The Facilitators and Barriers in Coping with Clinical Stress: The Experiences of Nursing Students in Iran View PDF

About half of a nursing program consists of clinical course. These settings enable the students to put the knowledge, skills and concepts which they have acquired in the academic setting to use in actual patient care settings [1]. The experience of learning in the clinical setting is influenced by a variety of factors that can either reinforce or hinder learning in students [2]. In the process of dealing with patients in clinical settings, nursing students experience potential sources of stress [3,4]. Nursing students are reported to experience higher levels of stress than students of other health disciplines [5] and stress levels are constantly increasing among them [6]. A study conducted in Iran reported that 99.3% of students have above-average levels of perceived stress [7]. Stress can lead to poor physiological, psychological and social health [8], psychological burnout, disrupted learning and academic performance and decline in clinical performance in the students [9].

Coping is an important mediator of stress and illness. Nursing students should develop effective strategies for coping with the new stressors that they experience. Nursing requires good mental health and effective coping strategies. The coping strategies adopted by nursing students affect their physical and mental health and the quality of the services they provide. Studying coping strategies in nursing students and their contributing factors is therefore necessary for performing any kind of primary intervention [1]. Many studies have examined the stressors experienced by nursing students in clinical settings [10-12] and their coping strategies [13-15] however, despite the growing number of studies on clinical stresses and coping strategies in nursing students, there are very few descriptions available on the facilitators and barriers in coping with clinical stress. Learning about the facilitators and barriers in coping with clinical stress can enhance nursing students' knowledge of the key factors aff?ecting their coping and thus enable them to proactively manage this stress, and instructors can also take advantage of the findings of such studies for helping to students' better cope with clinical stress. Thus, the present study was carried out with the purpose experiences of the facilitators and barriers in coping with clinical stress through a qualitative method

This qualitative study was done using conventional content analysis method [16]. Qualitative studies provide an important tool for understanding information, feelings, and perceptions about the complexity of human responses that cannot be accessed through quantitative studies [17] and is one of the many qualitative methods available for the analysis of data and the interpretation of their meanings [18].

Sample and setting

The study setting consisted of Jiro  School of Nursing and Midwifery, Jiro University of Medical Sciences, and its associated settings, including hospitals and dormitories. Purposive sampling was used to collect data. The study participants were 19 undergraduate nursing students and two nursing instructors. The inclusion criteria for the students consisted of having taken at least one clinical course and having no previous history of working in hospitals; for the instructors, the only criterion was to have at least two years of experience teaching nursing. Maximum variation sampling was used to have participants from a diverse background in terms of age, gender, marital status and academic year. In this study, data analysis and collection was done simultaneously and this process took 6 months in 2016-2017.

Data were collected using semi-structured interviews held with the nursing students and based on their experiences of the facilitators and barriers in coping with clinical stress. The interviews began with general questions such as "How do you cope with the clinical stresses that you experience?" and "What factors effect on your coping with clinical stresses?” and more probing questions were asked to clarify participants' responses wherever necessary. Each interview lasted from 45 to 80 min. The interviews were held in a quiet place in the School of Nursing and at a time of participants' choosing, with the exception of two interviews that were held in the dormitory. All the interviews were conducted by the first author, who was not involved in the training and evaluation of the students and were recorded with participants' consent. Data saturation occurred with 19 interviews, but two further interviews were conducted to ensure saturation (Table 1).

Table 1:Overview of participant demographics.

Ethics

The research approved by the ethical committee center of jiro? University of Medical Sciences (ethic cod: IR.JMU.REC.1396.41). In order to observe ethical consideration, permission was obtained from the ethics committee of the jiro? University of Medical Sciences. Written consent was got from participants. While giving information about research purposes and obtaining consent for recording their voice, they were assured about the confidentiality of information. In addition, Participation was also voluntary. they were informed that they could leave the study whenever they want, but no one of them left.

Data analysis

The data was analysed by Graneheim and Lundman [19], who have proposed five steps for content analysis of qualitative data. ?ese steps are: 1) Writing the whole interview immediately after each interview. 2) Reading the interview transcripts several times to gain the concept of the whole, 3) Determining themes and subthemes of initial codes, 4) Categorizing the similar themes in a more comprehensive classes, 5) determining the latent content in the data. Therefore, the contents of interviews were immediately transcribed, typed and read many times. Codes were extracted and themes emerged. Then themes were categorized based on their similarities. At the end, the latent concept and content of data was extracted. To ensure that the data were authentic in all aspects, Lincoln and Guba’s evaluative criteria were used, including credibility, conformability, dependability and transferability [20]. To ascertain the credibility of the data, the researcher tried to collect valid data through prolonged engagement with the participants and immersion in their ideas and constantly summarized and repeated their statements during the interviews for clarification of their purposes. The codes and categories were shown to two of the participants for comments. An external check was also performed. For the conformability of the data, the complementary views of two faculty members with an expertise in qualitative research were also taken. The careful scrutiny of the data by the project collaborators in the course of its analysis helped ensure the dependability of the data. Maximum variation sampling, rich description of the findings and confirmation of the findings by two non-participating nursing students helped ensure the transferability of the data.

The findings obtained showed that the nursing students experienced stresses such as feeling of professional inadequacy, stressful relationships, confront to harrowing and disgusting scenes, clinical rotation, and irrelevance of theory to clinical practice and ineffcient training and evaluation.

The analysis of data three main themes:

1. Personal facilitators, with subthemes including motivational beliefs, family support and the influence of the individual context.
2. Professional facilitators, with subthemes including the attractiveness of the discipline, the joy of helping and a supportive professional network.
3. The uneven clinical path, with subthemes including barriers associated with superiors, a restrictive individual context and role conflict.

The majority of the participants were endowed with personal attributes that helped them cope with clinical stress, including beliefs, characteristics, personal experiences and family support.

Motivational beliefs

Some of the participants had beliefs that, when focused on, would help better cope with clinical stress, including beliefs about death as part of life, which often originated from their religious doctrines and helped them face the stress caused by a patient's death, or religious beliefs about concepts such as patience and reliance on God in the face of problems, which helped them in coping with the stress caused by their interactions with others (especially with patients), or the belief in the equality of humans based on virtuousness rather than academic discipline, or faith in the spirituality nursing as a field, since it creates an opportunity for helping others, saving lives and gaining God's satisfaction, which helped the students better cope with the profession.

One of the participants remarked:

"Being used to patience and reliance makes me tolerate problems better. To cite the Quran, God is with those who are patient" (N 9).

Family support

Family support had an important effect on participants’ coping with clinical stress, and the main sources of support perceived were participants’ mother or spouse, in the case of married students. In addition to helping reduce their stress, family support heartened the participants to continue in their chosen field and increased their desire to continue their nursing education and prevented them from quitting nursing. One participant explained:

Another participant described her experience of the support that she received from her spouse:

The instructor asked me a question, I couldn’t answer. She then gave me a contemptuous look and told me that I was such an unmotivated student. When I got home, I was so sad; I cried many times. My spouse consoled me and took me out for some fun and calmed me down" (N 6).

The Influence of the individual context

The results of this study showed that certain personal characteristics, experiences and histories facilitated participants’ coping with clinical stress, some of which were associated with demographic characteristics such as older age and having close relatives working in the health system. The older participants argued that patients accepted older students better and did not reject the nursing interventions offered by them and also said that older students were more respected by other personnel and had more experience in managing relationship stress.

Other personal factors concerned personal characteristics and capabilities, such as the informed selection of nursing, being interested in the chosen discipline, acquiring more nursing skills, having a higher threshold of tolerance compared to others and being forgiving and sociable.

One participant remarked:

"It’s easier for the personnel and patients to accept me because I’m older than my classmates" (N 19).

One participant commented on the e??ect of having prior familiarity with hospital environments:

"It was our first training. Everyone was stressed out because it was their first entrance to the hospital. I was much more comfortable than others though as I was familiar with this environment since childhood cause of my mother's job (operating room technician). As a kid, I even went to a kindergarten located inside X hospital" (N 16).

Another participant said:

"One of my qualities is that I communicate well with others. So whenever there’s any tension between me and other personnel or them patients or even the instructors, I can solve everything much better than others" (N 12).

In addition to personal factors, some factors associated with the nature of nursing as a field or the support that the participants received from persons related to profession such as the hospital personnel and instructors or their peers and even the patients helped them better cope with clinical stress.

The Attractiveness of the discipline

The majority of the participants argued that, although they were faced with many sources of stress in the clinical setting, they enjoyed the variety of new experiences it off?ered, which diminished their mental preoccupation with sources of clinical stress. For example, one participant said:

"We had just finished the first semester and the prospect of training was very attractive to us. So, despite working hard, we never got tired" (N 3).

Another participant said:

"We are faced with so many sources of stress –enough to make me think about quitting from time to time. But I can cope with the stresses and hardships much better when I remember the good things. Meeting new people, new cultures and people with different levels of health information the clinical setting requires creativity and flexibility from us. It has diverse fields and this is less o?en the case in other disciplines. These are all very enjoyable for me" (N 15).

The joy of helping

The participants unanimously acknowledged that helping patients, alleviating their pain and suffering and being involved in saving lives were enjoyable experiences that made them forget the hardships that they had had to bear. One of the participants described his experiences of this joy:

There was a young guy (patient) who had lymphoma and his family was poor and couldn’t afford the heavy medical costs and he had come to this hospital from a faraway town. My thoughts were constantly with this particular patient when I went back to my dormitory. I was so sad for him. But I had been able to comfort him and inform him about the charity organizations that were available to him that he knew nothing about and remembering this, comforted me and made me feel like, I had been helpful to a fellow human-being" (N 18).

Another student said:

"When I went to say goodbye to my patient at the end of my shift, I noticed this great contentment in his eyes that was indescribably enjoyable and meant the world to me. It helps get rid of all your tiredness" (N 6).

Supportive professional network

personnel, peers and even patients in the clinical setting that helped alleviate their stress and better cope with it, especially in the case of stress caused by performing nursing interventions. To the participants, support meant encouragement and a respectful and helpful interaction for performing interventions. The participants unanimously believed that the support they received from their peers was more important than all the other types of support they received. One instructor remarked:

"I often notice that when a student is not totally confident about her own practical skills, a skilled peer volunteers to accompany her to the patient’s bedside. This can be a great reassurance, and learning from peers is great for alleviating the students’ stress" (N 20).

The uneven clinical path

This theme refers to the barriers that hindered the process of coping with clinical stress for the students.

The students noted the dissociation between the authorities in charge of nursing education, including the school officials and instructors, and the nursing staff? as one of the barriers to their coping. They believed that many of their stresses would be spontaneously resolved if their education authorities were better linked to the nursing staff and argued that, in the absence of an adequate and eff?ective link between the education authorities and the nursing staff,? they regards students as uninvited guests who have invaded their territory, and the students also become deprived of a sense of belonging to the clinical setting.

"We can’t be part of the clinical team no matter what we do. But it is possible to lower this gap. When the instructor is distanced from the personnel, then the students also end up distancing themselves too, of course. The absence of a link between the school authorities and nursing staff deprives the students of the nursing staff's support" (N 2).

Another barrier to coping associated with superiors was the poor support provided to the students by the instructors. One participant remarked:

"When the instructor doesn’t support us, others treat us in any way they want to" (N 4).

Restrictive individual context

The analysis of the students’ experiences revealed a wide range of personal factors and characteristics that hindered coping with clinical stress, including having a negative attitude toward the discipline, a disinterest in the discipline, the loss of motivation due to daily encounters with worn-out nurses working like robots and a low self esteem, all of which somehow impeded the development of professional knowledge and skills.

One of the participants remarked:

"Unlike my friends, I suff?er from a low self-esteem. That's why they take the initiative for all the tasks proposed and so better learn how to perform nursing interventions; still, I’m constantly worried that I may not be able to manage the job and be embarrassed" (N 1).

Role Conflict

Those of the female students who were married or had children regarded their parenting and spousal roles as interfering with their role as student and argued that this conflict hindered their coping to the clinical setting. This problem was truer in the case of the stress caused by assignments and learns. One of the participants argued:

"I am a mother first and should take care of my mothering duties first. I can go to the library to study only during the exam period and not at any other time. But I could be more prepared and less stressed out for assignments and exams if I were single or at least had no children" (N 7).

Most of the students discussed instances in which they had been unable to handle the stresses of patient care due to their role conflicts.

"They'd brought in a four-month-old lactating infant to the emergency room and the nurses were trying to take the baby’s IV line. The baby reminded me of my own child and I was badly affected by this and could hardly stop my tears from running down. Because she was exactly the same age as my daughter" (N 11).

According to the results, a series of personal and professional factors\ helped the participating nursing students cope with clinical stress. Motivational beliefs comprised one of the factors that facilitated the students' coping with clinical stress. The findings of studies conducted by Hsiao in Taiwan [21] also showed a negative correlation between nursing students' religious and spiritual beliefs and their stress levels. A significant negative correlation was also observed between religious beliefs and stress levels in Iran in nursing, laboratory sciences and radiology students [22]. The results of a study conducted in Hong Kong by Chen also showed that students with no religious beliefs often used avoidance as a coping strategy. It is possible that religion creates a sense of power for facing problems and identifying appropriate stress-reducing strategies [23]. Given these studies, Asian students appear to use religious beliefs more commonly for coping with clinical stress. The results obtained by Chai in New Zealand showed that Asian students utilize religious coping strategies more commonly than European students and that these strategies are very effective in helping improve the quality of life and psychological state in Asian students [24]. Since religion can act as a strategy for coping with stress [25], instructors can take advantage of its potentials to help relieve clinical stress in students who have religious beliefs.

According to participants' statements, family support was another factor that contributed to the students’ coping with clinical stress and desire to continue nursing program. In a study conducted in Iran by Dadgran, family support was also one of the themes obtained in relation to the sociocultural factors affecting clinical learning [26]. Family support is a type of social support and other study has also confirmed the moderating effect of social support on stress [27].

The present study also found that certain demographic variables and personal characteristics contribute to the students' coping. In line with the present findings, in a study conducted in the UK by Galvin et al. older students revealed that they coped better to mental health course [28,29]. This finding may be partly due to the fact that older people have accumulated more life experience for coping with stress and also because of others’ reaction toward older students, especially the nurses’, instructors and patients, which contributes to the sense of control over stressful situations in older students.

The present study found that being interested in the discipline and having consciously chosen it, comprised another factor that facilitated coping with clinical stress. Other studies on nursing students have also confirmed the relationship between academic satisfaction and positive coping strategies [15]. The subjects examined by Motlaq et al. had also expressed that a positive attitude toward nursing and job satisfaction lead to a better coping with the special circumstances of nursing as a profession [14]. In one study, Khater et al. also confirmed the lower levels of stress in the nursing students who were interested in studying nursing [13]. Those of the participants who were more sociable and had better communication skills stated that this attribute made them better cope with clinical stress. Ozdemir and Kaya have also confirmed the effect of this attribute [30]. Effective learning in the clinical setting also requires interpersonal communication skills. It may be the case that exhibiting good communication skills in the clinical setting alleviates stress by improving the quality of negotiation with others in stressful situations, encouraging the individual to seek greater support from others and affecting the patients’, instructors’, personnel’s and peers' reaction to the individual.

In addition to personal factors, some of the features of the nursing profession, such as the attractiveness of the discipline and the joy of helping others, provide the students with positive experiences that help them in their coping with clinical stress. Positive experiences improve the attitudes toward nursing and affect the students’ feelings despite the many negative experiences [30]. Philanthropy and the sense of compassion are among the factors that cause nurses to carry on with this profession despite the difficult work conditions it presents [14].

The present findings also showed that the professional support which the participants received from the personnel, instructors, peers and patients contributed to their coping with clinical stress. In a study conducted by Jahanpoor et al., nursing students expressed that a positive and friendly relationship between the students, nurses and instructors affects the clinical learning environment and leads to greater self-confidence and learning in the students [31]. Similarly, the results obtained by Shoqirat revealed that poor support from the personnel adversely aff?ects the students' confidence [32]. In clinical settings, support from the personnel is a source of motivation for the students that makes them feel that they, too, are part of the treatment team. Supportive environments facilitate the students’ socialization, reduce their anxiety, improve their confidence and learning [33], increase their self-respect [34] and enhance their professional competence and identity [35]. The authorities in charge of nursing education can therefore take advantage of the support potential of clinical personnel for improving the quality of clinical education through mentoring programs.

This study also found that instructors have a paradoxical role in the students’ coping with clinical stress. Instructors’ support facilitates coping while their poor support hinders it. In another study conducted in Iran, nursing students stated that clinical instructors are more effective when they better support the students [36].

All the participants of the present study stated that their peers were greater sources of support for their coping with clinical stress. It also showed positive and significant relationship between peer support and coping in the university setting [37]. Papas examined the factors affecting students' success in nursing programs and extracted themes including communication with the instructor and peer support [38]. Students should therefore be encouraged to present to clinical settings in the company of those peers with whom they are most friendly, so that they can support each other [39]. Students often prefer to ask their questions from peers with similar levels of experience, as they have more common experiences in the clinical setting that make them develop a better understanding of the problem at hand and better provide support to each other.

The present findings showed that some of the barriers to coping in nursing students are associated with superiors, i.e. the education authorities and instructors. Although, in Iran, the authorities of nursing schools are in contact with clinical settings through the education supervisor nurse, the participants considered this arrangement inadequate and believed that the authorities' direct communication with the first-line clinical nurses can contribute to their coping with clinical stress.

Another barrier to participants’ coping was the instructors’ poor support. In a study conducted by Reeve et al., students did not consider faculty members as a source of social support in stressful situations [5]. Since the focus on humane and caring relationships in clinical settings strengthens the students' ability to cope with the challenges and stressors of the practice of nursing, measures need to be taken to enhance the supportive role of instructors in the clinical setting. Although personal factors facilitated coping with stress, at times, they hindered it; for example, in the case of a disinterest in the discipline, negative attitudes toward the discipline and the lack of selfesteem. In a study conducted by Wolf et al. [40], students with a poor self-esteem were found to experience higher levels of stress. The results of a study conducted by Eisenbarth [41] also showed that self-esteem is positively related to problem-oriented coping strategies and seeking social support but negatively to the avoidant coping strategy. It seems that a lower self-esteem leads to a sense of inability to control and/or avoid stressful situations.

Another barrier to coping with stress that was discussed by the participants and mostly by the married female participants was the conflict between professional roles and the traditional mothering and spousal roles. In Iran, although women are in transition toward democracy and despite of the larger number of female university graduates than male graduates and although women have a greater desire for finding outside employment now, but the main duties of a woman still revolve around her mothering and spousal roles.

Since all participating men were single, therefore, cannot be judged on role conflict in Iranian men students.

The present findings help gain a better understanding of the facilitators and barriers in coping with clinical stress in nursing students. Instructors and education authorities can use these results to further improve the facilitators and eliminate the barriers. Just as is the case in other countries, nursing authorities in Iran should consider interviewing all prospective nursing students before admission in order to prevent the entry of students into the field with no interest in nursing and so that, in addition to preserving the uninterested student’s own health, futile expenses are not imposed on the medical education system.

This work had no external sources of funding. The authors have no conflicts of interest to declare.

The authors are thankful to all of the nursing students who participated in this study. Without their support and cooperation, this research could not have been conducted.

1. Elcigil A, Sari HY (2007) Determining problems experienced by student nurses in their work with clinical educators in turkey. Nurse Educ Today 27: 491-498.
2. D’Souza MS, Venkatesaperumal R, Radhakrishnan J, Balachandran S (2013) Engagement in clinical learning environment among nursing students: role of nurse educators. Open J Nurs 3: 25-32.
3. John B, Al-Sawad M (2015) Perceived stress in clinical areas and emotional intelligence among baccalaureate nursing students. JIAAP 41: 75-84.
4. Shultz ME (2011) Factors related to stress in nursing students: University of Central Florida Orlando, Florida.
5. Reeve KL, Shumaker CJ, Yearwood EL, Nancy A, Nancy A, et al. (2013) Perceived stress and social support in undergraduate nursing students ‘educational experiences. Nurse Educ Today 33: 419-424.
6. Labrague LJ (2013) Stress, stressors, and stress responses of student nurses in a government nursing school. Health Sci J 7: 424-435.
7. Pourafzal F, Inanloo M, Haghani H (2013) Relationship between perceived stress with resilience among undergraduate nursing students. Hayat 19: 41-52.
8. Chernomas WM, Shapiro C (2013) Stress, depression, and anxiety among undergraduate nursing students. Int J Nurs Educ Scholarsh 10: 255-266.
9. Jan LK, Popescu L (2014) Israel's nursing students stress sources and coping strategies during their first clinical experience in hospital wards-a qualitative research. Revista de Asistenta Sociala 4: 163-188.
10. Liu M, Gu K, Wong TK, Luo MZ, Chan MY(2015) Perceived stress among Macao nursing students in the clinical learning environment. Int J Nursing Sci 2: 128-133,
11. McKenna L, Plummer V (2013) Indonesian student nurses' perceptions of stress in clinical learning: A phenomenological study. J Nursing Edu Pract 3: 56.
12. Rafati F, Nouhi E, Sabzehvari S, Dehghan-Nayyeri N(2017) Iranian nursing students experience of stressors in their first clinical experience. J Prof Nurs 33: 250-257.
13. Khater W, Akhu-Zaheya L, Shaban I (2014) Sources of stress and coping behaviours in clinical practice among baccalaureate nursing students. Int J Human Soc Sci 46: 194-202.
14. Motlagh FG, Karimi M, Hasanpour M (2012) Iranian nursing students experiences of nursing Iran J Nurs Midwifery Res 172: 107-114.
15. Hirsch CD, Barlem ELD, Almeida LKd, Tomaschewski-Barlem JG, Figueira AB, et al. (2015)Coping strategies of nursing students for dealing with university stress. Revista Brasileira de Enfermagem 68: 783-790.
16. Polit DF, Beck CT (2013) Essentials of nursing research: Appraising evidence for nursing practice: Lippincott Williams & Wilkins, Pennsylvania, USA.
17. Holloway I (2005) Qualitative research in health care: McGrawHill Education, Berkshire, England.
18. Schreier M (2012) Qualitative content analysis in practice: Sage Publications. Olive’s yard, London.
19. Graneheim UH, Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 24: 105-112.
20. Lincoln YS, Guba EG (1985) Naturalistic inquiry: Sage. New Delhi, India.
21. Hsiao YC, Chien LY, Wu LY, Chiang CM, Huang SY (2010) Spiritual health, clinical practice stress, depressive tendency and health-promoting behaviours among nursing students. J Adv Nurs 66: 1612-1622.
22. Pourghane P, Zaer sabet E, Khorsandi M (2010) Survey the effect of religious beliefs in stress reduction in students of Langroud Faculty of Medical Sciences. J Holist Nurs Midwifery 20: 10-15.
23. Chan CK, So WK, Fong DY (2009) Hong Kong baccalaureate nursing students' stress and their coping strategies in clinical practice. J Prof Nurs 25: 307-313,
24. Chai PPM, Krägeloh CU, Shepherd D, Billington R (2012) Stress and quality of life in international and domestic university students: cultural differences in the use of religious coping. Ment Health Relig Cult 15: 265-277.
25. Krok D (2008) The role of spirituality in coping: Examining the relationships between spiritual dimensions and coping styles. Ment Health Relig Cult 11: 643-653.
26. Dadgaran I, Parvizy S, Peyrovi H (2013) Nursing students' views of sociocultural factors in clinical learning: a qualitative content analysis. J Nurs Sci 10: 1-9.
27. Y?ld?r?m N, Karaca A, Cangur S, Ac?kgoz F, Akkus D (2017) The relationship between educational stress, stress coping, selfesteem, social support, and health status among nursing students in turkey: a structural equation modeling approach. Nurs Educ Today 48: 33-39.
28. Galvin J, Suominen E, Morgan C, Connell EJ, Smith AP (2015) Mental health nursing students' experiences of stress during training: a thematic analysis of qualitative interviews. J Psychiatr Ment Health Nurs 22: 773-783.
29. Özdemir G, Kaya H (2013) Midwifery and nursing students communication skills and life orientation:correlation with stress coping approaches. Nurs Midwifery Stud 2: 198.
30. Pearcey PA, Elliott BE (2004) Student impressions of clinical nursing. Nurs Educ Today 24: 382-387.
31. Jahanpour F, Azodi P, Azodi F, Khansir AA (2016) Barriers to Practical Learning in the Field: A Qualitative Study of Iranian Nursing Students’ Experiences. Nurs Midwifery Stud 52.
32. Shoqirat N, Abu-Qamar MeZ (2013) Clinical placement in jordan: qualitative views of final year nursing students. Aust J Adv Nurs 30: 49-58.
33. Lawal J, Weaver S, Bryan V, Lindo JL (2016) Factors that influence the clinical learning experience of nursing students at a Caribbean school of nursing. J Nurs Educ Pract 6: 32.
34. Dale B, Leland A, Dale JG (2013) what factors facilitates good learning experiences in clinical studies in nursing: Bachelor students’ perceptions. ISRN nursing 2013: 1-7.
35. Jokelainen M, Turunen H, Tossavainen K, Jamookeeah D, Coco K (2011) A systematic review of mentoring nursing students in clinical placements. J Clin Nurs 20: 2854-2867.
36. Alavi M AH (2008) Nursing students' experiences and perceptions of effective instructor in clinical education. Iran J Med Educ7: 325-334.
37. Horgan A, Sweeney J, Behan L, McCarthy G (2016) Depressive symptoms, college adjustment and peer support among undergraduate nursing and midwifery students. J Adv Nurs 72: 3081-3092.
38. Pappas MW (2006) The Nursing student experience: student perceptions concerning factors leading to success in an associate of science in nursing program at montana state universitynorthern: ProQuest. Bozeman, USA.
39. Roberts D (2009) Friendship fosters learning: the importance of friendships in clinical practice. Nurse Educ Pract 9: 367-671.
40. Wolf L, Stidham AW, Ross R (2015) Predictors of stress and coping strategies of US accelerated vs. generic baccalaureate nursing students: an embedded mixed methods study. Nurse Educ Today 35: 201-205.
41. Eisenbarth C (2012) Does self-esteem moderate the relations among perceived stress, coping, and depression? Coll Stud J 46: 149-157.