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Nurse Education Today (2007) 27, 808–818

Nurse
Education
Today
intl.elsevierhealth.com/journals/nedt

A descriptive study of Bruneian student nurses’


perceptions of stress
Philip Burnard a,*, Hajah Thaibah Binti PDPD DP Haji Abd Rahim b,
Derek Hayes b, Deborah Edwards a

a
School of Nursing and Midwifery Studies, Cardiff University, Wales, UK
b
Penigiran Anak Puteri Rashidah Sa’adatul Bolkiah College of Nursing, Brunei Darussalam

Accepted 22 November 2006

KEYWORDS Summary While much has been written about stress in nursing in the ‘West’, less
Stress; research has been done on this issue in many ‘Eastern’ countries. This paper offers
Student nurses; the findings of the first study of stress in student nurses in Brunei. The paper
Brunei; describes a study of 20 Brunei nursing students and their views about stress in nurs-
Nurse education ing. A modified grounded theory approach was used in collecting and analysing data
(and the ‘modifications’ are described). Findings were organised around the
themes: stressors, moderators and outcomes [Carson, J., and Kuipers, E., 1998.
Stress management interventions. In: Hardy, S., Carson, J., Thomas, B. (Eds.),
Occupational Stress: Personal and Professional Approaches. Stanley Thornes, Chel-
tenham. pp. 157–174.].
Students often found their status as students caused them stress in the clinical
setting: with other nurses, with doctors and even with patients. Academic related
stressors included having to complete assignments and having to study in English.
Various ways of moderating stress were reported including talking to ‘trusted
friends’, engaging in sports or simply being quiet. Positive and negative outcomes
of stress were identified: stress could lead to mental illness but, also, it could be
motivating. This report concludes with a Weberian ‘ideal type’: a composite
word-picture of the findings.
c 2006 Elsevier Ltd. All rights reserved.

Literature review (1984). Although many definitions of stress and


coping exist the majority of research conducted
Stress, coping are the guiding concepts of this with nursing literature utilise this approach. Laza-
study, reflecting the view of Lazarus and Folkman rus and Folkman (1984) define stress as
* Corresponding author. Tel./fax: +44 2920 743738. ‘‘a particular relationship between the person and
E-mail address: burnard@cardiff.ac.uk (P. Burnard). the environment that is appraised by the person as


0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2006.11.002
A descriptive study of Bruneian student nurses’ perceptions of stress 809

taxing or exceeding his or her own resources and  Finances (Beck and Srivastava, 1991; Clarke and
endangering his or her well being.’’ Ruffin, 1992; Thyer and Bazeley, 1993; Brown
and Edelmann, 2000; Timmins and Kaliszer,
It is recognised that nursing is a stressful occupa-
2002).
tion (Jones and Johnston, 2000; Bennett et al.,
 Female students experienced higher levels of
2001), and that the problem of stress first becomes
stress than male students (Tully, 2004).
evident during nursing training (Rhead, 1995).
 Not being treated as an adult learner, confusing
Stress has been identified as an important psycho-
assignment guidelines and the amount of self-
social factor in the educational process because it
directed learning (Hamill, 1995).
may influence academic performance and well-
 First year of academic study (Wang, 1991).
being. Studies conducted within the UK among Pro-
 Higher stress levels for those enrolled in a part
ject 2000 students, in USA, Australia and Ireland
time evening programme. (O’Connor and Bevil,
have identified a wide variety of stressors associ-
1996)
ated with their course of study and clinical
 Showed a relationship between stress and aca-
experiences.
demic performance (Maville and Huerta,
Clinical stressors
1997).
 Handling emergencies in the clinical area
Various studies have been conducted in a variety
(Clarke and Ruffin, 1992).
of other countries (South Africa: Basson and Van
 Initial ward experiences (Mahat, 1998).
der Merwe, 1994; Nepal: Mahat, 1996; Jordan:
 Clinical experience for those students in the
Abu Tariah and Al-Sharaya, 1997; Israel: Admi,
care of children courses (Oermann and Stand-
1997; South Africa: Kirkland, 1998; South Africa:
fest, 1997).
Gwele and Llys, 1998; India: Saxena, 2001; Taiwan:
 Death of a patient (Clarke and Ruffin, 1992;
Sheu et al., 2002) and have reported similar
Rhead, 1995; Timmins and Kaliszer, 2002).
findings.
 Lack of practical skills, negative attitudes of
Lindop (1989) suggests that many of the stress
ward staff and misunderstanding of supernumer-
reactions in nursing students go unnoticed with
ary status (Hamill, 1995).
the consequence that stress levels increase until
 Relationships with clinical staff (Hamill, 1995;
a person responds by leaving the profession. Stress
Thyer and Bazeley, 1993; Lo, 2002; Timmins
does not always have negative effects only but also
and Kaliszer, 2002; Evans and Kelly, 2004).
positive ones. The effect of stress on health de-
pends on the adequacy of coping behaviours. Cop-
Academic stressors
ing behaviour is described as the
 Pressure of grades or fear of failing (Beck et al., ‘‘continuous effort to overcome the unbalanced
1997; Sheu et al., 2002; Jones and Johnston, condition caused by internal and external
2000). demands.’’ (Lazarus and Folkman, 1984, page 141)
 Intense amount of work (Beck and Srivastava,
When effective coping strategies are used, the
1991; Clarke and Ruffin, 1992).
emotions can be adjusted and the stressful situa-
 Evans and Kelly (2004).
tion can be resolved. Coping efforts may be direc-
 Study associated with the programme (Clarke
ted toward changing the environment (problem-
and Ruffin, 1992; Thyer and Bazeley, 1993;
focused) or inward toward changing the meaning
Jones and Johnston, 2000; Evans and Kelly,
of the event (emotion-focused or palliative). Much
2004).
is still unexplored about the coping processes of
 Lack of free time (Beck and Srivastava, 1991;
nursing students and only eight studies have inves-
Jones and Johnston, 2000).
tigated this (Jones and Johnston, 1997; Kirkland,
 Finding academic work difficult including exam-
1998; Brown and Edelmann, 2000; Mahat, 1998;
inations (Beck and Srivastava, 1991; Clarke and
Lo, 2002; Sheu et al., 2002; Tully, 2004; Evans
Ruffin, 1992; Beck et al., 1997; Evans and Kelly,
and Kelly, 2004).
2004).
As this literature review shows much has been
 Long hours of study long hours of study (Beck
written about stress in nursing in the ‘West’, and
and Srivastava, 1991; Jones and Johnston,
less research has been done on this issue in many
2000).
‘Eastern’ countries. All of the research with a few
 Relationships with academic staff (Hamill, 1995;
exceptions where open ended questions have been
Thyer and Bazeley, 1993; Lo, 2002; Timmins and
used has been of a quantitative nature. This review
Kaliszer, 2002; Evans and Kelly, 2004).
has also identified that further work is also needed
810 P. Burnard et al.

to explore coping within the student nursing popu- close their names and by ascribing a number to
lation. The aim of this study was therefore to iden- each of the transcripts. It was explained to stu-
tify aspects of stress and coping as described by dents that the researchers were interested in
nursing students in Brunei Darussalam using a qual- those students’ views about stress and nursing,
itative approach. Brunei is a small Islamic sultanate that their names would not be recorded and that
in northwest Borneo. In cultural terms, Brunei is a they were under no pressure to take part in the
collectivist (as opposed to an individualist) culture, research and that, if they chose to, they could
with a strong emphasis on the centrality of the withdraw at any time.
family and on the ‘group’ rather than on the ‘indi-
vidual’ (Hofstede, 1994).
The country’s current College of Nursing opened Sample
in 1986, and offers nurse education up to diploma
level and a range of post-registration courses. A purposive and convenience sample (Coyne,
The nursing curriculum is broadly based on a British 1997), comprising 20 Bruneian nursing students
model, although includes many specific cultural undertaking the Diploma in Nursing course, took
references including the teaching of the philosophy part in the study. Seventeen respondents were fe-
of Melayu Islam Berja (MIB). This blends Malay tra- male and 3 were male, all within the age range of
ditions and culture with the religious teachings of 21–26 years. One female respondent was married
Islam and calls for loyalty to the state and mutual and the rest of the sample was single. The students
respect between ruler and subjects. were drawn from all 4 years of the Diploma course.

Data collection
Research approach
All respondents were interviewed, using a semi-
This was a descriptive, qualitative study using a structured approach. All interviews were con-
grounded theory strategy (Strauss and Corbin, ducted in Brunei and in the medium of English.
1998; Glaser, 1998). However, the ‘modifications’ Most Bruneians’ first language is Malay but English
of the grounded theory approach included the is taught in all schools in line with the official gov-
use of thematic content analysis and the report- ernment bilingual policy (Jones et al., 1991). Nurs-
ing of a considerable number of direct, verbatim ing students are taught and examined in English.
quotes from the data, within a framework sug- In keeping with the grounded theory approach
gested by Carson and Kuipers (1998) (described being used, interviews were modified to clarify, ex-
below). The study also draws together the find- pand on or reject concepts and ideas that arose
ings into an ‘ideal type’ (after Weber, discussed during previous interviews. Interviews were con-
below), as an alternative approach to the gener- ducted until ‘saturation’ had occurred. This was
ation of a theory. achieved by interview 18 and reasonably confirmed
Describing grounded theory procedures, Strauss by interview 20. All interviews were recorded and
and Corbin (1998) suggest: analysis was carried out on the verbatim accounts
of the respondents.
. . .these procedures were designed not to be fol-
lowed dogmatically but rather to be used crea-
tively and flexibly by researchers as they deem
appropriate.
Data analysis
The study also contains ethnographic features, A constant comparative method was used, in which
in that it reports cultural issues that may be spe- each new transcript was compared and contrasted
cific to the location of the study (Bodley, 2000). with previous ones. This helped in both the framing
of new questions and also in helping to identify cat-
egories of data. Transcriptions of the interviews
Ethical issues were also analysed via thematic content analysis
(Burnard, 1991), involving organisation of the data
A full research proposal was submitted for ethical into categories and sub-categories, through the
approval and approval obtained. All respondents search for emerging themes. The aim of this process
took part in the study because they freely agreed was to account for most of the data under this cate-
to do so and all data were anonymised. Anonymity gory system. The category system was also checked
was achieved by not asking the students to dis- and validated by an independent adjudicator.
A descriptive study of Bruneian student nurses’ perceptions of stress 811

Findings These responses point to the emotional aspects


of stress and, broadly, their causes in both clinical
Carson et al. (1997) reports that studies, which and academic settings, with emphasis placed on
attempt to investigate specific stressors, should both people and on environmental considerations
add to the robustness of the study by locating (themes that were developed in more detail in
the research into an empirically derived, field these and other interviews).
tested model of the stress process. The catego-
ries that were derived from the content analysis Clinical stressors: ‘wearing pink’
were therefore located within Carson and Kuipers
(1998) model of stress which identifies three com- A pink uniform denotes the grade of (and, for some
ponents: stressors, moderators and stress out- respondents, seems to symbolise the status of) stu-
comes. Stressors are seen as arising from three dent nurse. Indeed, uniform colour appears to in-
main sources: those relating to one’s occupation, form other staff of how students should be
major life events and hassles, and uplifts. The fo- treated and viewed. Brunei is a hierarchical society
cus of stressors in this study was on occupational and, within the nursing profession, it would appear
and academic stress. The critical factor in the that those who wear pink occupy the lower rungs of
model is the mediating or buffering factors which that hierarchy. This is a source of stress for some of
the students can call upon to help them. Modera- the students.
tors are those processes that students can call on
to help them cope with the external stressors We are wearing a pink uniform and the staff nurses
that are impinging on them. The focus of moder- wear a different colour and this creates a barrier
ators in this study was on coping skills. Stress out- and we cannot object to anything. When we are
comes are then determined by the nature of the criticised; we can’t answer back. This can be
occupational and academic stress and by the cop- stressful. (R9)
ing strategies that are used manage such Because we are still students and attached to clini-
experiences. cal areas, sometimes we have to adapt very quickly
to the environment, get to know the other staff, the
doctors (what they like and what they don’t like) and
Stressors
most of our opinions may not be acceptable. We are
The themes that emerged within this category still students so we cannot say very much – we are
were nursing as a stressful activity, clinical stress- wearing the pink uniform! (R10)
ors: ‘wearing pink’, academic stress and ‘paper- Status in the nursing hierarchy was a theme for
work’, and language. many of the respondents, perceiving a sense of ten-
sion at being a student in a clinical setting. On the
Nursing as a stressful activity one hand, their lowly status may make it difficult
to receive help from others; on the other, senior
A number of respondents were able to define, in staff may expect them to have certain knowledge
general terms, what they meant by the term and skills that they, the students, felt they did
‘stress’ and how both clinical and academic as- not possess. However, the degree to which this
pects of nursing contributed to it: was stressful varied:
Stress is very common in nursing. My definition is It is the staff there [in the clinical setting]. Because
that it is a mental disorder because it affects our sometimes I don’t feel very good in doing the skills
mental state and it involves us emotionally. As a and I feel they criticise me. Clinical practice isn’t
student, I have been going to the clinical place- always stressful: sometimes it is. (R17)
ment and I have found stress in the hospital. Some Lack of communication between the staff, in the
of the pressure is peer pressure and sometimes it is clinical setting is very stressful – there is a dis-
from other staff and lack of facilities in the hospi- tance between students and trained staff. (R1)
tal – poor management sometimes. At the end of
the day I feel very stressed. (R1) Sometimes, too, the volume of work expected of
students was seen as a stressor. The uncertainty of
Well, what is stressful in nursing is the way it is what might be expected of them also lead students
managed. The system, the nursing schedule, to doubt their own abilities:
sometimes the people and the environment: both
in the college and in the clinical setting are stress- In clinical it is stressful because of workload and
ful. (R6) sometimes the nurses tend to ask students to do all
812 P. Burnard et al.

the simple things, like taking temperatures, taking Academic stress and ‘paperwork’
patients to X-rays and so on – they are more likely
to ask students to do that – we have to do so much! College life and the nursing education system were
I like the clinical work but I find it very stressful and significant stressors for some respondents. Various
more stressful than working in the college. We are themes were frequently mentioned: having to com-
new and we do not have much experience and this plete assignments and dissertations, the organisa-
gives me a very stressful feeling when I do not have tion and changing nature of the college and the
the skills I feel I should have. (R8) college environment itself. Often, the written work
was referred to as ‘paperwork’, perhaps to be con-
A constant theme throughout the study was rela- trasted with the more ‘practical’ or ‘hands on’ ap-
tionships between students and trained nursing proach taken in the clinical setting.
staff. Where trained staff were prepared to help,
support and teach students, stress seemed less evi- I guess working in the college is more stressful than
dent. However, it often appeared that senior staff clinical – you tend to have to do more paperwork.
would not adopt teaching/supportive roles, but ex- It is the time management that is difficult. (R4)
pected students to still be able to demonstrate It is more stressful in the college because I love to
nursing skills and knowledge: work in the clinical area. When I am in the college I
Somehow, in the clinical area, if we are very close have to think about my paperwork, the disserta-
to one person, they tend to show you how that area tion, the exams, the people around me, the study
works, but if you do not get close to a person, you schedule. . . (R6)
may be just told to get on with it. . .If communica- For some, academic ‘paperwork’ was extremely
tion is not very good, in the clinical setting, some- stressful. The following respondent notes that the
times staff talk about you behind your back. (10) dissertation, in particular, was the most stressful
There is only one thing that is stressful in clinical activity she had taken part in to date:
practice and that is mingling with the seniors who In the college we are stressed because we have to
look down on us and who do not want to teach learn a lot of theory and every year we have our
us. (R18) assignments to do and these are very stressful.
It sometimes appeared to be a case of the de- We didn’t have much guidance for the disserta-
gree to which students could ‘manage’ other peo- tions. The dissertation was the most stressful thing
ple. One student suggested the difference I have done in my life. Sometimes we have to do
between the clinical setting and the academic set- lectures in front of peers and that is very stressful
ting in terms of this type of management: and particularly when the lecturer gives you the
title very late.
It is more stressful in the clinical area because in
the college we can deal with the teachers and they Language
know how we feel. (R10) [emphasis added]
Caring for patients and staff shortages were other As we have noted, in Brunei, nursing is taught in
sources of stress. Due to the human element of English but practiced in Malay, reflecting another
nursing and the need to deal with physical, psycho- source of stress for some students.
logical and social issues, many students perceived We have presentations in front of our colleagues,
nursing as more stressful than other occupations: our English is not good and we tend to feel down
For me, nursing is more stressful than other jobs and have negative thinking. I feel my English is
because we are dealing with human beings, not not good, due to teachers cannot understand, and
only to cure them but we deal with their physical, explain: they cannot understand, and it causes us
psychological and psychosocial [problems]. (R1) to fail English tests. (R13)

Nursing is stressful, it is a very stressful job because In the college, studying in English is the main prob-
when I did my occupational health option, I visited a lem for most of the students in Brunei. I like to
website and it showed nursing to be one of the most learn in English but I have difficulty in understand-
stressful occupations. I think it is, because in clinical ing sometimes: that’s why I feel stressed. (R11)
nursing, we have to care for people in a ward and Discussions with the college’s educational staff
there are too many patients and too big a workload. also indicated that students better English writing
There is conflict with colleagues, doctors, relatives skills tend to be more successful in their examina-
and even the patients themselves. (R3) tions, assignments and dissertations.
A descriptive study of Bruneian student nurses’ perceptions of stress 813

Moderators Trusted friends

Moderators are the processes that are used to A number of the respondents said that they could
either relieve stress or modify it into a form that talk about their stress to ‘trusted friends’. These
makes it acceptable, and students used a range trusted friends could be described and compared
of techniques to manage stress. The themes that and contrasted with more general friends; or
emerged within this category were interpersonal ‘friends you hang out with’.
issues, trusted friends, sports and hobbies, prayer
Trusted friends are ones who understand me at the
and nature, organisational and institutional moder-
same level, depth. Trusted friends are ones you can
ators and other ways of coping with stress.
share your feelings with – but not, normally, your
depression. Trusted friends are normally my age.
Interpersonal issues (R18)
A trusted friend is someone you can trust, someone
Stress was often moderated through other people. you are really close to, someone who knows your
Students spoke to friends, to their tutors and some- background, someone who understands your feel-
times – but by no means always – to their parents. ings and who is much the same as myself. Other sorts
Some felt that they would only burden their par- of friends are just ones you hang out with. (R20)
ents by talking to them about stress.
For one respondent, having trusted friends was a
I talk with my friends, sometimes they joke with vital asset. Other sorts of friends might not be reli-
me and they take me window shopping or we go able or they may even be potentially threatening:
to the cinema and also I call my parents. (R7)
It is not easy to find a trusted friend, some friends
I watch TV or go out with friends. Also we eat. I can are back-stabbers. When you face difficulties they
talk to my friends about things that stress me but if just drift away from you and back stab. A trusted
they are personal I keep them to myself. I can also friend will help you in difficulties and help you
talk to my sisters – one of my sisters is also a nurse. out. Sometimes there is bullying: I was one! I
I can talk to my mum but mostly I keep things from nearly quit: they were not good. A ‘trusted friend’
her. (R5) [is] someone you can confide in. Other friends are
The social and ‘joking’ function of friends was just ones to hang out with and have fun with.
often referred to: it would appear that rather than (R19)
having ‘deep’ discussions about stress, the function
of friends was often to joke and help relieve the Sports and hobbies
tension. Sometimes, friends were chatted to after
the initial feelings of stress had passed. The follow- A number of students referred to sporting and
ing respondent did not appear to need friends while other hobby activities as means of moderating
acutely stressed and preferred not to worry her stress:
parents about her stress:
I also play sports, so I think that I give out all of my
I don’t talk to my friends until I have calmed stress in my sports – I play netball and badminton
down – after a few days. I do need friends to – this is organised by the college. (R2)
talk to but not immediately when I feel stressed.
I do not share with my parents when I am I prefer to go bowling and do some outdoor activities
stressed – I do not want to make them more – go to the beach. I talk to my friends – they are very
stressed about my studies because they are pay- supportive and my family are also supportive. (R4)
ing for my studies – I do not want to make them
feel anxious. (R10) Prayer and nature
Similarly, another student preferred to attempt
For some, a form of communion with nature was a
to calm herself first, before talking to friends. If
means of relieving stress. This was sometimes
this failed, friends or tutors could help:
linked to a religious theme:
If I am stressed I feel I don’t want to talk to anyone:
Above all, I go to lonely places, lakes, appreciate
I want to think about my problem on my own. If I
God’s creation. (R14)
cannot, I will find someone I really trust and who
can help me, like my husband. If he cannot help I When I am stressed I go to the sea and shout at the
can talk to a best friend or a tutor. (R11) sea. (R6)
814 P. Burnard et al.

The latter response seemed to be a form of both tai chi. Sometimes if I cannot cope, I cry and this
catharsis and social isolation; it seemed important helps to release tensions. (R3)
to be able to get away from others but also to have
This student notes the availability of a counsel-
some form of ‘safe’ emotional release.
lor, but also alludes to a certain stigma attached
to going to see such a person. In collectivist cul-
Organisational and institutional moderators tures, it is frequently the case that people will talk
about their problems most readily to their family
Many students articulate examples of what they and friends, rather than to a disinterested outsider
felt could be done to lessen stress within the nurs- (Hofstede, 1994). This student also summarises a
ing profession. These ideas might be thought of as range of methods discussed by many of her col-
‘organisational moderators.’ In the first example, leagues in the study: crying, using humour, relaxing
the student felt that ‘someone’ should be made by listening to music and talking to friends and
responsible for the issue of stress and also noted family.
staff and equipment shortages:
Nursing should provide a consultant who can solve
the problem. Also, I think that nursing officers Stress outcomes
should be able to work alongside doctors without
bias. The stressed person should be able to talk The themes that emerged within this category
to someone who they can trust. Shortage of staff were being motivated, somatic symptoms and psy-
is also a cause of stress and the lack of appropriate chological symptoms.
equipment – sometimes we only have one ther-
mometer for example. (R11) Positive outcomes: being motivated
Another student identified the human and caring
features that needed to be attended to in order to For some students, stress could be a motivator,
reduce stress; perhaps identifying a ‘core’ aspect forcing the individual to reconsider his or her posi-
of the health care professional/patient relationship: tion and to be challenged to do something:

It goes back to patient care, doctors need to Yes, I guess everyone has stress. Everyone has to
respect patients, and give a feeling of really being deal with it. Sometimes stress can make us self-
cared for, as well as nurses, for the patient and motivated. It makes you think further and further.
family. Not all do at the moment. New doctors (R1)
are better and there are signs of change. Latest We can learn to cope with it; we learn how to cope
things on internet, research on patient centered with difficult situations. (R2)
on bedside care – this will help all. (R14)
I think, it a way, it is important for one to have
stress: it is a signal to say ‘Hello! This is too much!’
Other ways of coping with stress This is one of the best things about stress. With
proper management of stress, it is a healthy to
Individual students identified particular, some- have some stress. Everyone has stress! Even if your
times idiosyncratic, ways of dealing with stress. pockets are filled with money, you still have stress!
One, for example, suggested: (R4)
Sometimes when I get home from work I like to put The last student, quoted above, notes both the
the music on very loud and drive so fast! (R8) ‘warning call’ of stress but also a way of rationalis-
ing stress by appreciating that ‘everyone has
Another student identified a range of strategies
stress’. However, one student felt unable to find
that she used to moderate the effects of work
anything positive in stress and suggested:
and study related stress:
I don’t think there are good effects of stress!
We have counsellors who can help, in the hospital
(R5)
for all the working people, if they have stress.
Some people feel guilty about seeing a counsellor
and say ‘talk to your friends and family’. I like to Negative outcomes: somatic symptoms
talk to my mother, my family and my friends and
share with them what makes me feel stressed and Students described their experiences of stress.
seek their help. With humour, I deal with it also Stress sometimes produced somatic as well as psy-
and I also like to relax by listening to music, doing chological symptoms, and even changed appetites:
A descriptive study of Bruneian student nurses’ perceptions of stress 815

I feel a headache and sometimes not really mental described psychological symptoms of stress, such
block but I cannot do things when I am stressed, it as feelings of depression, anger, tension and
distracts me and stops me from doing things. It anxiety:
makes me a little upset but I do not cry. (R2)
Well I feel long and short term, my mood and
I get a migraine, I just want to bang my head behaviour changing, negative thinking, long term
against the wall and shout. (R6) I feel just, lonely, don’t want to speak to anyone
– my self-esteem is low, confidence low. (R13)
Its kind of like rough: I feel like shouting and I
become angry- even towards the person closes to I just keep myself in the room and get rest: I do not
me. In my stressed mood I get a high pitched voice. want to think any more until the stress has gone. I
(R8) also loose my temper sometimes. I don’t want to
talk to anyone. (R9)
When I am stressed I eat a lot. Stress really, really
affects my mood and my relationships with friends. I feel I can’t really do anything. I feel like crying
(R7) and normally I would look for my friends to have
a laugh or something. I try not to be angry with
I don’t know how to deal with the stress. Some-
people but sometimes I am without realising. (R16)
times I don’t eat. (R1)
The use of moderators seemed, in most cases, to
relieve stress (if only temporarily). A number of
Negative outcomes: psychological symptoms students noted, also, that there were both positive
and negative effects of stress; particularly unmo-
Negative effects – particularly long term effects – derated stress.
were noted by the students, including the ideas
that stress could cause depression and other men-
tal illness, and might even lead students to leaving
Ideal type
their training. However, one student also seemed
Finally, the findings were used to produce an ‘ideal
particularly aware of the immediate effects. She
type’: an idealised word-picture of an ‘aggregated’
noted that one may lose friends in the processes
Bruneian student and her/his relationship with
of becoming or being stressed:
stress. Originally developed by the sociologist,
I find stress is always negative and it can give you Max Weber (Coser, 1977), the concept of an ideal
mental problems and you will be like in stress all type is a model, and perhaps a set of exaggerated
of the time and ignored by people and you let it characteristics defining the essence of certain
out to people and you will loose people – they will types of behaviour observable in the real world.
just go! If you are not stressed, people will come to The ideal type, then, is formed from characteris-
you. If you are stressed, people will leave you! tics and elements of a given phenomenon (in this
(R19) case students experiencing stress), and is intended
to illustrate certain elements common to most
For some others, negative views of stress were
cases of that phenomenon. It is not, however,
almost the mirror image of positive ones:
meant to correspond to all of the characteristics
I think stress can demotivate you. You feel not of any one particular case, or to reflect statistical
comfortable and you do not accept what people averages. The ideal type as defined by the current
say to you and you feel unlikable. You work with data is as follows:
less confidence and you feel lost in the ward. You
The Bruneian nursing student comes from a close
become lonely and don’t want to talk to people
family background. She is usually Muslim. She has
and you say to yourself: ‘I am not that good’. (R10)
a circle of friends, some of whom are trusted
Again, the suggestion, here, is that stress can friends – people she can talk to about problems
make you unpopular. This may go some way to and to whom she will turn before she talks to her
explaining some students’ reluctance to talk to parents. Others are simply friends to have fun with
the friends and family about stress. Again, in col- – and ‘having fun’ or joking is an important feature
lectivist cultures, a sense of inclusion and a sense of friendship. In clinical nursing, she finds herself
of oneness with friends and family is very impor- having low status and may or may not be helped
tant (Hofstede, 1994). to learn by more senior staff. In the nursing col-
In stressful times, some wanted to be with lege, she finds the physical environment not always
friends but others wanted to hide themselves away conducive to study and finds learning resources
until the stress feelings had passed. Students often sparse. She sometimes feels overwhelmed by the
816 P. Burnard et al.

diet of assignments and by completing the disserta- and outcomes of stress (Carson and Kuipers, 1998).
tion – the ‘paperwork’. Having to learn and write Students often found their status as students
in English, rather than her native language (Malay) caused them stress in the clinical setting: with
causes problems. Out of all this she experiences other nurses, with doctors and even with patients.
stress. This manifests itself in various ways: some- Academic related stressors included having to com-
times she feels like crying and sometimes she plete assignments and dissertations which has been
wants to shut herself away in her room. To allevi- identified internationally has an area of concern for
ate the stress, she may engage in sporting activi- nursing students (Beck and Srivastava, 1991; Clarke
ties, listen to music or talk to her trusted friends. and Ruffin, 1992; Thyer and Bazeley, 1993; Beck
She may not, immediately, talk to her parents, et al., 1997; Jones and Johnston, 2000; Sheu
for fear of worrying them unnecessarily. She feels et al., 2002; Evans and Kelly, 2004).
that both the nursing college and the clinical set- It is recognised that students possess language
tings could be better organised and resourced and difficulties that affect their academic achievement
realises that shortage of clinical staff contributes in nursing programs where English is their second
to work-related stress. language (Petro-Nustas et al., 2001; Pardue and
Haas, 2003). A key stressor identified by this study
was having to study in the medium of English. Stud-
Limitations ies conducted where nursing is taught in English in
other countries have noted that English language
A limitation of this study is, perhaps, the less than skills are important skills as they can facilitate the
detailed reference to Islam and its effects on the acquisition of up-to-date scientific information and
students’ perceptions of stress in their work and promote life long learning (Abriam-Yago et al.,
study. Furthermore it should also be noted that 1999).
culture does much to define both how we concep- We note, in our findings, that the relationship
tualise psychological problems and stress and the between nursing staff (students and trained) on
degree to which we are prepared to discuss it with the clinical area was an important issue. This is also
a third party (in this case, with a ‘local’ researcher evident in the previous literature as demonstrated
and a ‘foreign’ one). This would explain why the by Hamill (1995), Thyer and Bazeley (1993), Lo
students did not discuss any of the more negative (2002), Timmins and Kaliszer (2002) and Evans
coping strategies i.e. smoking, comfort eating, and Kelly (2004).
medication, hostility, taking it out on others The Previous research has indicated that students
literature, in other cultural contexts, clearly high- reporting low levels of stress/distress use a number
lights this behaviour across a number of other stud- of coping methods to manage their stress for exam-
ies (Jones and Johnston, 1997; Kirkland, 1998; ple problem solving (Jones and Johnston, 1997;
Mahat, 1998; Lo, 2002; Tully, 2004). Mahat, 1998; Lo, 2002; Tully, 2004; Sheu et al.,
It should also be noted that the terms mental 2002), talking to others – relatives, friends and
health and stress mean different things to people peers (Evans and Kelly, 2004; Tully, 2004), recrea-
across different studies and therefore only tenta- tion and sport (Lo, 2002), social support – family,
tive comparisons should be made with other stud- spouse, partners workmates, classmates, lecturers
ies. Helman (2001) summarises the relationship of and tutors (Kirkland, 1998; Lo, 2002) Other coping
culture to psychological and mental health issues strategies reported included having outside inter-
in that it influences the clinical presentation and ests, using mentors, and having friends outside
distribution of mental illness and that it determines nursing (Brown and Edelmann, 2000), staying opti-
the ways that mental illness is recognised, la- mistic (Sheu et al., 2002), the desire to obtain a
belled, explained and treated by other members qualification, the need to finish something I started
of that society. and determination (Evans and Kelly, 2004) and bet-
ter studying techniques and time management
skills (Lo, 2002). In the present study various ways
of moderating stress were reported including social
Discussion support talking to friends and family, talking to
‘trusted friends’, engaging in sports or simply being
This paper reports a qualitative, descriptive study, quiet. There is a lot of similarity with previous work
using a modified grounded theory approach to but this paper reveals that talking to ‘‘trusted
researching stress in Bruneian students. Through friends’’ which was identified separately to that
interviews, students expressed their views about of talking to everyday friends and family is impor-
stressors (both academic and clinical), moderators tant for students from this culture.
A descriptive study of Bruneian student nurses’ perceptions of stress 817

Potential stressors will only lead to negative References


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