by nursing students 54

CHAPTER 1: INTRODUCTION

This chapter focuses on the statement of the problem, prevalence of the stress of nursing students in hospital practice, purpose of the research, research questions, research hypothesis, conceptual definitions and significance of the research This research aims to understand the stress, physio-psycho-social status and coping behaviors of nursing students

1.1 Statement of the Problem

Stress has been acknowledged as a main challenge to the health of workers and it also affects their labor organizations (International Labour

warned and stressed that stress as a global pandemic (WHO, 2002) One of the main sources of disability by 2020 is stress-related confusions (WHO, 2002) In the 20th century, stress has also been recognized as a main mental health issue (Kaplan, Madden, Mijanovich, & Purcaro, 2013) It is an inevitable part of human existence

Stress is also mentioned as a connection between the environment and the personal (Pulido-Martos, Augusto, & Lopez-Zafra, 2012) It is "a specific correlation between the environment and the individual that is considered by the individual as taxing and/ or surpassing his or her capitals and risking his

or her well-being" (Lazarus & Folkman, 1984) Lazarus and Folkman also say that "persons and groups differ in their sympathy and susceptibility to assured types of events, as well as in their interpretations and responses" Awareness

of stress is identified as the extent to which a circumstance in a person's life is considered stressful (Cohen, Kamarck & Mermelstein, 1983) People who experience the same occurrence can elicit different stress reactions Studies propose that environmental state, emotional responses to need and one's response to events are the main stressors (Fliege et al., 2005)

According to a variety of reports from job-related health organizations, stress influences almost every occupation However, the level of stress was higher and there was more stress in health experts, especially nurses, with negative health outcomes (Demerouti, Bakker, Nachreiner, & Schaufeli, 2000; Humpel & Caputi, 2001; Lim, Bogossian, & Ahern, 2010) Especially,

in the stage before becoming professional nurses, it is their training time that reasons a substantial total of stress Nursing students undergo and state high levels of stress as they learn nursing curriculum (Bremner, F Aduddell, & Amason, 2008; Jimenez, Navia-Osorio, & Diaz, 2010; Shaban, Khater, & Akhu-Zaheya, 2012) Stecker (2004) considered the level of stress in university and medical students, showing that nursing students report higher levels of stress than medical, pharmacy, therapy, dental and graduate students (Stecker, 2004) Linden, Turner, Young, and Bruce (2001) showed that nursing students undergo higher psychological and physiological symptoms than other students (Young, Bruce, Turner, & Linden, 2001) Nursing students state higher academic stress than external stress Stress and nursing seem to go together High accountability, the increasing demand of today's health care system, is leading to greater levels of stress and anxiety for nursing students

They not only face university stress but also face stress throughout practice Burnard stated that throughout clinical training, nursing students have high levels of stress (Burnard et al., 2008) They engage in a variety of clinical tasks in the same learning process as the experience of professional nurses In addition, stressed nursing students are involved in educational research and personal / social experiences Nursing students face various stressors, such as stress related to their learning problems (eg, exercises, scores, exams); clinical training stress (eg lack of skills and professional knowledge); In addition, external tensions (eg individual problems, financial

tensions and daily life) (Alzayyat & Al-Gamal, 2014; Jimenez et al., 2010; Khater, Akhu-Zaheya & Shaban, 2014)

Not all stress is harmful Some of the main stressors are motivational dynamics at work These stressors create eustress because it motivates us to act - perhaps in the face of an impending event or some urgent situation However, if there is a chance that there will be too much long-term stress, then stress will become distress, even causing the body to affect its behavior and lead to many different pathological conditions Getting overdosed with stress can lead to symptoms such as lightheadedness, fatigue and possibly depression Stress can harm people with physical and psychological symptoms This psychological distress can interfere with a student's academic achievement thereby impeding their pursuit of temporary or permanent careers Stress can also impair effective communication between individuals and empathy with others (Kendrick, 2000) Studies have shown that moderate and high stress impedes concentration, memory and problem solving, thereby negatively affecting academic achievement (Beddoe & Murphy, 2004) Hensel and Stoelting - Gettelfinger report that stress prevents students' capacity to think, thus preventing the student's expert development (Hensel & Stoelting-Gettelfinger, 2011) Prato and Yucha (2013) state that when nursing students are stressed and anxious while taking a test may not be able to prove their true competence and may perform poorly in their educational performance (Prato & Yucha, 2013)

Traditional full-time nursing syllabi are planed for a high school students graduatation The needs and design of nursing syllabus do not change, though the individuals of students (non-traditional students) have changed significantly Nursing education for students is implemented in a very tense environment, where heavy learning takes place with many hours of study (Godbey & Courage, 1994) Stress is exceptionally imperative in learning due

to it is likehood to interfere with learning and human activity (Yucha,

Kowalski, & Cross, 2009) In addition, current research on clinical teaching

of nursing students reveals that students are overcome in their clinical studies

to the extent that it can affect their well-being Nursing students, in all higher education programs, state a high ranking of stress and nervousness in hospital circumstances (Carlson, Kotze, & Van Rooyen, 2003; Elliott, 2002; Hayden-Miles, 2002; Sharif & Masoumi, 2005)

Rationale for present study

Nursing is one of the top choices after high school graduation This is because many students have to nursing school because of their parents expectations Vietnamese parents believe that nursing is a respected profession in the community, however they don‟t have much background information about what nurses do Therefore, the students do not have any previous knowledge about the nursing profession before entering nursing school Some of them still don‟t want to be a nurse So, they do not have an internal motivation to become a nurse

Nursing is a practical occupation, so in parallel with theoretical study through lectures to build a foundation of knowledge, there is a process of hands-on learning in the practice and pre-clinical rooms, and at hospitals by nursing students in Duy Tan University It has always been a highly imperative constituent in the training process of the Nursing Faculty at Duy Tan University

The design of the training program of Nursing Department at Duy Tan University is also a practical design with a great amount of practice hours In the Nursing Department, Duy Tan University students will have clinical practice starting from the third semester to the end of the 8th semester In clinical subjects such as medical care, child health care or mental health care, these courses will be held in the hospital for 2 to 3 weeks depending on the subject Students will be trained at specialized hospitals such as Da Nang Hospital, C Hospital, Military Hospital, Hai Chau Hospital, Da Nang Hospital

for Women and Children, Rehabilitation Hospital, Psychiatric Hospital, and the Son Tra Hospital,

I realized that my nursing students have a high level of stress when I guide them in practice at clinicals at Duy Tan University It affects them physiologically, psychologically and socio behaviorally This psychological stress can interfere with the student's academic achievement and thus impede the pursuit of their nursing care, but there is less study about that, specifically there hasn‟t been any research in Duy Tan University on this topic yet In particular, studies on stress origins and behavioral responses to stress After researching and understanding this, it can help us to support nursing students

to reduce their stress and help them motivate themselves during clinical practice

1.2 Prevalence of Stress

World Health Organization stated that "Stress" has been called the

“Health Epidemic of the 21st Century”, estimates that the fee for treatment in the United States is up to $300 billion/year (Insel, 2008) The effects of stress can wreak havoc on the emotional and physical health of people In a recent study in the United States, more than 50% of people who felt stress had a negative impact on productivity From 1983 to 2009, the level of stress increased from 10% to 30% in all demographic groups in the United States (Cohen et al., 1983)

Amount of college students with severe psychological diseases has increased substantially over the past few years, according to a systematic review that has been implemented to address the mental health and mental health problems of college students worldwide (Storrie, Ahern, & Tuckett, 2010) Studies have analyzed the stress and its impact on learning or supportive behaviors A study of first year nursing students demonstrated that clinical practice has higher levels of stress than theoretical classes (Killam,

Mossey, Montgomery & Timmermans, 2013) Furthermore, due to the influence of stress on student health, studies have highlighted the emergence

of depression, syndrome, and anxiety in these individuals (Bayram & Bilgel, 2008) Depression, stress and anxiety levels of moderate seriousness or above were 27.1, 27 and 47.1% of our responders, correspondingly among Turkish University students (Bayram & Bilgel, 2008) In the 743 medical students surveyed, moderate to severe stress, depression and anxiety were 3.6%, 1.9% and 54.5% (Yusoff et al., 2013) In the academic context, researchers found that 45% of the 545 students from Minnesota and 48.6% of 4287 medical students from Washington had Burn-Out Syndrome (Dyrbye et al., 2008) When Brazilian students of different university programs were investigated, 10.3% of 369 medical students and 17% of 235 dental students had Syndrome Burn – out (Campos, Jordani, Zucoloto, Bonafe & Maroco, 2012)

The results of research in Thailand showed that 62.0% of the 100 sophomore nursing students surveyed had high stress levels, 32.0% had moderate stress levels and 6.0% of them had severe stress level (Supawadee

et al., 2016) A previous study operated on the frequency of mental health matters in nursing students, in the nursing department, Mahidol University,

2009, found the prevalence rate of reduced mental health was 21.4 % (Thanoi

et al., 2009), these results are coherent with the research on the nursing department, Naresuan University, 3rd, semester, 2010, which found that anxiety in undergraduate nursing students in their 2nd year was 82.14%

Stress is no stranger to most people in Vietnam In 2006, The World Health Organization reported on mental health care in Vietnam, Trudy Harpham and Tran Tuan commented that a fifth of young Vietnamese people undergo mental health matters and in Vietnam, there is evidence of the burden

of mental illness but this is quite complicated and the research in this area has not been developed (Harpham, De Silva, & Tuan, 2006)

According to the results of a report on a national survey on pupils in Vietnam for the second time in 2009 (SAVY II), 73.1% of youth (14 to 25 years old) felt bored by psychological stress (Health & Vietnam, 2009)

A research at the Ho Chi Minh City University of Medicine and Pharmacy of public health students showed that students with psychological stress accounted for a high rate of their students, 24.2%, including 2.8% of students suffering severe pathological illnesses Statistics from the learning environment showed that more than 80% of students feel stressed, stress before each exam, and the lack of preparation for the exam (Huyen & Quynh, 2011) Another research on 483 second year medical and dentistry students at the Ho Chi Minh City University of Medicine and Pharmacy showed that the prevalance of stress, anxiety and depression was 71.4% , 28.8% , 22.4% , respectively; almost in mild and moderate level, 52.8% of student had all 3 states (Trang, 2012)

At the Hanoi Medical University, the proportion of depression among medical students was 38.9% Factors related to depression in preventive medical students are: financial difficulties, the ending of friendship, love, disagreement with parents, being beaten, being sick, not satisfied with their scores and learning outcomes There was no difference in the prevalence of

Medical University of Hanoi, found that the number of general students with signs of depression is quite high with the rate of students second year, Fourth year, sixth year respectively 51%, 50% and 40% (Lien, 2012) In 2009, Nguyen Huu Thu's research at the National University of Hanoi showed that 79% of students were stressed at a moderate level, while 3.2% were not stressed at all (Thu, 2009)

According to Vu Dung, in 2015, the stress score of nursing students at Thang Long University was 19.64 ± 4.72, in which 32% of students had high stress levels High pressure learning factors, lack of tuition and living

expenses are high risk factors for stress in students While having good friends, talking with friends, and exercise habits are factors that keep students from stressing at a high level (Dung, 2015)

Thai Binh Medical University, found that the rate of students with emotional stress is 58.8% In particular, emotional stress was high at 37.5% (Hien, 2013)

At Da Nang University in 2009, a research of Nguyen Thi My Anh showed that 7.6% students felt stress, 23.1% were not stressed, and the rest were mildly stressed (V H Anh, 2010) Another study of the stress of college students in Da Nang University showed that the percentage of students experiencing stress was 76.9% 81% of which is the University of Technology, the University of Education 66%, the University of Economics is 77.7% The biggest causes of stress are learning pressure, examinations, too many expectations and no time management The statistically substantial differences between gender and stress rates indicate that males are at greater risk of stress than females (Van, 2009)

In Vietnam, almost all research is about the prevalence of stress in students not about the source of stress, physio-psycho-social status or handling behaviors for stress The main objectives of those researches are on students in general However there is less specific research about nursing students

1.3 Purpose of the study

The objective of this research is to understand the stress, social status and coping behaviors of nursing students in clinical practice Research Objectives:

physio-psycho-1 To describe the stress, physio-psycho-social status and coping behaviors of nursing students in clinical practice

2 To describe the differences in stress, physio-psycho-social status and coping behaviors among nursing students of different demographic factors

3 Exploring the relationship between students' stress, social status and coping behavior

physio-psycho-1.4 Research Questions

Relied on the purpose of this study, research question was suggested as below:

1 What are the stress, physio-psycho-social status and coping behaviors

of nursing students in clinical practice?

2 What are the differences in stress, physio-psycho-social status and coping behaviors among nursing students of different demographic factors?

3 What is the relationship between students' stress, physio-psycho-social status and coping behavior?

1.5 Conceptual definitions

Stress is “a specific correlation between the individual and the situation

that is considered by the individual as taxing and/ or surpassing his or her

capacitys and imperiling his or her well-being” (Lazarus & Folkman, 1984)

Coping as “Continually altering awareness and behavioral attempts to

cope particular external and/internal stresses that are considered as taxing or surpassing the capacitys of the person” (Lazarus & Folkman, 1984)

Lazarus and Folkman (1984) recommended that there are 2 kinds of coping reactions; emotion focused and problem focused:

Emotion-focused coping related to “trying to decrease the negative

emotional reactions connected with stress such as embarrassment, excitement, fear, depression, anxiety and frustration”

Problem-focused coping goals the sources of stress in empirical ways

which tackles the problem or stressful condition that is affecting stress, subsequently decreasing the stress

Physical health is “the overall physical condition of a living organism at

a given time It is the soundness of the body, freedom from disease or abnormality, and the condition of optimal well-being.” (Ron Kurtus, 2017)

Proper psychological health “involves a normal behavioral, emotional

and social maturity to a person.” (Artem Cheprasov, 2017)

Social health “involves your capacity to form satisfying interpersonal

relationships with others.” (John Koshuta, 2015)

1.6 Significance of the study

This study seeks to profit researchers and nursing educators To explore the source of stress and stressful experiences of nursing students so that they can prevent unwanted effects arising in the present state of health care Organizing interventions to raise the student's competence to respond to stress

in professional education is critical and provide them with increased protection for their social health development

For researchers, in Vietnam the research on stress of a nursing student in clinical practice is limited, so this study provided the necessitated data to the researchers upcoming to use the database to compare, it may be used as an significant reference for further researchs

Furthermore, this research contributed to nursing education Findings from this research will define the level of stress of students when practicing in

a clinical setting which will give educators a better view of practice in a clinical envionment and to develop programs and measures to support the improvement of the quality of education It was possible to define the cause of stress for nursing students in the hospital circumstances, thereby reducing the risk of stressful situations for nursing students to increase the effectiveness of clinical practice education In addition, this study identified which students' coping behaviors helped to reduce their stress, this will lead to assisting other students in clinical practice

CHAPTER 2: LITERATURE REVIEW

This review encompasses quantitative researches of stress influences that nursing students are aware of between 2000 and 2018 Pubmed, Search Resources, MEDLINE, PsycInfo, Researchgate, Google scholar and CINAHL are databases used for this research The keywords used to search were 'stressful' (words such as social stress, perceived stress, source of stress, stress response, physiological stress, psychological stress, etc.); physical, psychological, social status, coping and 'nursing' students (words such as physical symptoms, psychological symptoms, social behavior symptoms, nursing students, nursing education, college students, education programs, forestry practices sieves, nursing schools, etc.) in different combinations In addition, by examining the relevant literature in previous studies, I carried out

a secondary search to determine related to data and obtain a strong portrait of the research issue

This review of the literature encompasses four parts which address the major variables and factors in the study The first section discusses to clinical practice The second section discusses perceived stress The third section discusses coping behaviors The last part of this chapter discusses to physio-psycho-social status

Research on stress and its impact on students has received considerable attention over the years (Akhu-Zaheya, Shaban, & Khater, 2015; Alsaqri, 2017; ; Chan, So, & Fong, 2009; Elsayes & Obied, 2017; Hamaideh, Al-Omari, & Al-Modallal, 2017; Karaca, Yildirim, Ankarali, AÇIKGÖZ, & AKKUŞ, 2017; Khater et al., 2014; Labrague, 2013; Mohamed & Ahmed, 2012; Shaban et al., 2012; Sham, 2018; Shdaifat, Jamama, & AlAmer, 2018; Sheu, Lin & Hwang, 2002; Zhao, Lei, He, Gu & Li, 2015)

2.1 Clinical Practice

According to the definition from the Vietnamese Dictionary - Institute of Linguistics - by Hoang Phe, clinical is what is directly observed of the sick person lying in bed Therefore, clinical practice is practice on someone in bed

or practice at the hospital The field of medicine is directly related to human life so clinical practice plays a very important role for students in this field, because clinical practice both helps students cultivate professional skills as well as they are trained in ethics to help them become good health workers and have professional ethics in the future Therefore, in the training program

of nursing students, clinical practice takes up more and more time Clinical practice is the process of implementing what has been learned in theory, been practiced in the school then trying on the "real" patient in the hospital Clinical practice is also a process of learning about different situations such as; eye problems, hearing aids, and case studies Case studies, this is the other key to learning at school, each patient is a different lesson, one can never have the same two patients despite them having the same disease Teachers in the medical profession often say that learning in school is to study "disease" while clinical education is to study "sick people," and “sick children” But in clinical terms, it is not possible to generalize what is measured, which is different from the theory that the general lesson is now specific Thus, clinical practice is the process of training and learning about patients

In nursing programs, nursing students have to complete practice in clinical and academic programs in preparation for becoming a professional and competent nurse in the future Bisholt et al., (2014) also stated that hospital practice is a crucial stipulation for training and teaching of experienced expert nurses (Bisholt, Ohlsson, Engstrom, Johansson, & Gustafsson, 2014) Clinical practice is an essential section of nursing curriculums The clinical section of nursing curriculum would participate psychometric (doing, skills) and the sentimental (knowing) side of studying

(Sharif & Masoumi, 2005) Hospital practice gives nursing students the chance to improve the knowledge they need and gain the psychological skills required for their career development (Chesser-Smyth, 2005; Sendir & Acaroglu, 2008) In almost all nursing programs, students use about half their time practicing clinical training It is disturbing that students assessment clinical teaching as extremely taxing (Chan et al., 2009)

In the learning and teaching procedure the Nursing Department guarantees students have the chance to rehearsal the elementary skills that they will use throughout clinical practice time However, with a focus on the hospital condition that is so infinitely different from the laboratory room and the classroom condition, with variety of diseases, its new equipment, the requirements of patients, the role of the supporter nurses in hospitals, staff nurses and nurse instructors who oversee their clinical practice skills together with making the nursing students with knowledge and skills All these parts source stress to nursing students and need care and suitable supervision so as not create physical and mental health problems in the upcoming, mainly upon progressing (Selye, 1976)

Jones and Johnston (2000) showed that evaluating stress interferences during practice formation is particularly appropriate as they found that solving these problems early in nursing practice is likely to be counterproductive issues related stress in the future (M C Jones & Johnston, 2000)

Finally, clinical posting was the highest stressful phase for nursing students throughout their education process in most countries As nursing students enter the real hospital environment with a lack of knowledge and nursing skills, their health can be affected Nursing research can support that nursing students recognize the practicum piece of class as being specifically stressful in clinical practice (Chesser-Smyth, 2005; Sendir & Acaroglu, 2008)

2.2 Perceived stress

No concept of "stress" is commonly accepted Orlans (1991) concluded that although large amounts of stress information were created and available, considerable disagreement persisted Originally, stress was considered a burden from the environment, followed by a stress from the person (Orlans, 1991) The accepted meaning today is one of the interactions between circumstances and individuals (Michie, 2002) The term "stress", that is used nowadays, was put forward by Hans Selye in 1936, who identified it as a non-particular reaction of the body to any need for alteration Stress is the reaction

of the body to any condition, burden or influence that menaces the physical well - being of a individual Stress is a polymorphic concept: in everyday life,

we experience stress in many different aspects of our activities: at work, at home, at school, and even in physical activity, sports are also considered stress, stress is always around us Stress can be helpful and good as it

developing Roy's theory is identified as the transaction between the environmental needs of the person's coping and responses (Roy & McLeod, 1981) Stress psychology refers to a connection with the environment beyond the available coping capacity (Lazarus & Folkman, 1984) Stress can be identified as relied on the response (i.e occurring from a person's response to

an incident), relied on the effect (i.e the consequence of the incident) or interaction (i.e., relation between stimulation and response) (Furnham, 2005) Stress and stress events in the hospital of nursing students have been studied by several researchers (Akhu-Zaheya et al., 2015; Al-barrak, El-nady,

& Fayad, 2011; Alzayyat & Al-Gamal, 2014; Karaca et al., 2017; Mohamed

& Ahmed, 2012; Pulido-Martos et al., 2012; Shaban et al., 2012; Sheu et al., 2002; Zhao, Lei, He, Gu, & Li, 2015) Nursing students experienced and disclosed stress increases throughout their nursing curriculum (Bremner et al., 2008; Jimenez et al., 2010; Shaban et al., 2012) Acording to Burnard et al,

nursing students must endure stress when disclosure to unknown environments in personal practice and stress, consist of individual relationships, a sensation of value, faith, outlook and future, educational matters and financial matters (Burnard et al., 2008) In addition, some researchers have explored that stress take places in the early stages of clinical practice more than at any other stage (Akhu-Zaheya et al., 2015; Karaca et al., 2017; Mohamed & Ahmed, 2012; Pulido-Martos et al., 2012; Sheu et al., 2002)

The stressors of nursing students can be showed in three categories: 1 stressors in learning (eg, being examined, scared of failure in theoretical knowledge, and issues with an interest in studying nursing) 2 Stress factors

in clinical practice (eg, exercises, environment, anxiety over making mistakes, scared of giving negative reactions to a dying or suffering patient, and relationships with people other in a facility) 3 Personal / social stresses (eg, economic matters and imbalances between home and school work) (Pryjmachuk & Richards, 2007) But in this study, I mention stress in clinical practice The research of stress in the empirical implementation of nursing training has recognized the following normal stressors: being responsible for caring for the sick, face a dying patient, lack of support and confidence in clinical training Zupiria et al (2007) stated that other causes of stress for nursing students including low capacity, reluctance, frailty, exposure to distress, overloading, emotional involvement, difficult patient relationships, relationships with instructors, mates and finally patients wanting a close connection (Zupiria Gorostidi et al., 2007) Kim & Duda (2003) reported a number of special clinical circumstances that lead to higher levels of stress among students including: being late, overseed by tutors, talking with physicians, and beginning clinical practice (Kim & Duda, 2003)

According to many studies, workload and assignments are the highest causes of stress for nursing students in hospital practice A research of Alsaqri

conducted in Saudi Arabia showed that the major cause of stress were assignments and workload (Alsaqri, 2017) A same result is „„assignments and workload‟‟ and „„teachers and nursing staff‟‟were the main causes of stress in hospital practice (Hamaideh et al., 2017) Zhao et al aslo showed that assignments and workload were the highest sources of stress (Zhao et al., 2015) Stress from assignments and workload [mean (SD) =2.68 (0.58)] were the highest source of stress recognized (Labrague, 2013) The cause of stress for nursing students came mostly from assignment and the hospital condition (Shaban et al., 2012) The main cause of stress were stress from assignment followed by stress from patients‟care and stress from nursing (Khater et al., 2014) Most causes of stress were stress from assignments and workload, teachers and nursing, peers and daily life, and taking care of patients (Shdaifat

et al., 2018) Students‟ assignments were recognized as the most cause of stress, followed by stress of taking care of patients and stress from teachers and nursing staff The lowest cause of stress is from students‟ lack of professional knowledge and skills (Akhu-Zaheya et al., 2015) The highest three perceived stress means were 3.07, 3 and 2.97 concerning assignment & work load, teachers & nursing staff, peers and daily life correspondingly indicate high levels of stress While the lowest perceived stress mean was 2.58 concerning lack of knowledge & skills show a moderate level of stress (Elsayes & Obied, 2017) But in research of Chan et al the highest cause of stress was lack of professional knowledge and skills (Chan et al., 2009) In addition, results of Karaca et al showed that stress was caused by instructors, nursing staff, assignments and workload (Karaca et al., 2017) Three causes of stress were substantial which are stress from taking care of patients, stress from peers and daily life, stress from medical staff (Mohamed & Ahmed, 2012) From reflection and discussions with the nurse tutors, who work closely with the nursing students, it was exposed that the stress was in correlation to the education and anxiety of caring for patients in the hospital,

anxiety of disappointment and discharge from the curriculum (Rakmaneewong et al., 2013) The study of Elliott (2002); Beck (1993); Jones (2008) also showed that the aspects that cause stress among nursing students

in hospital practice were training of both the skills and knowledge essential for patient care were insufficient, their case load was too heavy, too many patients to care for, a reduced correlation with tutors, problems with managers, specifically those who did not have adequate capability and knowledge to provision students, or lack of mentoring skills and are not ready

to give guidance or are incapable to teach sympathetically (Beck, 1993; C Jones & Wylie, 2008; Elliott, 2002) Elliott (2002) stated that the clinical practice time caused stress to the nursing students because of the unaccustomed circumstances with nursing and medical devices that they are not skilled adequate to use positively and meet the requirements of patients (Beck, 1993; Elliott, 2002)

Pulido-Martos et al (2012) implemented a systematic review of literature on perceived stress in nursing students The highest cause of stress was the course loading include assignments and learning-related issues While clinical stresses include fears about unclear curriculums or using new technical equipment (Pulido-Martos et al., 2012) Ross and Goldner (2009) find that health care experts often form a negative attitude toward seeking help for stress during their clinical training (Ross & Goldner, 2009) The highest causes of stress in the clinical setting consist of first clinical practice, scared of implementation of practice skills, assessment of faculty, lack of support from nursing staff and differences in academic learning and the clinical setting (Moscaritolo, 2009) Pryjmachuk and Richards stated that there are 3 causes of stress among nursing students: resource of learning that combines evaluation and testing, assignment and scared of failure; the clinical source combines beginning clinical practice, scared of errors, patient death and student relationships with other medical staff; and private / social

resources combined with a lack of free time and finance (Pryjmachuk & Richards, 2007)

Sheu, Lin and Hwang (2002) analyzed students' stressors and psychosocial symptoms in the first stages of clinical practice (Sheu et al., 2002) Nursing students had finished their preliminary clinical training Stress for lack of skills and knowledge were the main stressful factors Stress from patient care is the second main emphasized factor to be aware of In this aspect, lack of experience and capacity to supply nursing care and given scores rated as one of the highest stressful factors (Sheu et al., 2002) Jimenez

social-et al., (2010) studied factors of stress in 357 nursing students It showed that nursing students stated higher levels of stress from clinical stressors rather than academic stress and other external stressors Among the stressors, stress from patient care was found to be one of the stressors In addition, the students showed that the greatest clinical stress was "seeing the pain and suffering of patients and loved ones." The most common stresses are clinical factors such as the provision of patient care, lack of knowledge and skills in the clinical setting, and practical exercises and workload An analysis of the differences between the three types of stressors showed that students perceived that clinical stress was more extreme than educational or exterior stress (p <0.01) (Jimenez et al., 2010) Sharif and Masoumi (2005) used a focus group to test the student experience Of the 90 undergraduate nursing students, 30 were sophomore nursing students, 30 junior nursing students and

30 senior nursing students Participators showed that clinical experiences were considered to produce stress and nervousness The results stated that initial clinical practice is a main reason of stress Nursing students showed that initial hospital practice was the most stressful More stressful is the anxiety of making mistakes in the hospital practice and being judged on their practice skills in the beginning of hospital practice Sophomore nursing students pointed out that stress arises from the concern of injuring patients in

clinical practice due to being deficient in knowledge and skill Senior nursing students showed that their stress diminishes as the training practice progresses, but pointed out that hospital practice was initially considered to be the main stressors in their education Among all nursing students, theoretical distance-practice is also a cause of stress They pointed out that the lack of theoretical incorporation into hospital practice was a perceived stress, as the difference between the definite behavior and the supposed behavior in the context of hospital disagree more in the nursing students They also reported feeling stressed because they are instructed in different procedures than what they have studied in the lab (Sharif & Masoumi, 2005)

With a continued nursing shortage, professional nurses continue to deal with different aspects of work, once again pointing out the importance of conducting stress interventions from the beginning of their training “If nurses are to integrate the ethics and skills essential for a long-career, self-care and stress administration methods must be integrated during nursing education programs” (Grossman, Niemann, Schmidt, & Walach, 2004)

2.3 Coping behaviors

Coping has been considered as a stable aspect that can help people preserve social psychological coping skills in stressful situations The response progression is a highly complicated reaction that happens when a person tries to eliminate stress or a cognitive danger from the condition Therefore, the real response to an environmental event may be as significant

as the event itself (Folkman, Lazarus, Gruen, & DeLongis, 1986)

Most of the research approaches responded to Folkman and Lazarus

endeavors done by mastering, tolerating, or reducing external and internal needs and conflicts "(a) Response actions are not categorized according to their effects (eg, as actual distortion), but by some characteristics of response

(b) This process includes behavioral and cognitive responses in the personality (c) The response involves a variance in individual behaviors and

is planned consecutively, forming a chain of responses In this case, response

is usually distinguished by a concurrent occurrence of different deed series, a connection of response sequences (d) Response deeds can be differentiated

by focusing on different factors of stress (Folkman & Lazarus, 1980) They can try to change the reality of the person - the environment behind negative emotions or stress (focusing on the problem) They may also involve internal factors and attempt to decrease negative emotional states, or alter the assessment of the required condition (emotional focus)

Coping influences contain three imperative areas: health, social functioning and psychological well-being These three areas are interdependent, and when one area is influenced all of areas are influenced

To cope with these stresses, the approaches accepted were hobbies and pursuit, self care, looking for social assistance and maladaptive behavior Responses to a response can be expressed as either positive or negative and as responsive (i.e reaction to a persons thoughts and feelings) or activity (responding to real stress situations or events) Response to an action or reaction may be positive or negative, relying on the condition and the substance of the reaction (Shields, 2001)

Students can not avoid these tensions In spite of this, in stress response approaches, the capacity to regulate the needs and responses to these factors will be more imperative than the substance of the stress The more suitable coping strategies help to reduce stress Consequently, students' stress study and coping strategies may have imperative inferences for higher education administrators (Shriver & Scott-Stiles, 2000) Coping is the intellectual and behavioral endeavor undertaken to control, withstand or minimize external and internal needs and disputes between them (Folkman & Lazarus, 1980) There are two kinds: primary and secondary A primary assessment is made

when the person appraises the problem at hand whether it is a damage or a profit, a menace or a trial If the main evaluation is negative, then it requests some kind of coping Secondary assessment takes place by assessing your own coping sources, encompassing physical sources, social sources, and psychological sources such as self-efficacy It points out that cognitive abilities, competence, and personal understanding have mediated the effects

of cognitive stress (Lazarus & Folkman, 1984) If stressed individuals are confident that they have sufficient coping behaviors, stress can be coped with and managed Albert Bandura stated that confidence is "a belief in a person's ability to organize and perform the actions necessary to manage future situations" (Bandura, 1995) Believing is one's capacity to achieve in a particular circumstances Bandura describes these faiths as the decisive factor

in how people think, behave and feel Self-reliance will look at the problems that are mastered, make a stronger commitment to their hobbies and activities, and recooperate promptly from failure and frustration

Results from the research on coping behavior of nursing students can see problem-solving behavior is the most used According to Shaban et al.: Problem-solving behavior, transference and staying optimistic were the main coping behaviors, while avoidance was the least regularly used (Shaban et al., 2012) The same is result of Khater et al and Shdaifat et al.: the highest coping behavior used by the nursing students was problem solving (Khater et al., 2014; Shdaifat et al., 2018) This result is also found in the study of Alsaqri: the highest coping behavior used by the students was problem solving, while avoidance was the least regularly used (Alsaqri, 2017) The main coping behaviors utilized were problem-solving and staying optimistic (Hamaideh et al., 2017)

Some studies have found other results Transference was the highest regularly utilized coping behavior by nursing students (Zhao et al., 2015) It consists of results by Zhao et al., transference was the highest regularly

utilized (Chan et al., 2009) While, the research implemented by Karaca et al stated that avoidance was utilized more regularly by nursing students (Karaca

et al., 2017) Around three quarters of the participants were senior nursing students (79%, 76%, 75% and 74%) they sometimes or always used wishful thinking, self-criticism, social withdrawal, and problem avoidance coping strategies separately to cope stress in hospital practice (Elsayes & Obied, 2017) AL-Zayyat and Al-Gamal (2014) implemented a vertical research with

65 Jordanian nursing students trained in psychiatric settings The results stated that nursing students used different coping behaviors to cope with the stress characteristic in their mental experiences Students used avoidance or transference (such as expecting others to solve problems, avoiding difficulties

in clinical practice, losing their temper, quarreling with others or eating a large meal and long sleep) found that clinical tensions were higher than those using problem-solving (such as setting goals to solve problems, result meaning of stress, applying other strategies to solve the problem and use past skills to solve the problem) Repeated high-levels of stress can make students unsuitable especially if students do not have the instruments to adequately deal with stress levels (Alzayyat & Al-Gamal, 2014) Research shows that age, education, GPA and dwelling are fine predictors of the use of delivery as a response (Shdaifat et al., 2018) The coping strategies used are leisure activities and leisure time, self-care, seeking social help and inadequate things like (crying, isolating ourselves and avoiding events tension) (Kaur et al., 2009)

In addition, response method such as the use of social assistance have been exposed to be efficient in administering the outcomes of stress and supporting personal well-being (Boey, 1999; Lo, 2002; Mahat, 1998; Payne, 2001; Tichy and Means, 1990) Hubbard et al stated that boosted levels of social assistamce were positively correlated directly with the involvement of positive health activities, consisted of sufficient nutrition, health promotion,

welfare and relaxation (Hubbard et al., 1984) In contrast, college students with lower social assistance are more likely to smoke and consume more alcohol in the face of the stress of examinations than those with higher levels

of social care (Steptoe et al., 1996) These results underscore the helpful outcomes that community assistance can be had on healthful lifestyle selections

Ceslowitz found a clinically useful influence and health outcomes of stress after coping with the problem (Ceslowitz, 1989), and others found similar gains for learning, presentation and student happiness (Lindop, 1999; Tully, 2004) Although students can not avoid the stress of clinical practice, their coping capacity is imperative to reaching achievement in their educational and social environment Their response has been recognized as a stabilizing aspect that can support them in adapting to social psychology during stressful states (Seyedfatemi, Tafreshi, & Hagani, 2007)

In summary, the stress of students in their hospital practice may be changed and affected by the coping behaviors they select to use Efficient coping behaviors support students present better in their education; coping strategies also help reduce stress for students The most beneficial coping behaviors are: transference (effort to retain a positive mind to stressful situations), problem solving and positive persistence (Shaban et al., 2012)

2.4 Effect of stress on student's physio-psycho-social status

Stress affects all individuals and has a profound impact on one's mind and health and well-being It is a feeling of tension and pressure, anxiety, and discomfort But it was also a part in incentive, coping and response to the environment Stress has a negative impact on health; consist of physical, psychological and behavioral confusions Response to stress: physiological responses, psychological reactions and social behavioral responses Stress is a complicated occurrence that has a substantial impact on students which can

upset them psychologically, psychosocially and their spiritual health and being

well-Physical and psychological stress can manifest as a stress reaction Physiological stress is identified as a modification in the exterior situation or a modification in the body that reasons physical or biological confusions in the cells that require some reaction to respond to a modification (Forshee & McCance, 2008) Psychological stress can also trigger a stress reaction The endocrine system and central nervous system show sympathy to emotional, psychological and social effects This sensitivity shows how an individual's thoughts and feelings about stress can produce endocrine neuronal reactions Psychological stress can lead to reactions or predictions Responding to a stressor is a physiological reaction as a result of a psychological factor (Forshee & McCance, 2008) Although there is no physical stress, psychological stress evokes a reactive physiological reaction For example, stress from exams can cause a person to undergo plentiful sweating or an rised heartbeat Though there is no physical stress in this circumstance, psychological stress from test consequences in a physical reaction to stress A possible reaction when the body creates a physiological reaction is basically anticipating a interruption in homeostasis (Forshee & McCance, 2008) Predictive feedback can be due to anxiety or memory The reaction may be a conditioned reaction, because individuals associate a particular incentive with risk Predictions of encounters with incentives can lead to physiological stress responses (Forshee & McCance, 2008)

In regards to stress affecting students H Kaplan & Sadock, (2000); Linn

& Zeppa, (1984) argue that optimality can improve education In spite of this, other researchers had the opposite opinion For example, Saipanish argues that stress can influence education and reminiscence (Saipanish, 2003) Similarly, Niemi & Vainiomäki suggest that stress can source mental and physical symptoms (Niemi & Vainiomäki, 1999); reducing students‟

confidence (Silver & Glicken, 1990) and impacting students‟ achievements (Saipanish, 2003)

Negative behaviors and the influences of stress can cause future health and psychological problems for nursing students Each student perceives and processes the stress differently It is important for every student to work tirelessly to maintain his or her ability to concentrate, operate and study

Stress is exceptionally imperative in learning because it can contribute to learning and human activity, however, it can lead to negativity (Yucha et al., 2009) The highest level of stress can improve education (H Kaplan & Sadock, 2000), however, excessive stress can source mental and physical symptoms (Burnard et al., 2008; Pulido-Martos et al., 2012) and may influence a student‟s success (Choi, Abbott, Arthur, & Hill, 2006; Elliott, 2002; Robbins, Allen, Casillas, Peterson, & Le, 2006; Trautwein, Lüdtke, Marsh, Köller, & Baumert, 2006; Was, Woltz, & Drew, 2006) It is said that

"stress and anxiety hamper attention, memory and problem solving capability, thereby negatively affecting academic achievement" (Beddoe & Murphy, 2004)

The negative impact of stress on students may consist of physical, psychological and behavioral confusions (Pulido-Martos et al., 2012) High anxiety levels may affect sleep, which in turn could affect clinical practice, test performance and an ability to focus in the classroom Stress can also reduce communication, effective relationships between individuals and empathy towards others (Kendrick, 2000) Hensel and Stoelting-Gettelfinger report that stress reduces students' capacity to think clearly, so by hampering the student's specialized development (Hensel & Stoelting-Gettelfinger, 2011) Prato and Yucha (2013) argue that nursing students are stressed and anxious while taking a test may not be able to prove their true comprehension and may be perform unwell in the learning modules of the nursing course (Prato & Yucha, 2013) A research conducted at Tanta University, Egypt with

400 fourth year nursing students had (2.84, 2.79 and 2.68) mean scores

correspondingly showed reduced health problems (Elsayes & Obied, 2017) The psychological condition of nursing students has an instant effect on their daily lives, educational achievement, quality of their nursing care and even the stability of the nursing group

In this research area, I mentioned nursing students' responses to stress as reflected in three factors: physical health, mental health, and behavioral health As a result of some studies: The most common reaction to stress was behavioral symptoms (Sham, 2018) Labrague conducted a study in the Philippines with 61 nursing students, they found that emotional symptoms were the most common reaction to stress (Labrague, 2013) Physical symptoms such as increased heartbeat, hypertension, headache and ulcers are often experienced by nursing students (Shaban et al., 2012) The highest

stress developed by nursing students was social behavioral symptoms, which triggered unhealthy behaviors such as smoking, drug and drinking use (Sham, Sham, 2018) According to the results of Sheu et al., the highest symptoms were social behavioral symptoms (Sheu et al., 2002)

Stress is closely relationship with psychological status (Allen, Kennedy, Cryan, Dinan, & Clarke, 2014; Luo & Wang, 2009), it is essential to improve the considerate of stressful experiences of nursing students in clinical courses (Alzayyat & Al-Gamal, 2014) whether students are adequately equipped with effective coping skills to control clinical stress in the future Furthermore, it is essential to recognize early physical, emotional, social behavioral symptoms

of students in the clinical practice for timely intervention to prevent unwanted effects of stress on students