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The frequency and perceived effectiveness of coping strategies used by registered nurses returning to… Thompson, Mary Catherine 1988

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THE FREQUENCY AND PERCEIVED EFFECTIVENESS OF COPING STRATEGIES USED BY REGISTERED NURSES RETURNING TO UNIVERSITY By MARY CATHERINE THOMPSON B.S.N., MARQUETTE UNIVERSITY, 1966 A THESIS SUBMITTED I N PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE I N NURSING i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l o f N u r s i n g ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA MARCH 1988 ( c ) M a r y C a t h e r i n e Thompson THE FREQUENCY AND PERCEIVED EFFECTIVENESS OF COPING STRATEGIES USED BY REGISTERED NURSES RETURNING TO UNIVERSITY By MARY CATHERINE THOMPSON B.S.N., MARQUETTE UNIVERSITY, 1966 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA MARCH 1988 (c)Mary Catherine Thompson In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia 1956 Main Mall Vancouver, Canada Department V6T 1Y3 nr. c/noi\ i i A b s t r a c t T h i s study examines the s t r e s s and coping behaviors of r e g i s t e r e d nurses r e t u r n i n g to s c h o o l to pursue a ba c c a l a u r e a t e degree i n n u r s i n g ( r e t u r n i n g RNs). The sample included 72 v o l u n t e e r s who were r e t u r n i n g RNs c u r r e n t l y e n r o l l e d i n a n u r s i n g program. Data were c o l l e c t e d u s ing the Ways of Coping C h e c k l i s t and the P e r s o n a l S t r a i n Q u e s t i o n n a i r e which assessed the causes of s t r e s s r e l a t e d to a t t e n d i n g school/ the use of s p e c i f i c coping b e h a v i o r s , and the e f f e c t i v e n e s s of those coping behaviors i n r e d u c i n g s t r e s s . The major sources of s t r e s s i n c l u d e d : 1. s c h o o l -r e l a t e d s t r e s s o r s such as lack of academic s k i l l s and concerns with the program and f a c u l t y , 2. s o c i a l and domestic concerns, 3. lack of time, and 4. lack of money. The study concludes that coping s t r a t e g i e s used most f r e q u e n t l y were a l s o r a t e d as most e f f e c t i v e . These coping s t r a t e g i e s d e a l t d i r e c t l y with the s t r e s s o r or the emotional r e a c t i o n to i t by problem-solving or seeking s o c i a l support. Coping s t r a t e g i e s seldom used and r a t e d as i n e f f e c t i v e , on the other hand, avoided d e a l i n g with the s t r e s s o r , f o r example, by the use of w i s h f u l t h i n k i n g . A f t e r an i n i t i a l term a t s c h o o l , r e t u r n i n g RNs, who had not been students f o r a t l e a s t two years, had no more d i s t r e s s than r e t u r n i n g RNs who had attended school r e c e n t l y . Returning RNs In the f o u r t h year of the program were l e s s . s t r e s s e d by s c h o o l - s p e c i f i c s t r e s s o r s such as study s k i l l s and managing sc h o o l assignments than were students i n the t h i r d year. T h i s i m p l i e s t h a t these students l e a r n to cope with s t r e s s o r s , a process which c o u l d perhaps be f a c i l i t a t e d through an o r i e n t a t i o n program.In summary, the m a j o r i t y of r e t u r n i n g RNs cope q u i t e w e l l i n the present s t r u c t u r e by u s i n g the s t r a t e g i e s of problem-solving and seeking s o c i a l support. I m p l i c a t i o n s f o r n u r s i n g education are d i s c u s s e d and areas f o r f u r t h e r r e s e a r c h are i d e n t i f i e d . i v Table of Contents A b s t r a c t i i Table of Contents i v L i s t of T a b l e s . . . v i i Acknowledgements v i i i CHAPTER ONE I n t r o d u c t i o n . . . . 1 Background to the Problem . . . 1 Problem Statement 4 Purpose 4 D e f i n i t i o n of Terms.. 5 Assumptions . 6 L i m i t a t i o n s 6 Overview 7 CHAPTER TWO L i t e r a t u r e Review and Conceptual Framework 8 Overview 8 S t r e s s and Coping of Returning RNs 8 Conceptual Framework 20 Summary 24 CHAPTER THREE Methodology .25 Overview 25 Sample 25 E t h i c s and Human Rights 25 Procedure f o r Data C o l l e c t i o n 26 Instrumentation 26 Ways of Coping C h e c k l i s t 26 Personal S t r a i n Q u e s t i o n n a i r e 28 Demographic Data - 29 Data A n a l y s i s .30 CHAPTER FOUR P r e s e n t a t i o n and D i s c u s s i o n of F i n d i n g s 32 Overview 32 Demographic and D e s c r i p t i v e Information 33 Age 3 3 M a r i t a l Status 33 Number of C h i l d r e n 33 Nursing Education 33 Nursing Experience 34 Current Work Status 34 Fi n d i n g s 3 4 Research Question One: What Is the L e v e l of D i s t r e s s of RNs Returning to School? 34 Research Question Two: What Are the School-Related S t r e s s o r s of Returning RNs? 35 Research Question Three: What Coping S t r a t e g i e s Are Used by Returning RNs to Deal with S c h o o l - r e l a t e d S t r e s s ? 38 Research Question Four: Which Coping S t r a t e g i e s Do Returning RNs P e r c e i v e As Most E f f e c t i v e i n Reducing S t r e s s ? 40 Research Question F i v e : Which coping S t r a t e g i e s Do Returning RNs Pe r c e i v e As Least E f f e c t i v e i n Reducing S t r e s s ? .41 D i s c u s s i o n of F i n d i n g s 42 v i Comparison of the Sample with Other Returning RNs and Employed Nurses 42 Le v e l of D i s t r e s s . . . . . 45 S t r e s s o r s 50 Frequency and E f f e c t i v e n e s s of Coping S t r a t e g i e s 57 Summary 65 CHAPTER FIVE Summary, Co n c l u s i o n s , I m p l i c a t i o n s and Recommendations for Future Research 67 Summary 67 Conclus ions 69 I m p l i c a t i o n s 7 0 Recommendations f o r Future Research 72 B i b l i o g r a p h y 74 Appendix A: Cover L e t t e r 82 v i i L i s t of Tables Table 1 Most Important S t r e s s o r 36 2 Three Most Important S t r e s s o r s 37 3 Most F r e q u e n t l y Used Coping S t r a t e g i e s 39 4 Least F r e q u e n t l y Used Coping S t r a t e g i e s 40 5 Most E f f e c t i v e Coping S t r a t e g i e s 41 6 Least E f f e c t i v e Coping S t r a t e g i e s 42 7 Demographic and D e s c r i p t i v e Data: Sample and N a t i o n a l P o p u l a t i o n 44 Acknowledgements I would f i r s t of a l l l i k e to thank God f o r His many b l e s s i n g s which enabled me to complete t h i s t h e s i s . I am g r a t e f u l to my f a m i l y f o r t h e i r t o l e r a n c e : Mark f o r h i s i n v a l u a b l e support and c o n s t r u c t i v e comments, James f o r h i s l i s t e n i n g , J u l i e f o r her help a t home, and Andrew f o r h i s hugs. I a l s o thank my f r i e n d s , e s p e c i a l l y Ann McElroy, and f e l l o w n u r s i n g students f o r t h e i r c o n t i n u a l encouragement and i n s i g h t f u l d i s c u s s i o n s P r o f e s s i o n a l l y , I would l i k e to thank Dr. Bonita Long, whose i n t e r e s t and enthusiasm were in s t r u m e n t a l i n my chosing t h i s t o p i c of s t r e s s to r e s e a r c h . I a l s o thank Barb R i d i n g and Toni S t o v e l who c a t e g o r i z e d the s t r e s s o r s . To my committee, Dr. M a r i l y n Willman, chairman, and P r o f e s s o r C l a r i s s a Green I am p a r t i c u l a r l y g r a t e f u l f o r t h e i r i n s i g h t f u l comments and a s s i s t a n c e i n o b t a i n i n g respondents. F i n a l l y , I am indebted to the r e t u r n i n g Rns, those " r e s i l i e n t a c t i v e copers" who shared t h e i r time and r e f l e c t i o n s by answering my g u e s t i o n n a i r e . 1 Chapter One I n t r o d u c t i o n Background to the Problem Large numbers of r e g i s t e r e d nurses (RNs) are r e t u r n i n g to u n i v e r s i t y to pursue a b a c c a l a u r e a t e degree i n n u r s i n g (BSN). In December 1985, 3,765 RN's were e n r o l l e d i n n u r s i n g degree programs i n Canada (Canadian Nurses A s s o c i a t i o n , 1987). Although numbers are l e s s r e a d i l y a v a i l a b l e , there are a l s o many nurses t a k i n g courses towards a degree who are not r e g i s t e r e d i n a n u r s i n g program. Because the Canadian Nurses A s s o c i a t i o n has endorsed the BSN as the minimum educa t i o n f o r nurses beginning to p r a c t i c e i n the year 2000, many nurses want to r e t u r n to s c h o o l i n order to maintain t h e i r s t a t u s i n the p r o f e s s i o n . As many as 178,544 RNs i n Canada may •return to u n i v e r s i t y to pursue a BSN ( S t a t i s t i c s Canada, 1986). Because r e t u r n i n g RNs are competent p r a c t i t i o n e r s who are g e n e r a l l y seeking c a r e e r advancement ( H i l l s m i t h , 1978; Jackson, 1984), they are e s p e c i a l l y important to the p r o f e s s i o n . The BSN i s c u r r e n t l y the minimum e n t r y requirement f o r v i r t u a l l y a l l l e a d e r s h i p p o s i t i o n s i n management, educati o n , c l i n i c a l n u r s i n g and a requirement f o r graduate e d u c a t i o n . For the f o r e s e e a b l e f u t u r e , t h e r e f o r e , BSNs w i l l p l a y an i n f l u e n t i a l r o l e i n 2 the development of the p r o f e s s i o n . As the BSN becomes more common i n n u r s i n g , the views of c u r r e n t degree holders w i l l shape a t t i t u d e s of other nurses about edu c a t i o n , n u r s i n g t h e o r i e s , and r e s e a r c h . Despite the a t t r a c t i v e n e s s of the BSN degree, when RNs r e t u r n to s c h o o l , they o f t e n experience s t r e s s ( H i r a k i & P a r l o c h a , 1983; Shane, 1983; Smith & Reeves, 1984; Wooley, 1978) s e r i o u s enough to i n t e r f e r e with t h e i r l e a r n i n g and p e r s o n a l development (MacMaster, 1979), and to c o n t r i b u t e to high drop-out r a t e s (Wilson & Levy, 1978). Whitman, Spendlove, and C l a r k (1984), f o r example, noted t h a t e x c e s s i v e s t r e s s can i n t e r f e r e with student performance by causing h y p e r v i g i l a n c e i n c l u d i n g e x c e s s i v e a l e r t n e s s to d e t a i l , or premature c l o s u r e such as r u s h i n g through an exam to end the s t r e s s f u l e x p erience. High l e v e l s of s t r e s s among students should a l s o be a concern because of the negative impact of s t r e s s on g e n e r a l h e a l t h and p s y c h o l o g i c a l w e l l - b e i n g (Folkman, Lazarus, Guen, & DeLongis, 1986). Jackson (1984) suggested that s u r v i v a l r a t h e r than l e a r n i n g can become the s t u d e n t s ' g o a l . Although many other f a c t o r s c e r t a i n l y c o n t r i b u t e to dropout r a t e s , a t t r i t i o n i s one way students d i s t a n c e themselves from the source of s t r e s s (Whitman, et a l . , 1984). Shane (1983) a l s o observed that dropping out i s a common way of r e s o l v i n g the s t r e s s of r e t u r n i n g to s c h o o l . 3 Mature RNs* f e e l i n g s of anger and f r u s t r a t i o n at the f a c u l t y and program have been i d e n t i f i e d by both f a c u l t y (Perry, 1986) and students (Balogh et a l . , 1980; H i l l s m i t h , 1978). Besides i n t e r f e r i n g with the s t u d e n t s ' e d u c a t i o n a l experience, these f e e l i n g s can c r e a t e a negative a t t i t u d e toward n u r s i n g education and widen the gap between theory and p r a c t i c e . Such a t t i t u d e s may discourage these students from using n u r s i n g t h e o r y and r e s e a r c h i n t h e i r p r o f e s s i o n a l c l i n i c a l p r a c t i c e , and promoting the s c i e n c e of n u r s i n g based on theory. Negative a t t i t u d e s may a l s o discourage those i n t e r e s t e d i n l e a d e r s h i p from pursuing graduate education i n n u r s i n g . Future n u r s i n g l e a d e r s need graduate p r e p a r a t i o n i n order to encourage and d i r e c t n u r s i n g r e s e a r c h and theory development, and/or to become high l e v e l a d m i n i s t r a t o r s , c l i n i c a l s p e c i a l i s t s and t e a c h e r s . Obviously, the best way to d e a l with the n u r s i n g students' high s t r e s s l e v e l s i s to e l i m i n a t e the cause (the s t r e s s o r ) . However, e l i m i n a t i o n of c e r t a i n s t r e s s o r s i s f r e q u e n t l y not p o s s i b l e . Many s t r e s s o r s , such as the t r a n s i t i o n from p r a c t i t i o n e r to student, or time and s c h e d u l i n g problems r e s u l t i n g from m u l t i p l e r o l e s of student, wife, and mother, are i n e v i t a b l e . T h e r e f o r e , students must l e a r n to cope with these unavoidable s t r e s s o r s i n order to perform s u c c e s s f u l l y . Consequently, the r e a c t i o n of r e t u r n i n g RNs to a 4 s t r e s s o r , t h a t i s , t h e i r coping s t r a t e g y can promote s u c c e s s f u l adjustment to school (Sabina, 1985). Wilson and Levy (1978) noted that e f f e c t i v e coping s t r a t e g i e s can promote r e t e n t i o n i n an academic program. Both n u r s i n g f a c u l t y and students (Balogh, et a l . , 1980; H i r a k i & P a r l o c h a , 1983; Perry, 1986) recommend t h a t students use peer support groups and s p e c i f i c coping s t r a t e g i e s such as s e t t i n g p r i o r i t i e s , e x e r c i s e , or r e l a x a t i o n techniques to d e a l with s t r e s s . These f i n d i n g s suggest t h a t s p e c i f i c coping s t r a t e g i e s can be e f f e c t i v e i n d e c r e a s i n g the s t r e s s of r e t u r n i n g to s c h o o l . The use of coping s t r a t e g i e s by stude n t s , however, has never been s y s t e m a t i c a l l y examined. Problem Statement L i t t l e i s known about how RNs cope with the s t r e s s they experience when r e t u r n i n g to s c h o o l . More knowledge i s needed to b e t t e r understand the s t r e s s and coping s t r a t e g i e s . T h i s understanding i s c e n t r a l to improving the e d u c a t i o n a l experience f o r these s t u d e n t s . Purpose The purpose of t h i s study i s to expl o r e and d e s c r i b e the s t r e s s and coping s t r a t e g i e s of RNs r e t u r n i n g to sc h o o l by a d d r e s s i n g the f o l l o w i n g q u e s t i o n s : 1) What i s the l e v e l of d i s t r e s s of RNs r e t u r n i n g to 5 school? 2) What are the s c h o o l - r e l a t e d s t r e s s o r s f o r r e t u r n i n g RNs? 3) What coping s t r a t e g i e s are used by r e t u r n i n g RNs to d e a l with s c h o o l - r e l a t e d s t r e s s ? 4) Which coping s t r a t e g i e s do r e t u r n i n g RNs p e r c e i v e as most e f f e c t i v e i n reducing s t r e s s ? 5) Which coping s t r a t e g i e s do r e t u r n i n g RNs p e r c e i v e as l e a s t e f f e c t i v e i n reducing s t r e s s ? D e f i n i t i o n of Terms S t r e s s - - t h e r e l a t i o n s h i p between the person and the environment that i s a p p r a i s e d by the person as t a x i n g or exceeding h i s or her resources (Lazarus & Folkman, 1984). P e r c e i v e d d i s t r e s s - - t h e i n d i v i d u a l ' s r e a c t i o n to s t r e s s measured by the Personal S t r a i n Q u e s t i o n n a i r e (Osipow & Spokane, 1981). S t r e s s o r - - t h e source or cause of s t r e s s Coping--the person's c o n s t a n t l y changing c o g n i t i v e and b e h a v i o r a l e f f o r t s to manage s p e c i f i c e x t e r n a l or i n t e r n a l demands t h a t are appraised as t a x i n g or exceeding the person's resources (Lazarus & Folkman, 1984). Coping s t r a t e g i e s — a l l b e h a v i o r a l or c o g n i t i v e e f f o r t s that attempt to reduce s t r e s s ; what i n d i v i d u a l s a c t u a l l y do i n r e a c t i o n to a s p e c i f i c s t r e s s o r . 6 Returning RN--a r e g i s t e r e d nurse who has returned to s c h o o l to pursue the b a c c a l a u r e a t e degree i n n u r s i n g . Assumptions T h i s i n v e s t i g a t i o n assumes that the sample i s g e n e r a l l y r e p r e s e n t a t i v e of r e t u r n i n g RNs i n a BSN program. The study f u r t h e r assumes that r e t u r n i n g RNs r e v e a l a c c u r a t e l y t h e i r s t r e s s o r s , l e v e l s of d i s t r e s s , and the frequency and e f f e c t i v e n e s s of coping s t r a t e g i e s they use i n response to t h e i r s c h o o l - r e l a t e d s t r e s s o r s . L i m i t a t i o n s The study i s l i m i t e d to female r e t u r n i n g RNs at the U n i v e r s i t y of B r i t i s h Columbia School of Nursing who v o l u n t e e r e d to p a r t i c i p a t e i n t h i s r e s e a r c h study. The q u e s t i o n n a i r e on coping presents a f i n i t e number of p o s s i b l e coping s t r a t e g i e s . F i n a l l y , measuring coping s t r a t e g i e s a t one p o i n t i n time may not a c c u r a t e l y r e f l e c t the s t r a t e g i e s used d u r i n g the e n t i r e process of coping with s c h o o l . The amount of s t r e s s , the s t r e s s o r s , and the coping s t r a t e g i e s may change over time. The r e s u l t s of t h i s r e s e a r c h , t h e r e f o r e , r e f l e c t the s t r a t e g i e s employed at o n l y one p e r i o d of the s t u d e n t s ' c a r e e r s . 7 Overv iew Chapter One has i n t r o d u c e d the study by d i s c u s s i n g the importance of the problem and by d e s c r i b i n g what the study i n v o l v e s . Chapter Two w i l l now present a s e l e c t i v e review of r e l e v a n t l i t e r a t u r e and e x p l a i n the conceptual framework. Chapter Three w i l l then d e s c r i b e the r e s e a r c h methodology. The f i n d i n g s are presented and d i s c u s s e d i n Chapter Four. F i n a l l y , Chapter F i v e presents the summary, c o n c l u s i o n s , i m p l i c a t i o n s and recommendations. 8 Chapter Two L i t e r a t u r e Review and Conceptual Framework Overview The purpose of t h i s chapter i s to present r e l e v a n t l i t e r a t u r e concerning the s t r e s s and coping s t r a t e g i e s of RNs r e t u r n i n g to s c h o o l to pursue a BSN, and to d e s c r i b e the conceptual framework used i n t h i s study. The f i r s t s e c t i o n presents s e v e r a l ways of d e s c r i b i n g the s t r e s s and coping s t r a t e g i e s of RNs r e t u r n i n g to s c h o o l . The next s e c t i o n presents the conceptual framework chosen and d e s c r i b e s s e v e r a l r e l e v a n t s t u d i e s which have used t h i s framework. F i n a l l y , a summary of the l i t e r a t u r e concludes t h i s c h a p ter. S t r e s s and Coping of Returning RNs The s t r e s s and coping behaviors of RNs r e t u r n i n g to s c h o o l f o r the b a c c a l a u r e a t e degree has been documented i n the l i t e r a t u r e by both n u r s i n g f a c u l t y and s t u d e n t s . F a c u l t y r e s e a r c h has produced four d i s t i n c t l a b e l s to e x p l a i n r e t u r n i n g RNs' behavior. These a r e : r e s o c i a l i z a t i o n (Wooley, 1978), g r i e f r e a c t i o n (Smith & Reeves, 1986), academic shock ( H i r a k i & P a r l o c h a , 1983), and the Returning-To-School Syndrome (Shane, 1983). To r e p o r t the c u r r e n t l e v e l of understanding of the problem and to support the choice of the conceptual framework these w i l l be d e s c r i b e d b r i e f l y along with 9 s e v e r a l s e l e c t e d s t u d i e s on n u r s i n g s t u d e n t s ' s t r e s s . Wooley (1978) focused on r e s o c i a l i z a t i o n as the key f o r d e s i g n i n g and implementing a program f o r r e t u r n i n g RNs. She noted t h a t RNs were c h a l l e n g e d to change t h e i r behavior, a t t i t u d e s , r o l e s , and f u n c t i o n s as w e l l as a q u i r e knowledge when they r e t u r n e d to s c h o o l . Wooley c a t e g o r i z e d elements of change t h a t students encounter such as a d i f f e r e n t i n s t r u c t i o n a l s t y l e , from a u t h o r i t a r i a n , concrete t e a c h i n g to more s e l f - d i r e c t e d a b s t r a c t l e a r n i n g . Using Kelman's theory of s o c i a l i n f l u e n c e , she analyzed the process of l e a r n i n g new r o l e s which i n c l u d e s three phases: compliance, i d e n t i f i c a t i o n , and i n t e r n a l i z a t i o n . Schein's model of planned change with i t s three phases of u n f r e e z i n g , changing, and r e f r e e z i n g , was a l s o presented to help e x p l a i n RNs' behavior. F i n a l l y , she d e s c r i b e d "the t e r r i b l e f e e l i n g s of l o s s and g r i e f which accompany p e r s o n a l and s o c i a l change" (p. 104) and suggested that students were "mourning the death of t h e i r f a m i l i a r assumptions (about the a t t i t u d e s , r o l e s , and f u n c t i o n s of a p r o f e s s i o n a l n u r s e ) " (p. 107). She suggested t h a t they would have to pass through a stage of anger before r e a c h i n g acceptance. The g r i e v i n g process, used by Wooley, was expanded upon by Smith and Reeves (1984) to d e s c r i b e the intense p h y s i o l o g i c a l and p s y c h o l o g i c a l r e a c t i o n s experienced by 10 r e t u r n i n g RNs i n c l u d i n g : exhaustion, poor c o n c e n t r a t i o n , i r r i t a b l i t y , and changes i n e a t i n g or s l e e p i n g p a t t e r n s . Reeves' energy management model, developed f o r bereaved people, was presented to help students understand t h e i r r e a c t i o n s . In t h i s model the bereaved person's t o t a l energy i s d i v i d e d among three types of a c t i v i t i e s , namely: s u r v i v a l , life-enhancement, and g r i e v i n g . In the case of the RN student, g r i e v i n g the l o s s of a job or income consumes a l a r g e percentage of t h e i r energy, so l i t t l e energy i s l e f t f o r s u r v i v a l a c t i v i t i e s such as s t u d y i n g , l e t alone l i f e enhancement a c t i v i t i e s such as entertainment. The authors f u r t h e r presented f i v e stages of student adjustment with most of the energy being used f o r g r i e v i n g and s u r v i v a l i n the f i r s t stage. G r a d u a l l y , more energy i s f r e e d to be used fo r life-enhancement and s u r v i v a l so that by stage f i v e l i t t l e energy i s r e q u i r e d f o r g r i e v i n g . The authors acknowledged t h a t the speed and l e v e l of i n t e n s i t y of t h i s " i n e v i t a b l e g r i e v i n g " depends upon: the s t u d e n t s ' a t t i t u d e s and s t y l e s of d e a l i n g with l o s s , t h e i r p h y s i c a l and emotional h e a l t h , s o c i a l support, and t h e i r use of p o s i t i v e coping mechanisms. The authors d i d not, however, d i s c u s s s p e c i f i c a l l y which coping mechanisms are p o s i t i v e . Two other n u r s i n g educators, H i r a k i and P a r l o c h a (1983), coined the term "academic shock" to d e s c r i b e the 11 t r a n s i t i o n p e r i o d of r e t u r n i n g to s c h o o l . According to the authors, a l l students f i n d the t r a n s i t i o n s t r e s s f u l to some degree. T h e i r book, which i s based on years of c o n v e r s a t i o n s with r e t u r n i n g RNs, presents i n f o r m a t i o n to s t r e n g t h e n the student's a b i l i t y to cope and problem s o l v e , both of which are s k i l l s e s s e n t i a l to being an e f f e c t i v e student. Academic shock i s s i m i l a r to r e a l i t y shock (Kramer, 1974) because i t r e s u l t s from the d i s c r e p a n c y between the i n d i v i d u a l s ' e x p e c t a t i o n s and the r e a l i t y of the s i t u a t i o n . Academic shock i s d e f i n e d as "the s t a t e of c o n f l i c t r e s u l t i n g from the d i s c r e p a n c y between the RNs' e x p e c t a t i o n s of r e t u r n i n g to s c h o o l and the r e a l i t i e s they encounter" ( H i r a k i & P a r l o c h a , 1983, p. 68). Nurses o f t e n f i n d the academic experience d i f f e r e n t from what they expected. The authors l i s t e d s t r e s s o r s common to r e t u r n i n g RNs, i n c l u d i n g : i n t i m i d a t i o n concerning the a b i l i t y to s o c i a l i z e with younger s t u d e n t s , d i s i l l u s i o n m e n t because textbooks provide no u n i v e r s a l s o l u t i o n s , and misconceptions about the purpose of the program and the r o l e and f u n c t i o n of the f a c u l t y . Academic shock i s a s t a t e of emotional c o n f l i c t c h a r a c t e r i z e d by anger which can r e s u l t i n e i t h e r a g g r e s s i v e or a s s e r t i v e behavior. Aggressive responses i n c l u d e : (1) i n d i r e c t avenues such as d e p r e s s i o n , overdependency, and p a s s i v e - a g g r e s s i v e behaviors or (2) 12 d i r e c t methods of e x p r e s s i n g h o s t i l i t y such as undermining the teacher. A h e a l t h i e r response i s a s s e r t i v e behavior which promotes personal and s o c i a l growth. I t i s d e f i n e d as making one's wants and needs known to others without i n f r i n g i n g on t h e i r r i g h t s . The authors noted that while n u r s i n g f a c u l t y hope to see a s s e r t i v e behavior i n t h e i r s t u d e n t s , they f r e q u e n t l y f i n d i n s t e a d , l e s s h e a l t h y a g g r e s s i v e responses which are hard to channel i n t o p o s i t i v e outcomes. The authors c a t e g o r i z e d p o s s i b l e outcomes of academic shock as e i t h e r r e s o l u t i o n or n o n r e s o l u t i o n . N o n r e s o l u t i o n i n t e r f e r e s with l e a r n i n g and consumes a great d e a l of energy because i t i n v o l v e s m a i n t a i n i n g the anger. R e s o l u t i o n can be achieved by working c o n s t r u c t i v e l y on the anger through the use of a s s e r t i v e behavior. S t r a t e g i e s f o r p r e v e n t i n g or coping with academic shock are suggested by the a u t h o r s . These coping s t r a t e g i e s i n c l u d e : s e t t i n g p r i o r i t i e s , g a t h e r i n g support, n e g o t i a t i n g , making compromises, and e v a l u a t i n g p r o g r e s s . They a l s o recommend upgrading academic s k i l l s such as paper w r i t i n g and t e s t - t a k i n g , and t a k i n g time for o n e s e l f through p h y s i c a l a c t i v i t y , as w e l l as through r e l a x i n g q u i e t l y i n m e d i t a t i o n , prayer, r e a d i n g , or l i s t e n i n g to music. The f o u r t h and f i n a l d e s c r i p t i o n of t h i s s t r e s s and coping phenomenon i s the Returning-to-School Syndrome 13 (RTSS), which i s by Ear the best developed and most e x t e n s i v e l y researched. The d e f i n i t i o n of RTSS i s "a s e r i e s of p o s i t i v e and negative emotional s t a t e s experienced to some degree by a l l e d u c a t i o n a l l y mobile nurses ( r e t u r n i n g RNs)" (Shane, 1983, p.73). Shane and her c o l l e a g u e s conducted 639 i n t e r v i e w s , and examined 309 d i a r i e s of r e t u r n i n g RNs, as w e l l as c r i t i q u e s by 72 r e t u r n i n g RNs of RTSS over a s i x - y e a r p e r i o d . S t r e s s o r s which were f r e q u e n t l y r e p o r t e d by these students i n c l u d e d : lack of money, lack of time, l o s s of r o l e s t a t u s , s o c i a l i s o l a t i o n , and u n r e a l i s t i c e x p e c t a t i o n s of i n s t r u c t o r s . There are three phases of RTSS i n c l u d i n g : honeymoon, c o n f l i c t , and r e s o l u t i o n . The i n i t i a l phase i s the honeymoon phase which i s q u i t e p l e a s a n t . I t u s u a l l y begins when the r e t u r n i n g RN decides to study for a BSN. In t h i s phase the RN notes the s i m i l a r i t i e s between previous education and that being sought. T h i s r e i n f o r c e s i d e n t i f i c a t i o n as a nurse. This p e r i o d may l a s t o n l y a few hours to s e v e r a l weeks, but u s u a l l y ends with the f i r s t c l a s s t h a t i n c l u d e s n u r s i n g theory or c l i n i c a l p r a c t i c e . C o n f l i c t i s the next stage and i t i s c h a r a c t e r i z e d by d i s t u r b i n g and t u r b u l e n t emotions. Nursing students now experience c o n f l i c t with t h e i r previous b e l i e f s , r o l e s i n the f a m i l y and at work, and with i n s t r u c t o r s 14 and i n s t r u c t i o n a l t e c hniques. The c o n f l i c t f r e q u e n t l y g i v e s r i s e to d e p r e s s i o n i n the form of e x c e s s i v e f a t i g u e , s l e e p d i s t u r b a n c e s , i n s e c u r i t y , f e e l i n g s of h e l p l e s s n e s s , sadness, and withdrawal from s o c i a l c o n t a c t . T h i s d i s i n t e g r a t i o n can f u r t h e r impair the student's academic performance thus r e i n f o r c i n g the f e e l i n g s of i n s e c u r i t y and inadequacy. H o s t i l i t y u s u a l l y f o l l o w s with the students r e j e c t i n g the program and i n s t u c t o r s (the s c h o o l c u l t u r e ) as u n r e a l i s t i c and inadequate. At t h i s time students u s u a l l y seek out other h o s t i l e nurses or move i n t o a new understanding of the tasks a t hand. The u l t i m a t e h o s t i l e a c t i s to drop out of the program. In the f i n a l phase of r e s o l u t i o n there are three p o s s i b l e outcomes: b i c u l t u r a l i s m , f a l s e acceptance, and c h r o n i c h o s t i l i t y . B i c u l t u r a l i s m i s the most p o s i t i v e , with b i c u l t u r a l students r e a c h i n g the p o i n t of understanding the d i f f e r e n c e s i n v alues, e x p e c t a t i o n s and s k i l l s of s c h o o l and work, and being comfortable and e f f e c t i v e i n both c u l t u r e s . T h e i r view of n u r s i n g i s a l t e r e d , but c o n t a i n s elements of both c u l t u r e s . A n x i e t y decreases, humour r e t u r n s , and energy i s spent on growth-producing behaviors r a t h e r than c o n f l i c t . In f a l s e acceptance, students camouflage t h e i r f e e l i n g s and t r y to be "good" students i n order to please the i n s t r u c t o r s and a v o i d t r o u b l e . Students spend enormous 15 amounts of energy i n b o t t l i n g up t h e i r h o s t i l i t y and i n b e l i e v i n g they are b i c u l t u r a l when, i n f a c t , they are not. Although i t wastes energy and blocks the s t u d e n t s ' f u l l p o t e n t i a l , f a l s e acceptance does a l l o w f o r comfortable completion of the program. The t h i r d p o s s i b l e r e s o l u t i o n i s c h r o n i c h o s t i l i t y , i n which students use much of t h e i r energy to f i g h t the system. Although these students do not u s u a l l y drop out of s c h o o l , they do not become c o n f i d e n t or able to develop t h e i r f u l l p o t e n t i a l . They remain captured i n t h e i r host i 1 i t y . Shane noted t h a t these three phases of RTSS are i n e v i t a b l e and perhaps necessary f o r r o l e t r a n s i t i o n but t h a t f a c u l t y and students need to decrease the i n t e n s i t y because of i t s negative e f f e c t s on l e a r n i n g and p e r s o n a l growth. Based on her experience t e a c h i n g these students (as opposed to r e s e a r c h on c o p i n g ) , Shane o f f e r e d advice for coping " i n the s p i r i t t h a t grandmothers o f f e r home remedies." T h i s advice i n c l u d e s : being aware of the RTSS process, e s t a b l i s h i n g support systems, sharpening academic s k i l l s , s e t t i n g p r i o r i t i e s , and monitoring and managing s t r e s s . S p e c i f i c s t r a t e g i e s mentioned were reducing the s t r e s s o r s i f p o s s i b l e such as the work or s c h o o l l o a d , implementing r e l a x a t i o n techniques of m e d i t a t i o n or prayer, i n c r e a s i n g p h y s i c a l a c t i v i t i e s , and s e t t i n g g o a l s . 16 White and Luna (1983) d i s c u s s the a p p l i c a t i o n of RTSS to a cro s s s e c t i o n of nonnurse a d u l t women r e t u r n i n g to s c h o o l . Based oh t h e i r previous e d u c a t i o n a l e x p e r i e n c e s , c u r r e n t goals and personal backgrounds, f i v e d i s t i n c t groups of women are d e s c r i b e d . Authors noted many d i f f e r e n c e s between r e t u r n i n g RNs and these other r e e n t r y women, These i n c l u d e the s u c c e s s f u l completion of a post secondary program (RN), experience working i n t h e i r f i e l d , and t h e i r p u r s u i t of f u r t h e r education i n th a t f i e l d . These d i f f e r e n c e s probably account f o r the d i f f e r i n g r e a c t i o n s between mature RN students and other r e e n t r y women. White and Luna found that few, i f any, students i n t h e i r study experienced the honeymoon stage. A l l s t u d e n t s , however, appeared to experience the a n x i e t y and f r u s t r a t i o n of the c o n f l i c t stage. F i n a l l y , the authors b e l i e v e t h a t i n most cases the r e s o l u t i o n of b i c u l t u r a l i s m i s not p o s s i b l e f o r students i f values of the two c u l t u r e s c o n t r a d i c t one another. They suggested that s h i f t i n g back and f o r t h between work and school i s very s t r e s s f u l , t h e r e f o r e the student u s u a l l y e v a l u a t e s both c u l t u r e s and chooses aspects from each t h a t are most comfortable. This process r e q u i r e s d i s t a n c i n g o n e s e l f from both c u l t u r e s and not q u i t e f i t t i n g i n t o e i t h e r . Before c o n s i d e r i n g the student a r t i c l e s on the s u b j e c t , two other f a c u l t y s t u d i e s t h a t c a t e g o r i z e 17 common s t r e s s o r s and suggest p o s i t i v e coping s t r a t e g i e s w i l l be presented. F i r s t , Jackson's (1984) study of 195 r e t u r n i n g RNs assessed demographic data, m o t i v a t i o n a l f a c t o r s , b a r r i e r s or s t r e s s o r s when e n t e r i n g the program, and p s y c h o l o g i c a l and f i n a n c i a l support systems. Major b a r r i e r s or s t r e s s o r s i n c l u d e d : f i n a n c e s , s t u d e n t s ' lack of confidence i n t h e i r c a p a b i l i t i e s , and i n a b i l i t y to be a f u l l - t i m e student. Most recommendations f o r improving the e d u c a t i o n a l experience mentioned were d i r e c t e d at the sch o o l system r a t h e r than the i n d i v i d u a l and w i l l not be addressed here. However, Jackson d i d suggest that students develop r e q u i r e d l e a r n i n g s k i l l s , s e t r e a l i s t i c g o a l s , and i d e n t i f y and u t i l i z e u n i v e r s i t y r e s o u r c e s . Anderson (1983) c a t e g o r i z e d responses to an open-ended q u e s t i o n on how RNs f e e l about r e t u r n i n g to s c h o o l . Common problems emerged i n c l u d i n g : lack of money, lack of time, combined workload of sch o o l and job, b a l a n c i n g f a m i l y and s c h o o l , change i n the r e l a t i o n s h i p with c h i l d r e n and spouse, and lack of study s k i l l s . She recommended i n c r e a s i n g i n d i v i d u a l s e l f c o n t r o l , s e t t i n g g o a l s , t a l k i n g with someone about the problem, d e l e g a t i n g a c t i v i t i e s , and r e l a x i n g by m e d i t a t i o n and e x e r c i s e . Students have a l s o documented t h e i r r e a c t i o n s to r e t u r n i n g to s c h o o l . In a p r o f e s s i o n a l i s s u e s c l a s s designed to expore a t t i t u d e s and ex p e c t a t i o n s a s s o c i a t e d 18 with e a r n i n g a b a c c a l a u r e a t e degree i n n u r s i n g , students were r e q u i r e d to w r i t e a group paper on change and t r a n s i t i o n (Balogh et a l . , 1980). C l a s s e s were tape recorded and l a t e r a n a l y z e d . These students documented the i n t e l l e c t u a l and emotional s t r a i n s of t r a n s i t i o n which they experienced as p e r s o n a l d i s t r e s s . The students noted that they were not aware of a change process u n t i l they reviewed and analyzed the tape r e c o r d i n g s of t h e i r c l a s s . In r e s t r o s p e c t , students f e l t t h a t they needed to express anger at the p a i n f u l t r a n s i t i o n before emerging with a sense of s a t i s f a c t i o n . In another a r t i c l e , two students d i s c u s s e d the worth of the BSN, weighing the p o s i t i v e and negative f a c t o r s of r e t u r n i n g to s c h o o l (Hart, Crawford, & Hicks, 1985). Once again , c o n f l i c t , s t r e s s , and emotional t u r m o i l were mentioned as were the p o s i t i v e i n t e l l e c t u a l and emotional growth. Two graduates of a post-RN b a c c a l a u r e a t e program were interviewed about how they coped (Sabina, 1985). The f i r s t student d e s c r i b e d f a t i g u e and exhaustion, low s e l f - e s t e e m , t r y i n g to manage too many th i n g s and "wondering what was wrong with her." T h i s student r e l a t e d t h a t she r e a l l y needed someone to t e l l her: she was doing too much, to s e t p r i o r i t i e s , to d e l e g a t e , to ask f o r h e l p . The other student s t a t e d her marriage had undergone a great d e a l of s t r e s s and would probably end 19 i n d i v o r c e . She f e l t the c o m p e t i t i o n among the r o l e s of student, worker, mother, and wife was q u i t e d i f f i c u l t and she would have a p p r e c i a t e d an o p p o r t u n i t y to d i s c u s s t h i s with other students i n s i m i l a r s i t u a t i o n s . T h i s student a l s o suggested s e t t i n g p r i o r i t i e s f o r what i s n e g o t i a b l e and what i s not, and "doing what you f e e l i s important" i n terms of p e r s o n a l o b j e c t i v e s f o r each course. The student f u r t h e r d e s c r i b e d an i n e v i t a b l e time of c r i s i s when students q u e s t i o n t h e i r m o t i v a t i o n f o r r e t u r n i n g to s c h o o l , and the relevance and importance of what i s being taught. Sabina r e p o r t s that r e e n t r y women who a t t e n d programs to improve p s y c h o l o g i c a l and l e a r n i n g s k i l l s have lower dropout r a t e s , achieve b e t t e r grades, and r e p o r t higher s e l f - e s t e e m . She suggests c l a r i f y i n g one's goals and s e t t i n g a c h i e v a b l e s h o r t term g o a l s . Three RN graduate n u r s i n g students (Camooso, Greene, & R e i l l y , 1981) d e s c r i b e d a s i m i l a r s t r e s s process of r e t u r n i n g to school using an a d a p t a t i o n model. They repo r t e d high a n x i e t y i n the beginning that v a r i e d throughout the program but g e n e r a l l y decreased as they adapted to t h e i r new r o l e s . S o c i a l support, a s k i n g for h e l p , and r e g u l a r e x e r c i s e were repo r t e d as f a c t o r s h e l p f u l i n f a c i l i t a t i n g a d a p t a t i o n . Nurses who had been master's students were interviewed to i d e n t i f y types and management of r o l e 20 s t r e s s (White, 1981). Those who completed the program were compared with those who d i d not. P r o b l e m - s o l v i n g was r e p o r t e d by both groups to be the most f r e q u e n t l y used method of reducing s t r e s s , as opposed to r o l e r e d u c t i o n , r o l e b a r g a i n i n g , or p h y s i c a l e x e r c i s e . S p e c i f i c s t r a t e g i e s were not d e s c r i b e d nor was t h e i r e f f e c t i v e n e s s assessed. In summary, there i s general agreement t h a t RNs experience high l e v e l s of s t r e s s when r e t u r n i n g to s c h o o l . Lack of time and money, workload, m u l t i p l e r o l e s with f a m i l y and f r i e n d s , and s c h o o l - r e l a t e d worries about study s k i l l s and program and f a c u l t y e x p e c t a t i o n s are s t r e s s o r s commonly r e p o r t e d . Both f a c u l t y and students recommend coping s t r a t e g i e s such as s e t t i n g g o a l s , e s t a b i s h i n g p r i o r i t i e s , t a l k i n g with others to gather support, n e g o t i a t i n g and d e l e g a t i n g to decrease the workload, and r e l a x i n g through e x e r c i s e or q u i e t a c t i v i t i e s . Authors g e n e r a l l y agree that these coping s t r a t e g i e s , as w e l l as good o r i e n t a t i o n and s o c i a l support are important i n promoting a d a p t a t i o n and f o r f a c i l i t a t i n g l e a r n i n g , p e r s o n a l growth and a sense of w e l l - b e i n g . Conceptual Framework This study i s based on the c o g n i t i v e theory of s t r e s s and coping developed over a number of years by Lazarus and h i s c o l l e a g u e s (Lazarus, 1966; Lazarus & 21 Folkman, 1984). S t r e s s i s c o n c e p t u a l i z e d as a dynamic r e l a t i o n s h i p between the person and the environment t h a t i s a p p r a i s e d by the person as t a x i n g or exceeding per s o n a l resources and as endangering w e l l - b e i n g . The emphasis on r e l a t i o n s h i p d i s t i n g u i s h e s t h i s approach from those which c o n s i d e r s t r e s s as e i t h e r a s t i m u l u s such as t a k i n g an exam or a response such as p h y s i o l o g i c a l a r o u s a l or p s y c h o l o g i c a l d i s t r e s s . In t h i s p r o c e s s - o r i e n t e d approach, the s t r e s s i s not a s t a b l e p r o p e r t y of the person or the environment. Rather, both f a c t o r s c o n s t a n t l y change and a f f e c t each other. The person uses c o g n i t i v e a p p r a i s a l and coping to moderate the s t r e s s i n the context of the environment. C o g n i t i v e a p p r a i s a l and coping are c e n t r a l i n the person-environment r e l a t i o n s h i p and c o n s e q u e n t i a l immediate and long-term a d a p t a t i o n a l outcomes. In c o g n i t i v e a p p r a i s a l the person f i r s t e v a l u a t e s whether a p a r t i c u l a r event i s r e l e v a n t to h i s or her w e l l - b e i n g , and whether i t i s p o s i t i v e , or s t r e s s f u l . Next, the person e v a l u a t e s p e r s o n a l resources and coping options a v a i l a b l e to overcome or prevent the s t r e s s f u l encounter. Coping r e f e r s to the person's c o g n i t i v e and b e h a v i o r a l e f f o r t s to manage (reduce, minimize, master, or t o l e r a t e ) the i n t e r n a l and e x t e r n a l demands of the person-environmental t r a n s a c t i o n that i s a p p r a i s e d as 22 t a x i n g or exceeding the person's resources (Lazarus & Folkman, 1984). This i s d i f f e r e n t from e a r l i e r t r a i t -o r i e n t e d d e f i n i t i o n s which c h a r a c t e r i z e coping as a s t a b l e t r a i t of the person (Kobasa, 1979). Recent s t u d i e s have noted the t r a i t - o r i e n t e d approach to be a poor p r e d i c t o r of behavior i n s p e c i f i c s i t u a t i o n s (Jacobson & McGrath, 1983). Another d i s t i n c t i o n of t h i s d e f i n t i o n i s i t s l a c k of dependence on the outcome of the p r o c e s s . T h i s d i f f e r s from popular d e f i n i t i o n s i n which coping i m p l i e s managing or succeeding while f a i l u r e i m p l i e s not c o p i n g . Many psychodynamic t h e o r i s t s r e s t r i c t the term coping to those a c t i o n s which meet s p e c i f i c c r i t e r i a such as adhering to r e a l i t y and d e c r e a s i n g d i s t r e s s (Haan, 1977; Menninger, 1963). Coping serves two b a s i c f u n c t i o n s : a l t e r i n g the s t r e s s o r (problem-focused), and a l t e r i n g the s t r e s s f u l emotional r e a c t i o n to the s t r e s s (emotion-focused). Recent s t u d i e s show that i n d i v i d u a l s use a combination of both problem-focused and emotion-focused coping s t r a t e g i e s i n responding to most s t r e s s f u l encounters (Folkman & Lazarus, 1980, 1985). Although many r e s e a r c h e r s have used t h i s framework ( B r a i l e y , 1983), only two have s t u d i e d nurses or n u r s i n g students. Parkes (1984) s t u d i e d locus of c o n t r o l , a p p r a i s a l , and coping s t r a t e g i e s i n r e l a t i o n to 23 s t r e s s f u l episodes of 171 undergraduate student nurses. Three f a c t o r s of general coping, d i r e c t coping and s u p p r e s s i o n were d e r i v e d from the Lazarus's Ways of Coping C h e c k l i s t , and a s i g n i f i c a n t i n t e r a c t i o n was noted between locus of c o n t r o l and a p p r a i s a l f o r each of the f a c t o r s . C h i r i b o g a & B a i l e y (1986) are c u r r e n t l y s t u d y i n g the coping s t r a t e g i e s and resources of nurses working i n a v a r i e t y of h o s p i t a l s e t t i n g s . R e s u l t s are not yet a v a i l a b l e . Lazarus and c o l l e a g u e s have noted the need to study not o n l y the nature of coping s t r a t e g i e s but a l s o the r e l a t i v e e f f e c t i v e n e s s of d i f f e r e n t ways of coping (Lazarus & Folkman, 1984). McCrae and Costa (1986) s t u d i e d the use and p e r c e i v e d e f f e c t i v e n e s s of coping s t r a t e g i e s a c r o s s d i f f e r e n t s t r e s s o r s i n r e l a t i o n to w e l l - b e i n g and p e r s o n a l i t y . Both coping s t r a t e g i e s and p e r s o n a l i t y were r e l a t e d to w e l l - b e i n g . Coping s t r a t e g i e s which were rat e d e f f e c t i v e f o r one s t r e s s o r were a l s o r a t e d e f f e c t i v e f o r other s t r e s s o r s . Although the authors assumed that i n a normal p o p u l a t i o n more e f f e c t i v e coping s t r a t e g i e s would be used more f r e q u e n t l y , c o r r e l a t i o n s between use and e f f e c t i v e n e s s were onl y 0.49 to 0.64. For example, coping s t r a t e g i e s such as w i s h f u l t h i n k i n g were f r e q u e n t l y used but r a r e l y thought to be e f f e c t i v e . The coping s t r a t e g i e s r a t e d as most 24 e f f e c t i v e were: r a t i o n a l a c t i o n , seeking help, e x p r e s s i o n of f e e l i n g s , c o g n i t i v e r e s t r u c t u r i n g , drawing s t r e n g t h from a d v e r s i t y , f a i t h , and humour. Least e f f e c t i v e coping s t r a t e g i e s r e p o r t e d i n c l u d e d : h o s t i l e r e a c t i o n , i n d e c i s i v e n e s s , s e l f - b l a m e , w i s h f u l t h i n k i n g , i s o l a t i o n of a f f e c t , and p a s s i v i t y . Summary The l i t e r a t u r e reviewed i n t h i s chapter i n d i c a t e s that high l e v e l s of s t r e s s are a common and s e r i o u s problem f o r most RNs r e t u r n i n g to u n i v e r s i t y f o r a BSN. Despite somewhat d i f f e r e n t d e s c r i p t i o n s and l a b e l s f o r the r e t u r n i n g RNs 1 r e a c t i o n s to s c h o o l , a l l s t u d i e s d e s c r i b e a change process i n which the s p e c i f c coping s t r a t e g i e s of the students i n f l u e n c e t h e i r a d a p t a t i o n to s c h o o l . I t was f u r t h e r noted that l i t t l e i s known about the s t r e s s and coping of these s t u d e n t s . Information about s t r e s s o r s , l e v e l s of d i s t r e s s and which coping s t r a t e g i e s are used and which s t r a t e g i e s are h e l p f u l i n reducing the students' s t r e s s i s e s s e n t i a l f o r improving the e d u c a t i o n a l experience of these s t u d e n t s . T h i s study helps to f i l l the v o i d by e x p l o r i n g and d e s c r i b i n g those aspects of the s t r e s s and coping process of RNs r e t u r n i n g to s c h o o l . 25 Chapter Three Methodology Overview T h i s chapter d e s c r i b e s the methodology used i n t h i s e x p l o r a t o r y , d e s c r i p t i v e study i n c l u d i n g : the sample, e t h i c s and human r i g h t s , the data c o l l e c t i o n procedure, the instruments used, and the a n a l y s i s procedure. Sample The sample c o n s i s t e d of a l l female r e t u r n i n g RNs c u r r e n t l y e n r o l l e d and a t t e n d i n g c l a s s e s at UBC School of Nursing i n the winter term of 1986-1987. A l l students attended a weekly seminar group. Both f u l l - t i m e and part-time students i n the t h i r d and f o u r t h years of the program were i n c l u d e d . A l l respondents were v o l u n t e e r s . E t h i c s and Human Rights Students r e c e i v e d o r a l and w r i t t e n e x p l a n a t i o n s of the purpose of the study, the procedures f o r data c o l l e c t i o n , and the intended a n a l y s i s of the data. I t was f u r t h e r e x p l a i n e d that r e f u s a l to p a r t i c i p a t e would i n no way j e o p a r d i z e the students' grades or p o s i t i o n i n the School. A copy of the l e t t e r to students i s i n Appendix A. Responses remained anonymous. Informed consent was i n f e r r e d by the completion and r e t u r n of the 26 quest i o n n a i r e . Procedure f o r Data C o l l e c t i o n One week a f t e r the o r a l and w r i t t e n p r e s e n t a t i o n s of the study, the r e t u r n i n g RNs were asked to remain a f t e r e i t h e r t h e i r t h i r d year or f o u r t h year n u r s i n g c l a s s to complete the q u e s t i o n n a i r e . Q u e s t i o n n a i r e s were a l s o a v a i l a b l e on request f o r those students who d i d not att e n d e i t h e r of the c l a s s e s . Students e i t h e r completed the q u e s t i o n n a i r e i n the classroom and retu r n e d i t to the i n v e s t i g a t o r or took i t away. In the l a t t e r case, they r e t u r n e d t h e i r q u e s t i o n n a i r e s to a locked box i n the undergraduate n u r s i n g lounge. Instrumentat ion The instruments used i n c l u d e d the Ways of Coping C h e c k l i s t (Lazarus & Folkman, 1984) to assess coping s t a t e g i e s , the Per s o n a l S t r a i n Q u e s t i o n n a i r e (Osipow & Spokane, 1981) to assess the l e v e l of d i s t r e s s , and a demographic q u e s t i o n n a i r e to d e s c r i b e the sample. Ways of Coping C h e c k l i s t . The Ways of Coping C h e c k l i s t (Lazarus & Folkman, 1984) was chosen because i t was developed from Lazarus's framework which, as e x p l a i n e d i n Chapter Two, i s u s e f u l i n e x p l a i n i n g the s t r e s s and coping process of r e t u r n i n g RNs. The C h e c k l i s t i s a l s o e f f e c t i v e because i t asks 27 respondents what they d i d i n a s p e c i f i c i n s t a n c e i n the re c e n t past r a t h e r than what they u s u a l l y do f o r g e n e r a l s t r e s s o r s . T h i s has been noted to g r e a t l y reduce the s e l e c t i v e d i s t o r t i o n of s e l f - r e p o r t ( B r a i l e y , 1983). The instrument has been used with a wide v a r i e t y of p o p u l a t i o n s i n c l u d i n g u n i v e r s i t y students (Folkman & Lazarus, 1985), n u r s i n g students from h o s p i t a l - b a s e d programs (Parkes, 1984), and p r a c t i c i n g nurses ( C h i r i b o g a , 1986). The authors of the instrument i n i t i a l l y c a t e g o r i z e d i n d i v i d u a l coping s t r a t e g i e s as problem-focused or emotion-focused. Alpha c o e f f i c i e n t s of 0.80 and 0.81 are r e p o r t e d by Folkman & Lazarus (1984).. Respondents are asked to i n d i c a t e how they a c t u a l l y coped with a s p e c i f i c s i t u a t i o n which they p e r c e i v e d as s t r e s s f u l . The instrument c o n t a i n s 67 p o s s i b l e c o g n i t i v e or b e h a v i o r a l a c t i o n s such as "I t a l k e d to someone about how I was f e e l i n g " or "I prayed." The responses are r a t e d on a 4-point L i k e r t -type s c a l e ranging from "used a great d e a l " (4) to "not used" ( 1 ) . Respondents are asked to answer how o f t e n they used each i n d i v i d u a l a c t i o n (coping s t r a t e g y ) i n r e l a t i o n to one s p e c i f i c s t r e s s o r which has occurred w i t h i n a p r e v i o u s s p e c i f i e d p e r i o d of time. Respondents are asked to r a t e on a separate 4-p o i n t L i k e r t - t y p e response s c a l e , the e f f e c t i v e n e s s of 28 each of the 67 s t r a t e g i e s i n r e l i e v i n g t h e i r s t r e s s . T h i s type of e v a l u a t i o n of e f f e c t i v e n e s s i s recommended by Menaghan (1983), and McCrae and Costa (1986). They f u r t h e r suggest t h a t s e l f - r e p o r t may be the best index of p s y c h o l o g i c a l w e l l - b e i n g and coping e f f e c t i v e n e s s . In t h i s study, p a r t i c i p a n t s were requested to l i s t o n ly those s t r e s s o r s r e l a t e d to t h e i r a t t e n d i n g s c h o o l , thereby l i m i t i n g the p o s s i b l e range of s t r e s s o r s . McCrae & Costa (1986) noted that f o c u s i n g on p a r t i c u l a r types of s t r e s s o r s provided more i n f o r m a t i o n which i s u s e f u l in d e s i g n i n g coping i n t e r v e n t i o n s . In order to provide more i n f o r m a t i o n on s t r e s s o r s s p e c i f i c to these s t u d e n t s , respondents were asked to l i s t the three g r e a t e s t sources of s t r e s s r a t h e r than o n l y one s t r e s s o r . P a r t i c i p a n t s then checked which coping s t r a t e g i e s they used d u r i n g the previous month i n response to t h e i r g r e a t e s t source of s t r e s s . P e r sonal S t r a i n Q u e s t i o n n a i r e . The P e r s o n a l S t r a i n Q u e s t i o n n a i r e (Osipow & Spokane, 1981) was chosen to measure the l e v e l of d i s t r e s s because i t i n c l u d e s a broad range of types and l e v e l s of d i s t r e s s , and has been used e x t e n s i v e l y with mature employed a d u l t s . The Q u e s t i o n n a i r e c o n t a i n s 40 items a s s e s s i n g p h y s i c a l complaints, i n t e r p e r s o n a l behaviors, p s y c h o l o g i c a l measures of a f f e c t i v e s t a t e s , and work r e l a t e d measures of attendance, p r o d u c t i v i t y 29 and s a t i s f a c t i o n . Items are r a t e d on a 5-point L i k e r t -type response format. The response d e s c r i p t o r s range from "most of the time" (5) to " r a r e l y or never" ( 1 ) . Scores range from a minimum of 40 to a maximum of 200. The authors i n i t i a l l y i d e n t i f i e d twice the r e q u i r e d number of items i n the l i t e r a t u r e and i n c o n s u l t a t i o n with e x p e r t s . A f t e r t e s t i n g , the authors s e l e c t e d items which appeared to possess the g r e a t e s t content v a l i d i t y . The two week t e s t - r e t e s t r e l i a b i l i t y c o e f f i c i e n t was 0.94 u s i n g Pearson r - c o r r e l a t i o n on a sample of employed a d u l t s . Cronbach's alpha c o e f f i c i e n t f o r i n t e r n a l c o n s i s t e n c y was r e p o r t e d as 0.94 f o r a sample of 419 employed a d u l t s . V a l i d i t y was e s t a b l i s h e d i n an i n v e s t i g a t i o n which used the s c a l e as an outcome measure of s t r e s s r e d u c t i o n f o r employed a d u l t women (Osipow & Spokane, 1983). The Q u e s t i o n n a i r e was modified by t h i s i n v e s t i g a t o r by s u b s t i t u t i n g the word " s c h o o l " f o r the word "work" i n e i g h t of the 40 items (numbers 1, 2, 3, 4, 6, 7, 8, and 10). For example, "I am bored with work" became "I am bored a t s c h o o l . " Demographic data. Demographic and d e s c r i p t i v e data i n c l u d i n g age, m a r i t a l s t a t u s , number and ages of c h i l d r e n , type of n u r s i n g e d u c a t i o n , year graduated, recent experience at s c h o o l , and past and c u r r e n t n u r s i n g p r a c t i c e were c o l l e c t e d because these f a c t o r s may i n f l u e n c e the coping 30 s t r a t e g i e s used. These data a l s o provided i n f o r m a t i o n to determine i f t h i s sample i s r e p r e s e n t a t i v e of r e t u r n i n g RNs and employed nurses i n Canada. Data A n a l y s i s The s t r e s s o r s l i s t e d by respondents were analyzed and c a t e g o r i z e d on the b a s i s of content by the i n v e s t i g a t o r . T h i s method of content c l a s s i f i c a t i o n by an independent a s s e s s o r r a t h e r than by the respondent i n t o groups a c c o r d i n g to c o n t r o l l a b i l i t y , or c h a l l e n g e , l o s s , and t h r e a t , i s recommended by Parkes (1986) and has been used by others ( B i l l i n g s & Moos, 1981; McCrae & Costa, 1986). I t avoids the p o s s i b l e conceptual o v e r l a p between s e l f - r e p o r t e d s i t u a t i o n a l a p p r a i s a l s , coping s t r a t e g i e s , and d i s t r e s s responses. Once e s t a b l i s h e d , c a t e g o r i e s were then d e f i n e d and e x p l a i n e d to two judges who were nurse educators. The judges independently s o r t e d the respondents' s t r e s s o r s i n t o the p r e d e f i n e d c a t e g o r i e s . When the judges d i d not agree, they d i s c u s s e d and r e s o l v e d the d i s c r e p a n c y . An 96% agreement was noted between the two judges which i s w e l l w i t h i n the convention of i n t e r - r a t e r r e l i a b i l i t y of 80% or more (Kazdin & Straws, 1976). D e s c r i p t i v e s t a t i s t i c s of frequency and measures of v a r i a b i l i t y were used to analyze the demographic v a r i a b l e s , and the use and e f f e c t i v e n e s s of each coping s t r a t e g y examined using the SPSS:X (SPSS Inc., 1983). A 31 t_ t e s t was performed on the mean l e v e l s of d i s t r e s s between t h i r d and f o u r t h year r e t u r n i n g RNs, and between those students who had been out of school more than 2 years and those who had not. A s i g n i f i c a n c e l e v e l of l e s s than or equal to 0.05 was used. 32 Chapter Four P r e s e n t a t i o n and D i s c u s s i o n of F i n d i n g s Overv iew The f i n d i n g s of t h i s study are presented and d i s c u s s e d i n three s e c t i o n s . The f i r s t s e c t i o n r e p o r t s demographic and d e s c r i p t i v e i n f o r m a t i o n about the sample. The next s e c t i o n presents the f i n d i n g s i n r e l a t i o n to the f i v e r e s e a r c h questions concerning the l e v e l of d i s t r e s s , the s t r e s s o r s , the frequency of coping s t r a t e g i e s , the most e f f e c t i v e coping s t r a t e g i e s , and the l e a s t e f f e c t i v e coping s t r a t e g i e s . A d i s c u s s i o n of the f i n d i n g s concludes the chapter. These f i n d i n g s are based on 72 q u e s t i o n n a i r e s completed by 42 of 50 r e t u r n i n g RNs r e g i s t e r e d i n a t h i r d year c l i n i c a l n u r s i n g course and a l l 30 of the r e t u r n i n g RNs e n r o l l e d i n a f o u r t h year n u r s i n g course. E i g h t t h i r d year students d i d not remain a f t e r c l a s s to p a r t i c i p a t e . A t o t a l of 73 q u e s t i o n n a i r e s was d i s t r i b u t e d , of which 71 were completed a f t e r c l a s s i n the classroom and ret u r n e d immediately to the i n v e s t i g a t o r . Of the two q u e s t i o n n a i r e s taken away, one was returned to a locked box i n the n u r s i n g student lounge and the other was not r e t u r n e d . 33 Demographic and D e s c r i p t i v e Information The f o l l o w i n g p e r s o n a l , e d u c a t i o n a l , and p r o f e s s i o n a l i n f o r m a t i o n was c o l l e c t e d about the respondents: age, m a r i t a l s t a t u s , number of c h i l d r e n , type of n u r s i n g e d u c a t i o n , year graduated, recent experience a t s c h o o l , past and c u r r e n t n u r s i n g exper ience . Age . The respondents ranged i n age from 21 to 50, with an average age of 32 y e a r s . Most stude n t s , 43 (60.6%), were between 23 and 32 years of age. M a r i t a l s t a t u s . The sample was almost e q u a l l y d i v i d e d between married and s i n g l e persons, with 33 (45.8%) married and 31 (43.1%) s i n g l e . Of the remainder, 4 (5.6%) were d i v o r c e d and 4 (5.6%) were l i v i n g common law or s e p a r a t e d . Number of c h i l d r e n . More than h a l f of the respondents, 47 (65.3%), d i d not have c h i l d r e n . Seven respondents (9.7%) had one c h i l d , 16 respondents (22.2%) had two or three c h i l d r e n , and 2 respondents (2.8%) had four c h i l d r e n . Nursing education. More than h a l f of the respondents, 44 (61.1%), graduated from a three-year h o s p i t a l - b a s e d program, while the remaining 28 (38.9%). had completed a c o l l e g e 34 or u n i v e r s i t y non-degree program. The year of g r a d u a t i o n from n u r s i n g s c h o o l ranged from 1957 to 1986. Over h a l f of the respondents, 39 (54.2%), had returned to pursue a BSN w i t h i n 8 years of g r a d u a t i n g from t h e i r b a s i c program. S i x t e e n (22%) of the 72 respondents (38% of the 42 t h i r d year s t u d e n t s ) , had not attended a u n i v e r s i t y or c o l l e g e c l a s s on campus i n the l a s t two y e a r s . Nursing experience. The numbers of years working as a nurse ranged from 1 to 33 with a mean of 10.3 years and a median of 8 years experience. Current work s t a t u s . S l i g h t l y over h a l f , 40 (55.6%), of the respondents were c u r r e n t l y employed as RNs between 4 and 37 hours per week. Over h a l f of those employed, 25 (62.5%), were working one 8-hour or 12-hour s h i f t per week. In t h e i r c u r r e n t or l a s t n u r s i n g p o s i t i o n , 53 (73.6%) r e p o r t e d being s t a f f nurses, 15 (21%) a d m i n i s t r a t o r s , 1 (1.4%) a community h e a l t h nurse, 1 (1.4%) a n u r s i n g i n s t r u c t o r , and 2 (2.8%) o f f e r e d no response. Find ings Research Question one; What i s the l e v e l of  d i s t r e s s of RNs r e t u r n i n g to school? The l e v e l of d i s t r e s s was computed from the t o t a l score on the P e r s o n a l S t r a i n Q u e s t i o n n a i r e . Respondents 35 scores ranged from 48 to 156 out of a p o s s i b l e 200. The median was 88 and the mean was 9 3.47. There was no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n the mean l e v e l s of d i s t r e s s between the t h i r d year students (M = 94.59) and the f o u r t h year students (M = 91.90). Using a t_ t e s t , the t value was .54 with a two-t a i l e d p r o b a b i l i t y of .59. There was a l s o no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n the mean l e v e l s of d i s t r e s s between those r e t u r n i n g RNs who had been out of school f o r more than two years (M = 94.37) and those who had been a t t e n d i n g courses r e c e n t l y (M = 93.21). A t t e s t showed a t value of .20 with a t w o - t a i l e d p r o b a b i l i t y of .846. Research q u e s t i o n two; What are the s c h o o l - r e l a t e d s t r e s s o r s of r e t u r n i n g RNs? In response to an open-ended q u e s t i o n , respondents l i s t e d t h e i r three g r e a t e s t s c h o o l - r e l a t e d s t r e s s o r s i n order of t h e i r importance. These were c l a s s i f i e d by the r e s e a r c h e r i n t o four c a t e g o r i e s : s c h o o l - s p e c i f i c , time, s o c i a l and domestic, and money. Of the 72 respondents, 36 (50%) l i s t e d s c h o o l -s p e c i f i c s t r e s s o r s as the most important, 17 (24%) l i s t e d t i m e - r e l a t e d s t r e s s o r s most important, 12 (17%) l i s t e d s o c i a l and domestic concerns, and 7 (10%) l i s t e d money-related s t r e s s o r s as most important. Table 1 summarizes the f i n d i n g s of the most important s t r e s s o r s 36 r e l a t e d to going to s c h o o l . Table 1 Most Important S t r e s s o r Category of S t r e s s o r Frequency (N = 72) S c h o o l - s p e c i f i c 36 Academic S k i l l s 11 Academic Management, Workload 12 Nursing Program, Curr iculura 5 F a c u l t y - Role Models, Unclear E x p e c t a t i o n s 8 Time 17 S o c i a l and Domestic 12 Money 7 Because each respondent was asked to l i s t three s t r e s s o r s , there was p o t e n t i a l f o r a t o t a l of 216 s t r e s s o r s to be r e p o r t e d by the respondents. Only 193 s t r e s s o r s were a c t u a l l y l i s t e d . Table 2 summarizes these s t r e s s o r s l i s t i n g the r e s u l t s from t h i r d year and f o u r t h year students s e p a r a t e l y as w e l l as the r e s u l t s from the e n t i r e group. 37 Table 2 Three Most Important S t r e s s o r s Category of S t r e s s o r Groups T o t a l 3rd year 4th year (n=42) (n=30) S c h o o l - s p e c i f i c Academic S k i l l s Exams/Grades W r i t i n g Papers Study S k i l l s Academic Management Assignments Due At Same Time Workload Nursing Program, Curr iculum F a c u l t y - Role Models, Unclear E x p e c t a t i o n s S o c i a l & Domestic Time Money Mi s c e l l a n e o u s T o t a l S t r e s s o r s Reported * T o t a l S t r e s s o r s P o s s i b l e 8 4 4 16 9 22 17 8 3 107 126 6 3 0 6 5 11 23 16 11 4 86 90 14 7 8 22 14 20 45 33 19 7 193 216 *Not a l l respondents l i s t e d three s t r e s s o r s 38 Of the 193 s t r e s s o r s l i s t e d , almost h a l f , 89 (46%), were s c h o o l - s p e c i f i c . The next most common s t r e s s o r s r e p o r t e d were s o c i a l and domestic with 45 (23%). Time was mentioned 33 times (17%). Lack of money was r e p o r t e d 19 times (10%). There were 7 misc e l l a n e o u s s t r e s s o r s such as p e r s o n a l i l l n e s s and t r a n s p o r t a t i o n d i f f i c u l t i e s . S t r e s s o r s mentioned i n f r e q u e n t l y were: c h i l d c a r e , which was l i s t e d twice and placed i n the s o c i a l and domestic category, and work, which was re p o r t e d three times and c a t e g o r i z e d under the s t r e s s o r o f t i me . S e v e r a l d i f f e r e n c e s between t h i r d and f o u r t h year students can be noted i n the types of s t r e s s o r s r e p o r t e d . (See Table 2) A l l s c h o o l - s p e c i f i c s t r e s s o r s , except concerns with f a c u l t y , were more common among t h i r d year s t u d e n t s . Study s k i l l s were r e p o r t e d as s t r e s s o r s o n l y by t h i r d year s t u d e n t s . Assignments due at the same time was much more of a problem f o r t h i r d year students who repo r t e d i t 7 times compared with o n l y one time by a f o u r t h year student. The frequency of other s t r e s s o r s r e p o r t e d was v i r t u a l l y the same. Research q u e s t i o n t h r e e : What coping s t r a t e g i e s  are used by r e t u r n i n g RNs to d e a l with s c h o o l - r e l a t e d  s t r e s s ? Tables 3 and 4 present summaries of the coping s t r a t e g i e s used most f r e q u e n t l y and l e a s t f r e q u e n t l y i n r e l a t i o n to s c h o o l - r e l a t e d s t r e s s o r s . S t r a t e g i e s were r a t e d : (1) "not used," (2) "used somewhat," (3) "used q u i t e a b i t , " or (4) "used a great d e a l . " Coping s t r a t e g i e s with a mean use re p o r t e d between 3.00 and 4.00 were c a t e g o r i z e d as most f r e q u e n t l y used and those with means below 1.55 as l e a s t f r e q u e n t l y used. Table 3 Most F r e q u e n t l y Used Coping S t r a t e g i e s Coping S t r a t e g y Mean Frequency I t a l k e d to someone about how I w a s f e e l i n g . 3.29 J u s t concentrated on what I had to do next--the next s t e p . 3.21 I l e t my f e e l i n g s out somehow. 3.20 I made a plan and followed i t . 3.19 I accepted empathy and understanding from someone. 3.18 Talked to someone to f i n d out more about the s i t u a t i o n . 3.15 40 Table 4 Least F r e q u e n t l y Used Coping S t r a t e g i e s Coping S t r a t e g y Mean Frequency I avoided being with people g e n e r a l l y . 1 . 52 I d i d something which I d i d n ' t th i n k would work, but at l e a s t I was doing something. 1 .51 I went on as i f nothing had happened. 1 . 50 I took a b i g chance and d i d something r i s k y . 1 . 41 I got p r o f e s s i o n a l help. 1 . 33 Research q u e s t i o n f o u r : Which coping s t r a t e g i es do r e t u r n i n g RNs p e r c e i v e as most e f f e c t i v e i n r e d u c i n g  s t r e s s ? Table 5 l i s t s the s i x coping s t r a t e g i e s which were repor t e d as most e f f e c t i v e . Respondents were asked to r a t e how e f f e c t i v e each coping s t r a t e g y was, using the f o l l o w i n g s c a l e ; (1) "not a t a l l , " (2) "somewhat," (3) " q u i t e a b i t , " (4) "a great d e a l . " Again, s t r a t e g i e s with means of 3.00 and above were c a t a g o r i z e d as most e f f e c t i v e . 41 Table 5 Most E f f e c t i v e Coping S t r a t e g i e s Coping S t r a t e g y E f f e c t i v e n e s s Mean I t a l k e d to someone about how I was f e e l i n g . 3.32 I made a pl a n and f o l l o w e d i t . 3.19 I accepted empathy and understanding from someone. 3.18 I jogged or e x e r c i s e d . 3.09 I l e t my f e e l i n g s out somehow. 3.05 Ju s t concentrated on what I had to do n e x t — t h e next s t e p . 3.02 Research q u e s t i o n f i v e : Which coping s t r a t e g i e s  do r e t u r n i n g RNs p e r c e i v e as l e a s t e f f e c t i v e i n r e d u c i n g  s t r e s s ? Table 6 l i s t s the coping s t r a t e g i e s p e r c e i v e d as l e a s t e f f e c t i v e . S t r a t e g i e s with means below 1.55 were c a t e g o r i z e d as l e a s t e f f e c t i v e because they were r a t e d between "not a t a l l " and "somewhat" e f f e c t i v e . 42 Table 6 Least E f f e c t i v e Coping S t r a t e g i e s Coping S t r a t e g y E f f e c t i v e n e s s Mean I expressed anger to the person(s) who caused the problem. 1.54 I took i t out on other people. 1.52 T r i e d to get the person respon-s i b l e to change h i s / h e r mind. 1.50 I r e f u s e d to b e l i e v e t h a t i t had happened. 1.38 I hoped a m i r a c l e would happen. 1.25 D i s c u s s i o n of F i n d i n g s In d i s c u s s i n g the f i n d i n g s , the sample w i l l f i r s t be compared to other samples of r e t u r n i n g RNs and then to employed nurses i n Canada. Next, each r e s e a r c h q u e s t i o n w i l l be addressed i n c l u d i n g : the students' l e v e l of d i s t r e s s , the s t r e s s o r s , and the use and e f f e c t i v e n e s s of the coping s t r a t e g i e s . Comparison of the sample with other r e t u r n i n g RNs  and employed Canadian nurses. On the r e p o r t e d dimensions, t h i s sample i s q u i t e s i m i l a r to respondents i n other p u b l i s h e d s t u d i e s of RN students who have re t u r n e d to s c h o o l (George & Owen, 1983; Jackson, 1984; Zorn, 1980). The respondents i n 43 these s t u d i e s t y p i c a l l y were about 32 years o l d . Approximately h a l f were married and two t h i r d s were graduates of h o s p i t a l programs. These c h a r a c t e r i s t i c s are v i r t u a l l y i d e n t i c a l with the sample i n t h i s study: mean age of 32 years, 45.8% married, and 61.1% graduates of h o s p i t a l programs. In these r e s p e c t s , t h i s sample appears to be h i g h l y r e p r e s e n t a t i v e of the r e t u r n i n g RN p o p u l a t i o n . T h i s sample a l s o appears to be r e p r e s e n t a t i v e of employed nurses a c r o s s Canada i n terms of the percentage married, the percentage educated i n h o s p i t a l - b a s e d programs, and percentage employed as s t a f f nurses i n h o s p i t a l s ( S t a t i s t i c s Canada, 1986). (See Table 7) The sample i s , however, d i f f e r e n t i n the m a r i t a l s t a t u s c a t e g o r i e s of s i n g l e and other. T h i s may be because the c a t e g o r i e s i n the n a t i o n a l sample were not c l e a r l y d e f i n e d ; separated or d i v o r c e d respondents could have l i s t e d e i t h e r s i n g l e or other. The percentages of the r e t u r n i n g RN sample and employed Canadian nurses were v i r t u a l l y the same i n terms of the percentage educated i n a h o s p i t a l - b a s e d program and employed as h o s p i t a l s t a f f nurses. Table 7 Demographic and D e s c r i p t i v e Data: Sample and N a t i o n a l Populat ion Character i s t i c s % UBC Returning RNs % Employed Canadian Nurses* Age Under 25 14 25-29 29 30-34 22 35-39 14 40-44 11 45-49 8 50 & over 1 M a r i t a l Status Married 45 S i n g l e 43 Other 11 Nursing E d u c a t i o n H o s p i t a l Diploma 61 C o l l e g e Program 38 P o s i t i o n i n Nursing H o s p i t a l S t a f f 73 Nursing I n s t r u c t o r 1 Community Health 1 6 15 19 18 15 11 16 53 15 33 79 21 73 3 9 •Source: S t a t i s t i c s Canada, 1986 45 The sample in t h i s study has fewer nurse educators and community h e a l t h nurses because these p o s i t i o n s f r e q u e n t l y r e q u i r e someone who a l r e a d y has a BSN. Not s u r p r i s i n g l y , the sample i s somewhat younger than the n a t i o n a l nurse p o p u l a t i o n . Given t h a t Jackson (1984) found t h a t career advancement was one of the major reasons that RNs returned to u n i v e r s i t y , one c o u l d surmise that younger i n d i v i d u a l s would be more w i l l i n g to i n v e s t time and money i n advancing t h e i r career as they have more working years ahead of them. T h i s sample then, a p a r t from age, appears to m i r r o r both r e t u r n i n g RN:; and the employed Canadian n u r s i n g p o p u l a t i o n . Therefore i t i s l i k e l y t h a t t h i s sample a l s o r e p r e s e n t s the s t r e s s and coping p a t t e r n s of most r e t u r n i n g RNs. One c o u l d a l s o s p e c u l a t e that employed Canadian nurses might experience s i m i l a r s t r e s s and coping p a t t e r n s upon r e t u r n to s c h o o l . L e v e l of d i s t r e s s . The r e t u r n i n g RNs of t h i s sample do not appear h i g h l y d i s t r e s s e d . The a b s o l u t e l e v e l of d i s t r e s s r e p o r t e d was near the low end of the s c a l e : a mean of 88 i n a p o s s i b l e range of 40 to 200. D i r e c t comparisons, such as measures of the sample before they entered s c h o o l , or a cohort of working nurses not i n s c h o o l , are not a v a i l a b l e . However, there are norms of d i s t r e s s experienced i n r e l a t i o n to work s t r e s s . The mean score 46 of d i s t r e s s i n r e l a t i o n to a t t e n d i n g s c h o o l f o r the r e t u r n i n g RNs ( 8 8 ) 7 i s extremely c l o s e to the mean score of d i s t r e s s i n r e l a t i o n to work (84) rep o r t e d by a sample of mature working women, using the same s c a l e (Osipow, Doty, & Spokane, 1985). I t i s , t h e r e f o r e , reasonable to assume that these r e t u r n i n g RNs are not h i g h l y d i s t r e s s e d . Based on previous s t u d i e s (Kirk & Dorfman, 1983; Smith & Reeves, 1984; Roehl & Okun, 1984), i t i s s u r p r i s i n g t h a t there were no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s i n the o v e r a l l l e v e l s of d i s t r e s s r e p o r t e d : a) between the t h i r d and f o u r t h year students i n the program, and b) between those r e t u r n i n g RNs who had not been i n sch o o l f o r more than two years ( r e e n t r y women) and those who had been a t t e n d i n g courses d u r i n g that time. Each lack of d i f f e r e n c e w i l l be d i s c u s s e d i n d i v i d u a l l y , f o l l owed by a p r e s e n t a t i o n of f a c t o r s which may a f f e c t both f i n d i n g s . The lack of s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the t h i r d year and f o u r t h year s t u d e n t s ' l e v e l s of d i s t r e s s i s i n c o n s i s t e n t with e a r l i e r n u r s i n g r e s e a r c h . Smith and Reeves (1986) noted t h a t d i s t r e s s d e s c r i b e d as c o n f l i c t or g r i e v i n g was higher at the beginning of sch o o l and lower toward the end of the program. Shane (1983) d e s c r i b e d the honeymoon, c o n f l i c t , and r e s o l u t i o n stages as t y p i c a l and v a r y i n g i n 47 emotional d i s t r e s s with the c o n f l i c t stage by f a r the most u p s e t t i n g . Based on t h i s l i t e r a t u r e , one would expect the t h i r d year students to be more d i s t r e s s e d than those i n f o u r t h year. I t i s p o s s i b l e that both groups of students were i n the c o n f l i c t stage and t h e r e f o r e not d i f f e r e n t i n t h e i r l e v e l of d i s t r e s s . Perhaps the t h i r d year students had a l r e a d y s e t t l e d i n t o the student r o l e by the middle of the second term and the f o u r t h year students may a l r e a d y have begun to worry about money, jobs, and l i f e a f t e r g r a d uation which would be o n l y three months away. The causes of the s t r e s s ( s t r e s s o r s ) would then be d i f f e r e n t , but the o v e r a l l l e v e l of d i s t r e s s would be q u i t e s i m i l a r . The i n c i d e n c e of s t r e s s o r s was i n f a c t d i f f e r e n t . T h i s w i l l be d i s c u s s e d l a t e r . Regardless of the s t u d e n t s ' year i n s c h o o l , i t i s a l s o s u r p r i s i n g t h at there was no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n the l e v e l s of d i s t r e s s between those r e t u r n i n g RNs who had not been i n s c h o o l w i t h i n the past two years and those who had been a t t e n d i n g courses d u r i n g that time. T h i s i s i n c o n s i s t e n t with the f i n d i n g s of K i r k and Dorfman (1983) i n a study of 141 undergraduate r e e n t r y women, where the amount of s t r a i n ( l e v e l of d i s t r e s s ) was found to be p r o p o r t i o n a l to the length of time they had been away from s c h o o l . Roehl and Okun's (1984) study a l s o r e p o r t e d d e p r e s s i o n l e v e l s 48 twice as high i n r e e n t r y women i n the f i r s t semester of scho o l as i n the general p o p u l a t i o n of mature women. The time of data c o l l e c t i o n may be an important f a c t o r . Data were c o l l e c t e d f o r the above s t u d i e s i n the f i r s t semester, while, i n t h i s study, data were c o l l e c t e d from the r e t u r n i n g RNs a f t e r the middle of the second semester. These students had completed f i r s t term and h a l f of second term. They had r e c e i v e d feedback about t h e i r performance, which i s known to decrease d i s t r e s s (Brundage & MacKeracher, 1980). They had had time to e s t a b l i s h r o u t i n e s and to become f a m i l i a r with the system and environment. This a l s o decreases d i s t r e s s (Perry, 1986; Shane, 1983). Returning RNs who had not attended school i n the past two years were, by the second term, no longer new to the system. Perhaps the i n i t i a l adjustment time i s s t r e s s f u l f o r r e e n t r y s t u d e n t s , but by second term most have a d j u s t e d and experience l e v e l s of d i s t r e s s s i m i l a r to those who have been i n the e d u c a t i o n a l system longer. Lazarus's framework (1966; 1984) suggests that once the i n d i v i d u a l r e c o g n i z e s t h a t he/she has the resources to d e a l with the s t r e s s o r s (secondary a p p r a i s a l ) , those s t r e s s o r s no longer tax or exceed the resources so there i s l e s s s t r e s s and consequently l e s s d i s t r e s s . There are two f a c t o r s r e l a t e d to the re s e a r c h instrument and s e t t i n g , which may account f o r the lack 49 of d i f f e r e n c e s i n d i s t r e s s between a) t h i r d and f o u r t h year r e t u n i n g RNs, and b) r e e n t r y r e t u n i n g RNs and those who have been i n school r e c e n t l y . F i r s t , the instrument may not adequately r e f l e c t d i s t r e s s or be s e n s i t i v e enough to measure d i f f e r e n c e s i n l e v e l s of d i s t r e s s . Second, n u r s i n g students may not have r e p o r t e d the s e v e r i t y of t h e i r d i s t r e s s . George and Owen (1983) noted t h a t r e t u r n i n g RNs answered q u e s t i o n n a i r e s i n more s o c i a l l y approved ways than d i d other mature undergraduate women. A l s o , a l l but one respondent completed the q u e s t i o n n a i r e i n a nu r s i n g classroom which may have i n f l u e n c e d t h e i r responses. LeCompte and Goetz (1982) noted that what i s con s i d e r e d a p p r o p r i a t e to r e p o r t i n one s e t t i n g may be considered i n a p p r o p r i a t e to re p o r t i n another s e t t i n g . These authors c i t e d Ogbu's study of 1974, i n which there were major d i f f e r e n c e s i n in f o r m a t i o n r e p o r t e d by parents i n the school environment and i n t h e i r home neighborhood. The classroom may have i n f l u e n c e d the w i l l i n g n e s s of respondents i n t h i s study to r e p o r t d i s t r e s s . F i n a l l y , coping may have mediated the r e l a t i o n s h i p between the s t r e s s and d i s t r e s s of the respondents. McCrae and Costa (1986) have suggested that coping may not r e l i e v e the ap p r a i s e d s t r e s s or the s t r e s s o r s but i t may inc r e a s e the person's t o l e r a n c e , and t h e r e f o r e decrease the d i s t r e s s . The respondents r e p o r t e d using 50 more a c t i v e coping s t r a t e g i e s which d e a l with the s t r e s s o r or the emotional r e a c t i o n to i t . B i l l i n g s and Moos (1981) found t h a t more r e l i a n c e on a c t i v e attempts to d e a l with a s t r e s s o r and fewer attempts to avoid d e a l i n g with i t were a s s o c i a t e d with l e s s s t r e s s . R eturning RNs' use of these a c t i v e approach s t r a t e g i e s , as w i l l be d i s c u s s e d , may be one reason why these respondents were not more d i s t r e s s e d . S t r e s s o r s . S t r e s s o r s r e p o r t e d by the r e t u r n i n g RNs and l i s t e d i n Tables 1 and 2 (pages 36 and 37) w i l l be d i s c u s s e d f i r s t . The d i f f e r e n c e s i n type and number of s t r e s s o r s r e p o r t e d by t h i r d and f o u r t h year r e t u r n i n g RNs w i l l f o l l o w . The s t r e s s o r s l i s t e d were g u i t e s i m i l a r to those r e p o r t e d by K i r k and Dorfman (1983) f o r a sample of non-nu r s i n g r e e n t r y women. Those s t r e s s o r s i n c l u d e d : time, money, m u l t i p l e demands, and academic s k i l l s . The non-nu r s i n g respondents i n K i r k and Dorfman's study, however, d i d not i d e n t i f y problems with t h e i r programs and f a c u l t y . T h i s d i f f e r e n c e probably occurred because most other r e e n t r y women do not have t h e i r p r o f e s s i o n a l v a l u e s c h a l l e n g e d when they r e t u r n to u n i v e r s i t y , nor do they enter a b a s i c e d u c a t i o n a l program when they a l r e a d y have work experience and co n s i d e r themselves competent (Shane, 1983). White and Luna (1983) s t u d i e d r e e n t r y 51 women i n a l a r g e m u t i d i s c i p l i n a r y u n i v e r s i t y and d i s c o v e r e d f i v e d i s t i n c t types based on previous e d u c a t i o n and experience, c u r r e n t g o a l s , and p e r s o n a l backgrounds. Although they a l l experienced t r a n s i t i o n s i n r e t u r n i n g to s c h o o l , a l l but one group were q u i t e d i f f e r e n t from r e t u r n i n g RNs. The group t i t l e d "I need a c r e d e n t i a l i n my f i e l d " was s i m i l a r to r e t u r n i n g RNs i n d e s c r i b i n g a n x i e t y about succeeding at u n i v e r s i t y , and i n e x p e r i e n c i n g c o n f l i c t between p r i o r and new l e a r n i n g . F i n d i n g s of other s t u d i e s of r e t u r n i n g RNs (Anderson, 1983; Jacobson & McGrath, 1982; P e r r y , 1986; Shane, 1983) are c o n s i s t e n t with the f i n d i n g s of t h i s study r e l a t e d to e x p e c t a t i o n s of and r e l a t i o n s h i p s with the n u r s i n g f a c u l t y as major sources of s t r e s s . Returning RNs f r e q u e n t l y had been i n p o s i t i o n s of a u t h o r i t y , "knowing the answers," and c o n f e r r i n g with c l i n i c a l n u r s i n g f a c u l t y and other members of the h e a l t h care team. In t h e i r new r o l e as student, however, they are i n a more subordinate r o l e , being asked to accept the answers provided by o t h e r s . T h i s t r a n s i t i o n causes s t r e s s . By c o n t r a s t , g e n e r i c n u r s i n g students are g e n e r a l l y younger, more f a m i l i a r with the student r o l e , and r e s p e c t the knowledge and m a t u r i t y of the f a c u l t y . MacMaster (1979) and Zutewskyj & Davis (1985) have found that g e n e r i c n u r s i n g students experience s t r e s s o r s from t h e i r c l i n i c a l work, a s s e r t i n g personal independence, 52 and b o y f r i e n d s . These s t r e s s o r s flow from the age and experience of nur s i n g undergraduates. For r e t u r n i n g RNs, s c h o o l - s p e c i f i c s t r e s s o r s were found to be the most common, f i r s t l y , because the q u e s t i o n n a i r e s o l i c i t e d i n f o r m a t i o n only on s t r e s s r e l a t e d to going to sch o o l and secondly, because attendance a t u n i v e r s i t y was a new experience. Many of the s t r e s s o r s , such as concern with exams and w r i t i n g papers, are a f u n c t i o n of the lack of previous study i n a u n i v e r s i t y as we l l the number of years away from formal study of any ki n d . S o c i a l and domestic concerns arose from r e t u r n i n g RNs' m u l t i p l e r o l e s , such as student, wife, mother, and daughter. S t r e s s o r s such as "unable to meet a l l my o b l i g a t i o n s " and " g u i l t over lack of energy and time f o r f a m i l y " were commonly r e p o r t e d . These s t r e s s o r s are not s u r p r i s i n g given the circumstances of these respondents: mature women who tended to work par t - t i m e , be married, and have c h i l d r e n . These r e p o r t e d s t r e s s o r s are c o n s i s t e n t with other r e s e a r c h f i n d i n g s on r e e n t r y women (Kirk & Dorfman, 1983; S c o t t , 1980). Time was a major concern among the top three s t r e s s o r s i n t h i s study and was l i s t e d most f r e q u e n t l y , 17 times (24%), as the g r e a t e s t s t r e s s o r . T h i s i s c o n s i s t e n t with the f i n d i n g s of Jacobson & McGrath (1983), whose respondents l i s t e d time as a major 53 p r e o c c u p a t i o n . Money was a l s o a major s t r e s s o r f o r respondents i n t h i s study, but was not o f t e n l i s t e d as a f i r s t s t r e s s o r , 7 times (10%). T h i s may be because students had a n t i c i p a t e d and budgeted for a p e r i o d of lower income and may a l s o have been able to work p a r t -time. Students who a p p r a i s e d money as a s t r e s s o r , t a x i n g or exceeding t h e i r r e s o u r c e s , may have dropped out of the program to r e t u r n to work and would not be respondents i n t h i s study. S t r e s s o r s mentioned i n f r e q u e n t l y were c h i l d c a r e and employment. Although there were 5 mothers of p r e s c h o o l e r s and 7 mothers of school-age c h i l d r e n , c h i l d c a r e was mentioned only once as a s t r e s s o r and c h i l d r e n ' s a c t i v i t i e s were a l s o only mentioned once. Perhaps these students had arranged f o r c h i l d c a r e while they were employed and continued with these arrangements as s t u d e n t s , or perhaps they i n c l u d e d daycare under f a m i l y and domestic s t r e s s o r s . In a d d i t i o n , women who have chosen a p r o f e s s i o n a l career may have f e l t t h a t c h i l d c a r e was not a p p r o p r i a t e to r e p o r t as a s c h o o l -r e l a t e d s t r e s s o r . Employment i s another s t r e s s o r which has been commonly re p o r t e d as p a r t of r o l e overload f o r r e t u r n i n g RN students ( C a l l i n , 1983). Although 55.6% of the students i n t h i s study were employed while going to s c h o o l , employment was only mentioned three times as a 54 source of s t r e s s . When mentioned, i t was i n connection with the amount of time r e q u i r e d and the t o t a l workload. Examples of s t r e s s o r s r e p o r t e d were, "Having to work to pay f o r r e n t , thereby c u t t i n g back on time f o r homework," and "work commitments." I t i s i n t e r e s t i n g to sp e c u l a t e why employment was not reported as s t r e s s f u l . C l i n i c a l problems at work may w e l l have been f a m i l i a r , and t h e r e f o r e l e s s l i k e l y to be s t r e s s o r s for t h i s group of experienced and c l i n i c a l l y - c o m p e t e n t p r a c t i t i o n e r s . Although employment has been c i t e d as a source of s t r e s s fo r nurses (Jacobson & McGrath, 1983), the t y p i c a l employment p a t t e r n of these respondents, one s h i f t per week, would l i k e l y have e l i m i n a t e d many of the common s t r e s s o r s such as ward p o l i t i c s and the d a i l y p h y s i c a l and emotional s t r a i n of s t a f f n u r s i n g . In f a c t , working while a student has been d e s c r i b e d as a source of s a t i s f a c t i o n and a boost to s e l f - e s t e e m ( C a l l i n , 1983). However, t h i s i n v e s t i g a t o r b e l i e v e s that student employment i n combination with the other r o l e s f r e q u e n t l y r e s u l t s i n s t r e s s from lack of time, and energy f o r other a c t i v i t i e s . Although the o v e r a l l l e v e l s of d i s t r e s s were s i m i l a r , t h i r d and f o u r t h year students r e p o r t e d s e v e r a l d i f f e r e n c e s i n the type of s c h o o l - r e l a t e d s t r e s s o r s and number of s t r e s s o r s . F i r s t of a l l , the 30 f o u r t h year students l i s t e d more s t r e s s o r s per c a p i t a than the t h i r d 55 year s t u d e n t s . Fourth year students l i s t e d 86 out of a p o s s i b l e 90 (96%), while t h i r d year students l i s t e d o n l y 107 out of a p o s s i b l e 126 (85%). Perhaps the f o u r t h year students l i s t e d more s t r e s s o r s because they had more s t r e s s o r s than t h i r d year respondents. However, s e v e r a l t h i r d year s t u d e n t s , who l i s t e d only one s t r e s s o r , may have f e l t so preoccupied by that s t r e s s o r that they were unable to i d e n t i f y other sources of s t r e s s . I t i s a l s o p o s s i b l e t h a t the f o u r t h year students, who have been i n the s c h o o l system longer, were simply b e t t e r able to i d e n t i f y sources of s t r e s s r e l a t e d to attendance a t sc h o o l than students i n t h e i r second term of the program. The program i n c l u d e s i n f o r m a t i o n on s t r e s s management which may have made students more aware of t h e i r s t r e s s o r s . The conceptual framework for t h i s study d e s c r i b e s primary a p p r a i s a l , i n c l u d i n g i d e n t i f i c a t i o n of the s t r e s s o r , as only one aspect of the s t r e s s and coping p r o c e s s . Without a s s e s s i n g other f a c t o r s , one could not conclude t h a t f o u r t h year students have more s t r e s s or experience more d i s t r e s s j u s t because they l i s t e d more s t r e s s o r s . Indeed, the l e v e l s of d i s t r e s s i n t h i s study were not s i g n i f i c a n t l y d i f f e r e n t between t h i r d and f o u r t h year s t u d e n t s . With the ex c e p t i o n of problems with the f a c u l t y , a l l s c h o o l - s p e c i f i c s t r e s s o r s were more common among t h i r d year s t u d e n t s . Some s c h o o l - s p e c i f i c s t r e s s o r s , 56 such as w r i t i n g papers and study s k i l l s , were problems for t h i r d year students only. T h i s r e s u l t presumably demonstrates that f o u r t h year students have mastered the necessary academic s k i l l s , and learned to manage t h e i r workload, t h e r e f o r e those s t r e s s o r s d i m i n i s h or disa p p e a r . Problems with the f a c u l t y were repo r t e d by 11 of the 30 f o u r t h year respondents (37%) compared to 9 of the 42 t h i r d year respondents (21%). I t i s not s u r p r i s i n g t h a t r e t u r n i n g RNs may have p e r c e i v e d themselves to be i n powerless, subordinate r o l e s and may have been h y p e r s e n s i t i v e to a u t h o r i t y f i g u r e s such as f a c u l t y (Perry, 1986). Shane (1983) a l s o noted that students i n the stage of c o n f l i c t or c h r o n i c h o s t i l i t y f r e q u e n t l y focus t h e i r anger on the program as w e l l as the i n s t r u c t o r s . T h i s i s of concern, however, because p o s i t i v e regard from the f a c u l t y appears to be of c r u c i a l importance to r e e n t r y women and to mature" n u r s i n g s t u d e n t s . K i r k and Dorfman (1983) noted t h a t the st r o n g e s t p r e d i c t o r of s a t i s f a c t i o n ( d e f i n e d as a s u b j e c t i v e s t a t e of wel l - b e i n g ) with mature r e e n t r y women was the pe r c e i v e d h e l p f u l a t t i t u d e of the p r o f e s s o r s . White (1981) compared graduates and non-graduates of a master's program i n n u r s i n g and noted that the groups d i f f e r e d markedly i n t h e i r p e r c e p t i o n of support from f a c u l t y . Most graduates (62%) f e l t t h a t the 57 f a c u l t y were s u p p o r t i v e , but o n l y 29% of the non-graduates r a t e d the f a c u l t y as s u p p o r t i v e . There was a d i f f e r e n c e i n the r e l a t i v e number of time and money s t r e s s o r s r e p o r t e d by t h i r d and f o u r t h year s t u d e n t s . T h i r d year students r e p o r t e d lack of time more o f t e n (17 times) than lack of money (8 t i m e s ) . The t h i r d year respondents may s t i l l have some, i f not a l l , of whatever money they have saved or borrowed s t i l l a v a i l a b l e . They may have budgeted f o r working a g i v e n number of hours, and consequently, have p r e d i c t e d t h e i r f i n a n c i a l s t a t u s . Fourth year students l i s t e d lack of time 16 times compared with 11 times f o r lack of money. The f o u r t h year students have presumably learned to manage t h e i r time and/or probably reduce t h e i r t o t a l workload by c u t t i n g back on t h e i r employment, thus g i v i n g them more time but l e s s money. Frequency and e f f e c t i v e n e s s of coping s t r a t e g i e s . In a n a l y z i n g the coping s t r a t e g i e s l i s t e d i n Tables 3 and 5 (pages 39 and 41), i t can be seen that the s t r a t e g i e s r e p o r t e d as used most f r e q u e n t l y were almost i d e n t i c a l to those r e p o r t e d as most e f f e c t i v e . Because of t h i s , frequency and e f f e c t i v e n e s s w i l l be d i s c u s s e d t o g e t h e r . The l e a s t f r e q u e n t l y used coping s t r a t e g i e s w i l l be presented next, followed by the l e a s t e f f e c t i v e s t r a t e g i e s which are s i m i l a r but not the same. F i n a l l y , the r e l a t i o n s h i p between frequency and 58 e f f e c t i v e n e s s w i l l be d i s c u s s e d . F i v e out of s i x coping s t r a t e g i e s r a t e d as most e f f e c t i v e were a l s o r e p o r t e d as most f r e q u e n t l y used. The s i x most f r e q u e n t l y used s t r a t e g i e s are o f t e n r e p o r t e d i n the l i t e r a t u r e on coping and are d i s c u s s e d below. The one s t r a t e g y r e p o r t e d by r e t u r n i n g RNs as most e f f e c t i v e but not among the most f r e q u e n t l y used was: "I jogged or e x e r c i s e d . " I t s mean use was 2.93 which was very c l o s e to the mean of 3.00 used f o r the most frequent category. Jogging or e x e r c i s e may have been r a t e d as most e f f e c t i v e and used f a i r l y f r e q u e n t l y i n t h i s study because the respondents were r e q u i r e d to take a p h y s i c a l e d u c a t i o n course which d i s c u s s e d the b e n e f i c i a l e f f e c t s of e x e r c i s e and r e q u i r e d some r e g u l a r p h y s i c a l a c t i v i t y . A l s o , a d v e r t i s i n g f o r f i t n e s s programs and a r t i c l e s on the e f f e c t i v e n e s s of e x e r c i s e i n r e d u c i n g s t r e s s and promoting h e a l t h and w e l l - b e i n g are comtemporary phenomena. Coping s t r a t e g i e s r e p o r t e d as f r e q u e n t l y used and e f f e c t i v e had a d i f f e r e n t focus than those s t r a t e g i e s which were seldom used or repor t e d as l e s s e f f e c t i v e . Coping s t r a t e g i e s l i s t e d as used and e f f e c t i v e are ones which approach the problem, d e a l i n g e i t h e r with the s t r e s s o r or with the i n d i v i d u a l ' s emotional r e a c t i o n to i t . Coping s t r a t e g i e s r e p o r t e d as l e a s t e f f e c t i v e and seldom used, on the other hand, suppressed or avoided 59 d e a l i n g with the s t r e s s o r and the emotional r e a c t i o n to i t . H a l f of the coping s t r a t e g i e s rated as e f f e c t i v e and f r e q u e n t l y used focused on the problem or s t r e s s o r (problem-focused). These i n c l u d e d : "made a plan and followed i t , " " j u s t concentrated on what I had to do next," and " t a l k e d to someone to f i n d out more about the s i t u a t i o n . " The other h a l f of the e f f e c t i v e and f r e q u e n t l y used s t r a t e g i e s focused on the i n d i v i d u a l ' s emotional response (emotion-focused). These i n c l u d e d : " t a l k e d to someone about how I was f e e l i n g , " " l e t my f e e l i n g s out somehow," and "accepted empathy and understanding from someone." The respondents' use of both types of s t r a t e g i e s i s c o n s i s t e n t with previous s t u d i e s which note t h a t i n d i v i d u a l s almost always use both types of coping s t r a t e g i e s when d e a l i n g with most s t r e s s o r s (Folkman & Lazarus, 1980; 1985). Folkman et a l . (1986) have more r e c e n t l y l a b e l l e d the problem-focused s t r a t e g i e s l i s t e d above as p l a n f u l p r o b l e m - s o l v i n g . The emotion-focused s t r a t e g i e s mentioned above were l a b e l l e d seeking s o c i a l support. Researchers have found that seeking s o c i a l support was commonly used by other p o p u l a t i o n s i n a l l h i g h l y s t r e s s f u l encounters (Folkman et a l . , 1986). I t i s not s u r p r i s i n g , then, that the r e t u r n i n g RNs i n t h i s study rep o r t e d using s t r a t e g i e s such as those l a b e l l e d seeking 60 s o c i a l support. McCrae and Costa (1986) a l s o c l a s s i f i e d coping s t r a t e g i e s i n a s i m i l a r manner but l a b e l l e d two of them r a t i o n a l a c t i o n and seeking h e l p . In examining coping e f f e c t i v e n e s s they found that r a t i o n a l a c t i o n and seeking help were f r e q u e n t l y and e f f e c t i v e l y used t o g e t h e r . T h i s f i n d i n g i s c o n s i s t e n t with the r e t u r n i n g RNs' r e p o r t of the use of coping s t r a t e g i e s and t h e i r e f f e c t i v e n e s s . Coping s t r a t e g i e s which were used l e a s t f r e q u e n t l y avoided or suppressed the problem or the i n d i v i d u a l ' s r e a c t i o n to i t . These i n f r e q u e n t l y used s t r a t e g i e s have a l s o been c l a s s i f i e d i n t o s e v e r a l groups (Folkman et a l . , 1986) and l a b e l l e d : d i s t a n c i n g , escape/avoidance, and c o n f r o n t i v e coping. D i s t a n c i n g i n c l u d e d "I went on as i f nothing happened." Escape/avoidance included "I avoided being with people i n g e n e r a l . " C o n f r o n t i v e coping i n c l u d e d "I took a b i g chance and d i d something very r i s k y " and "I d i d something which I d i d n ' t think would work, but at l e a s t I was doing something." These c o n f r o n t i v e coping s t r a t e g i e s have been c l a s s i f i e d as a g g r e s s i v e behaviors by H i r a k i and P a r l o c h a (1983) because they i n v o l v e d r i s k y behaviors and a c t i v i t i e s which were not expected to work. The i n f r e q u e n t use of these s t r a t e g i e s by respondents i s somewhat s u r p r i s i n g , as H i r a k i and P a r l o c h a noted that n u r s i n g f a c u l t y f r e q u e n t l y saw a g g r e s s i v e behavior i n 61 r e t u r n i n g RNs. Respondents may not have re p o r t e d c o n f r o n t i v e coping s t r a t e g i e s because they may have been t o l d i n t h e i r c l a s s e s and/or by t h e i r classmates t h a t such s t r a t e g i e s were not h e l p f u l . The low frequency of c o n f r o n t i v e coping s t r a t e g i e s may a l s o have been because new students, o l d e r people, and nurses are noted to be harm/avoidant i n t h e i r coping s t y l e (George & Owen, 1983). George and Owen compared r e t u r n i n g RNs to a p o p u l a t i o n of c o l l e g e women and found the RNs more harm/avoidant and l e s s i m p u l s i v e . Authors suggested t h a t the f o l l o w i n g f a c t o r s may have c o n t r i b u t e d to the f i n d i n g : the p e r s o n a l i t y of i n d i v i d u a l s who choose n u r s i n g , the e d u c a t i o n a l p r e p a r a t i o n , the c l i n i c a l work experience, or the s o c i a l i z a t i o n i n t o the p r o f e s s i o n (George & Owen, 1983). F i n a l l y , the l e a s t f r e q u e n t l y used coping s t r a t e g y r e p o r t e d was "I got p r o f e s s i o n a l h e l p . " T h i s s t r a t e g y was a l s o used i n f r e q u e n t l y by undergraduate students i n other s t u d i e s (Tanck & Robbins, 1979). Tanck and Robbins suggested t h a t students may conside r s t r e s s a r o u t i n e part of t h e i r l i f e to be t r e a t e d with home remedies l i k e the common c o l d . They f u r t h e r e x p l a i n e d t h a t students may be r e l u c t a n t to admit to themselves or others that they need p r o f e s s i o n a l h e l p . The l e a s t e f f e c t i v e coping s t r a t e g i e s , those with mean e f f e c t i v e n e s s scores of 1.55 or below, can be 62 c a t e g o r i z e d as e i t h e r c o n f r o n t i v e coping or w i s h f u l t h i n k i n g (Folkman et a l . , 1986). S e v e r a l c o n f r o n t i v e coping s t r a t e g i e s were presented e a r l i e r i n the d i s c u s s i o n of the l e a s t f r e q u e n t l y used coping s t r a t e g i e s . T h i s category of s t r a t e g i e s a l s o i n c l u d e d three s t r a t e g i e s which were r a t e d as l e a s t e f f e c t i v e by the r e t u r n i n g RNs: "I expressed anger to the person who caused the problem;" "I took i t out on other people;" and " T r i e d to get the person r e s p o n s i b l e to change h i s mind." C o n f r o n t i v e coping has been p r e v i o u s l y d i s c u s s e d as a g g r e s s i v e behavior, which H i r a k i and Parlocha (1983) have found to be a negative r e a c t i o n to the anger of academic shock. H i r a k i and Parlocha a l s o found that these coping s t r a t e g i e s d i d not reduce s t r e s s and recommended a s s e r t i v e behaviors be used to achieve the r e s o l u t i o n stage. The conceptual framework of t h i s study, however, emphasizes that the context or environment i s an e s s e n t i a l f a c t o r i n the s t r e s s and coping process, i n c l u d i n g which coping s t r a t e g i e s are e f f e c t i v e . C o n f r o n t i v e coping s t r a t e g i e s have been found to be e f f e c t i v e i n other c o n t e x t s , such as s h o r t term a d a p t a t i o n to cancer and t u b e r c u l o s i s ( B i l l i n g s & Moos, 1981). The other c a t e g o r y of l e a s t e f f e c t i v e coping s t r a t e g i e s was w i s h f u l t h i n k i n g (Folkman et a l . , 1986). It i n c l u d e d : "I r e f u s e d to b e l i e v e i t had happened," and 63 "I hoped a m i r a c l e would happen." S e v e r a l other s t u d i e s have a l s o found w i s h f u l t h i n k i n g to be i n e f f e c t i v e i n reducing s t r e s s ( B i l l i n g s & Moos, 1981; Folkman et a l . , 1986; McCrae & Costa, 1986). As mentioned p r e v i o u s l y , there i s g e n e r a l l y a p o s i t i v e r e l a t i o n s h i p between the frequency and p e r c e i v e d e f f e c t i v e n e s s of r e t u r n i n g RNs' coping s t r a t e g i e s . T h i s r e l a t i o n s h i p i s evident not only f o r the extremes of most and l e a s t f r e q u e n t l y used and most and l e a s t e f f e c t i v e , but a l s o f o r the s t r a t e g i e s i n the middle of the d i s t r i b u t i o n . There i s an element of s e l f - s e l e c t i o n as these r e t u r n i n g RNs have not chosen to remove themselves from the s c h o o l - r e l a t e d s t r e s s o r s (by dropping out of school) and have not been f o r c e d to withdraw from s c h o o l (by f a i l i n g ) , t h e r e f o r e they must be f u n c t i o n i n g at l e a s t adequately. One would expect a sample of healthy, f u n c t i o n i n g a d u l t s to use coping s t r a t e g i e s they b e l i e v e are e f f e c t i v e i n r e d u c i n g s t r e s s . I n d i v i d u a l s l e a r n by e xperience. E f f e c t i v e coping s t r a t e g i e s promote success and good h e a l t h , while s t r e s s and d i s t r e s s are consequences of i n e f f e c t i v e coping s t r a t e g i e s . There are , however, some coping s t r a t e g i e s which were used f r e q u e n t l y but not p e r c e i v e d to be e f f e c t i v e . These g e n e r a l l y i n v o l v e d a v o i d i n g or suppressing the problem and have been l a b e l l e d : w i s h f u l t h i n k i n g , 64 d i s c u s s e d p r e v i o u s l y ; s e l f - b l a m e , "I c r i t i c i z e d or l e c t u r e d myself;" and t e n s i o n r e d u c t i o n , " E a t i n g , d r i n k i n g , smoking, using drugs and medications" (Folkman et a l . , 1986 ). Other s t r a t e g i e s were p e r c e i v e d as e f f e c t i v e , but not f r e q u e n t l y used. These i n c l u d e d some s t r a t e g i e s recommended i n the nu r s i n g l i t e r a t u r e such as r e l a x a t i o n : "Got away from i t f o r awhile," " T r i e d to take a r e s t or v a c a t i o n , " and "Prayed," Although these may be p e r c e i v e d as e f f e c t i v e , some of them may not be f r e q u e n t l y used because they may not be f e a s i l b e f o r many r e t u r n i n g RNs. Lack of money and lack of time might prevent the use of some of those s t r a t e g i e s such as ta k i n g a v a c a t i o n . F i n a l l y , another s t r a t e g y l a b e l l e d "escape/avoidance" (Folkman et a l . , 1986) may be per c e i v e d as f a i r l y e f f e c t i v e because i t allows a break or r e s t from the s i t u a t i o n . B i l l i n g s & Moos (1981) found that escape/avoidance was e f f e c t i v e f o r short- t e r m outcomes and with u n c o n t r o l l a b l e s t r e s s o r s . Summary Respondents i n t h i s study appear to be r e p r e s e n t a t i v e of r e t u r n i n g RNs and younger than, but g e n e r a l l y r e p r e s e n t a t i v e of employed nurses across Canada. There were no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s i n the l e v e l of d i s t r e s s between r e t u r n i n g 65 RNs i n the t h i r d and f o u r t h years of the program, or between those r e t u r n i n g RNs who had not attended school w i t h i n the past two years and those who had been a t t e n d i n g courses d u r i n g that time. The s t r e s s o r s r e p o r t e d were s i m i l a r to those i n other s t u d i e s of r e t u r n i n g RNs and r e e n t r y women i n g e n e r a l . S t r e s s o r s s p e c i f i c to s c h o o l such as academic s k i l l s , workload, and problems with the f a c u l t y were the most commonly r e p o r t e d . S o c i a l and domestic concerns, lack of time and money were the other major s t r e s s o r s . T h i r d year students r e p o r t e d more problems with academic study s k i l l s and lack of time. Fourth year students, on the other hand, repo r t e d more n o n - s c h o o l - s p e c i f i c s t r e s s o r s . The coping s t r a t e g i e s used most f r e q u e n t l y were a l s o r e p o r t e d as most e f f e c t i v e . These s t r a t e g i e s were both problem-focused and emotion-focused and d e a l t with the s t r e s s o r s d i r e c t l y . Coping s t r a t e g i e s , such as w i s h f u l t h i n k i n g or those t h a t are h o s t i l e and c o n f r o n t i v e , a l l avoided or suppressed the problem, and were used l e a s t f r e q u e n t l y and found l e a s t e f f e c t i v e . The coping s t r a t e g i e s used f r e q u e n t l y were among those recommended i n the l i t e r a t u r e by f a c u l t y and experienced s t u d e n t s . F i n a l l y , the r e t u r n i n g RNs i n t h i s study used coping s t r a t e g i e s they p e r c e i v e d to be e f f e c t i v e . They 66 d i d not r e p o r t e x p e r i e n c i n g s i g n i f i c a n t l y high l e v e l s of d i s t r e s s , even though they experienced s t r e s s o r s . T h i s i s c o n s i s t e n t with the conceptual framework, developed by Lazarus and h i s c o l l e a g u e s (1966, 1984), which suggests that a p p r a i s a l and coping s t r a t e g i e s moderate the r e l a t i o n s h i p between the person and the environment i n terms of the a p p r a i s a l of s t r e s s and the l e v e l s of d i s t r e s s . 67 Chapter F i v e Summary, C o n c l u s i o n s , I m p l i c a t i o n s and Recommendations f o r Future Research S umma r v Th i s study was designed to explore and d e s c r i b e the s t r e s s and coping process of RNs r e t u r n i n g to s c h o o l . The lack of r e s e a r c h i n t h i s area was a sti m u l u s f o r the study. S p e c i f i c questions to be answered were: (1) What i s the l e v e l of d i s t r e s s of RNs r e t u r n i n g to school? (2) What are the s c h o o l - r e l a t e d s t r e s s o r s of r e t u r n i n g RNs? (3) What coping s t r a t e g i e s do r e t u r n i n g RNs use to d e a l with s c h o o l - r e l a t e d s t r e s s ? (4) Which coping s t r a t e g i e s do RNs p e r c e i v e as most e f f e c t i v e ? (5) Which coping s t r a t e g i e s do RNs p e r c e i v e as l e a s t e f f e c t i v e ? The conceptual framework used to s t r u c t u r e the study was the c o g n i t i v e theory of s t r e s s and coping developed by Lazarus and h i s c o l l e a g u e s (Lazarus & Folkman, 1984). S t r e s s i s the r e l a t i o n s h i p between the person and the environment which i s a f f e c t e d by the person's a p p r a i s a l of the s i t u a t i o n , h i s / h e r a p p r a i s a l of h i s / h e r resources and coping o p t i o n s , the coping s t r a t e g i e s used, and the immediate and long-term outcomes. 68 Three instruments were used to gather data f o r t h i s study: The Ways of Coping C h e c k l i s t (Folkman & Lazarus, 1984) to assess s c h o o l - r e l a t e d s t r e s s o r s , the use of s p e c i f i c coping s t r a t e g i e s , and the p e r c e i v e d e f f e c t i v e n e s s of those coping s t r a t e g i e s ; The P e r s o n a l S t r a i n Q u e s t i o n n a i r e (Osipow & Spokane, 1981) to assess i n d i v i d u a l l e v e l s of d i s t r e s s ; and a general q u e s t i o n n a i r e to o b t a i n demographic and d e s c r i p t i v e i n f o r m a t i o n . Respondents were 72 r e t u r n i n g RN v o l u n t e e r s e n r o l l e d i n the t h i r d and f o u r t h years of the b a c c a l a u r e a t e n u r s i n g program at UBC i n 1987. Most respondents had over 8 years of n u r s i n g experience and continued to work, part time while i n s c h o o l . The data were analyzed using d e s c r i p t i v e s t a t i s t i c s with the SPSS:X (SPSS Inc., 1983) computer program. The scores r e p r e s e n t i n g l e v e l s of d i s t r e s s ranged from 48 to 156, but there were no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s between the scores of t h i r d and f o u r t h year r e t u r n i n g RNs, nor between the scores of those r e t u r n i n g RNs who had been out of s c h o o l f o r more than two years and those who had been a t t e n d i n g c l a s s e s more r e c e n t l y . The major s t r e s s o r s were s i m i l a r to those r e p o r t e d i n the n u r s i n g l i t e r a t u r e i n c l u d i n g : s c h o o l - s p e c i f i c problems, s o c i a l and domestic concerns, lack of time, and lack of money. There was some d i f f e r e n c e i n the 69 s t r e s s o r s r e p o r t e d by t h i r d and f o u r t h year s t u d e n t s . Fourth year students r e p o r t e d lower numbers of s c h o o l -s p e c i f i c s t r e s s o r s except f o r problems with the f a c u l t y . The most f r e q u e n t l y used coping s t r a t e g i e s were a l s o r e p o r t e d to be the most e f f e c t i v e , while the l e a s t f r e q u e n t l y used coping s t r a t e g i e s were r a t e d as the l e a s t e f f e c t i v e . The s t r a t e g i e s r e p o r t e d as f r e q u e n t l y used and e f f e c t i v e , approached or d e a l t with the s t r e s s o r or with the i n d i v i d u a l ' s emotional r e a c t i o n to i t . The l e a s t e f f e c t i v e and seldom used coping s t r a t e g i e s g e n e r a l l y suppressed or avoided the s t r e s s o r . Conelus i ons The f i n d i n g s of t h i s study lead to the f o l l o w i n g c o n c l u s i o n s : 1. A f t e r an i n i t i a l semester of s c h o o l , r e e n t r y nurses, who have not been students f o r at l e a s t two years, have no more d i s t r e s s than r e t u r n i n g RNs who have r e c e n t l y been i n s c h o o l . 2. Returning RNs i n the f o u r t h year of the program are l e s s s t r e s s e d by s c h o o l - s p e c i f i c s t r e s s o r s such as study s k i l l s and managing school assignments than are students i n the t h i r d year. 3. In d e a l i n g with s t r e s s r e l a t e d to a t t e n d i n g s c h o o l , r e t u r n i n g RNs r e p o r t a c t i v e coping s t r a t e g i e s , which de a l d i r e c t l y with the s t r e s s o r or the i n d i v i d u a l ' s emotional r e a c t i o n to i t , as more e f f e c t i v e i n 70 reducing s t r e s s than coping s t r a t e g i e s which a v o i d the s t r e s s o r . 4. The m a j o r i t y of r e t u r n i n g RNs cope q u i t e w e l l i n the present s t r u c t u r e and program by using the cuping s t r a t e g i e s of seeking s o c i a l support and p l a n f u l problem s o l v i n g . Both types of coping s t r a t e g i e s are recommended i n the n u r s i n g l i t e r a t u r e by s u c c e s s f u l graduates and experienced f a c u l t y (Sabina, 1985; Shane, 1983). I m p l i c a t i o n s The c o n c l u s i o n s of t h i s study have c e r t a i n i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n . These i m p l i c a t i o n s i n v o l v e the a d m i n i s t r a t i o n of the degree program, the r e t u r n i n g RN students, and the f a c u l t y who teach them. The study r e s u l t s demonstrate t h a t , by the second semester, most r e t u r n i n g RNs who have been out of s c h o o l f o r more than two y e a r s , a d j u s t to school with no more d i s t r e s s than the r e t u r n i n g RNs who have been a t t e n d i n g courses r e c e n t l y . T h i s comforting c o n c l u s i o n should be shared with the new r e t u r n i n g RNs to a l l e v i a t e the f e a r s which are documented i n the n u r s i n g l i t e r a t u r e ( H i r a k i & P a r l o c h a , 1983; Shane, 1983). F a c u l t y should a l s o be aware of t h i s so they can counsel students a p p r o p r i a t e l y and be prepared to t o l e r a t e s t r e s s - r e l a t e d student behaviors u n t i l students a d j u s t . 71 S c h o o l - s p e c i f i c academic s k i l l s and academic management were major s t r e s s o r s f o r r e t u r n i n g RNs, but decreased i n importance by f o u r t h year. T h i s i m p l i e s t h a t the students have learned to cope with these s t r e s s o r s . T h i s l e a r n i n g could perhaps be f a c i l i t a t e d by the n u r s i n g program or u n i v e r s i t y . An o r i e n t a t i o n course or workshop could provide i n f o r m a t i o n on academic s k i l l s , study methods, use of the l i b r a r y , p r e p a r a t i o n for exams, and w r i t i n g formal papers. Management of workload and d e a l i n g with assignments due at the same time were a l s o major concerns f o r t h i r d year s t u d e n t s . Workshops on time management and p l a n n i n g may help students d e a l with these s t r e s s o r s . F a c u l t y could a l s o l e s s e n the problem by c o o r d i n a t i n g assignments or p e r m i t t i n g more f l e x i b l e due dates (Green, 1987). Unclear e x p e c t a t i o n s and r e l a t i o n s h i p s with the f a c u l t y was another s c h o o l - s p e c i f i c s t r e s s o r which perhaps could be decreased by p r o v i d i n g more i n f o r m a t i o n at the beginning of the program about the f a c u l t y ' s r o l e and the o b j e c t i v e s of the courses. The r o l e of the f a c u l t y as f a c i l i t a t o r s and p r o f e s s i o n a l nurse educators who e v a l u a t e students on s p e c i f i c n u r s i n g course o b j e c t i v e s r a t h e r than on t e c h n i c a l s k i l l s , should be e x p l a i n e d c l e a r l y to the s t u d e n t s . F a c u l t y , on the other hand, - should be encouraged to be s u p p o r t i v e of s t u d e n t s , and to r e c o g n i z e student competencies and l i f e 72 experiences by c o n t r a c t i n g i n d i v i d u a l assignments, u s i n g c h a l l e n g e exams for p a r t s of courses, and u s i n g students as expert demonstrators i n n u r s i n g labs (Green, 1987). Time, money, and s o c i a l and domestic concerns were a l s o major s t r e s s o r s f o r these m u l t i p l e r o l e women. Perhaps some b e n e f i t c o u l d be d e r i v e d from i n s t r u c t i o n on time and money management. A s s e r t i v e n e s s t r a i n i n g , the importance of d e l e g a t i n g r e s p o n s i b i l i t y , and other t a c t i c s f o r b a l a n c i n g demands of s c h o o l , work, f a m i l y , and f r i e n d s may help to reduce some s t r e s s o r s . Coping s t r a t e g i e s which d e a l d i r e c t l y with the s t r e s s o r appear to be both used and e f f e c t i v e i n reducing s t r e s s and d i s t r e s s . These coping s t r a t e g i e s should be encouraged among the students through o r i e n t a t i o n courses and workshops. Returning RNs c o u l d a l s o be warned t h a t s p e c i f i c coping s t r a t e g i e s such as w i s h f u l t h i n k i n g and s e l f - b l a m e have not proven to be e f f e c t i v e i n reducing s t r e s s f o r previous r e t u r n i n g RNs. F i n a l l y , f a c u l t y could f a c i l i t a t e coping s t r a t e g i e s of s o c i a l support by e s t a b l i s h i n g a buddy system between experienced and new s t u d e n t s , s t r u c t u r i n g c o f f e e breaks i n the middle of long c l a s s e s , a s s i g n i n g group p r o j e c t s , and e s t a b l i s h i n g c l i n i c a l study groups (Green, 1987). Recommendations f o r Future Research The f i n d i n g s and i m p l i c a t i o n s of t h i s study suggest recommendations for f u r t h e r r e s e a r c h . These i n c l u d e : 73 1. Repeating t h i s study with a l a r g e r sample from a v a r i e t y of n u r s i n g s c h o o l s to d i s c o v e r i f the r e s u l t s are s i m i l a r . 2. Repeating t h i s study with a sample of mature women out s i d e of n u r s i n g to compare the s t r e s s o r s and coping s t r a t e g i e s as w e l l as l e v e l s of d i s t r e s s . 3. Designing a l o n g i t u d i n a l study to examine the s t r e s s and coping process of r e t u r n i n g RNs over the e n t i r e n u r s i n g program. 4. Designing a study to compare the coping s t r a t e g i e s of r e t u r n i n g RNs at s c h o o l and a t work. 5. Designing a study which i n c l u d e s measures other than s e l f - r e p o r t such as using c l i n i c a l e v a l u a t i o n s , absenteeism, drop-out r a t e s , and grade p o i n t average to assess l e v e l s of adjustment and d i s t r e s s more o b j e c t i v e l y . Comparison of o b j e c t i v e and s u b j e c t i v e data would permit v a l i d a t i o n of the l a t t e r i n a way not otherwise p o s s i b l e . 74 B i b l i o g r a p h y A d e l s t e i n , D., Sedlacek, W., & Martinez, A. (1983). Dimension u n d e r l y i n g the c h a r a c t e r i s t i c s and needs of r e t u r n i n g women st u d e n t s . J o u r n a l of the  N a t i o n a l A s s o c i a t i o n of Women Deans, Admin- i s t r a t o r s , and Counselors. 4_6, 32-36. Anderson, S. (1983). S t r e s s and the nu r s i n g student. In S. F. Jacobson & M. McGrath (Eds.), Nurses under  s t r e s s (pp.26-47). New York: Wiley. Balogh, E., Chasan, J . , D e v i t o , J . , D o l o f f , J . , F l y n n , J . , F r a z i e r , B., Okraska, C , Pemberton, J . , P o l i t o , M., T u r e l l , A., Walker, A., Wyer, W., & Portnoy, F. (1980). RN students analyze t h e i r e x p e r i e n c e s . Nursing Outlook. 28, 112-115. B a i l e y , J . & Claus, K. (1980). L i v i n g with s t r e s s and  promoting w e l l - b e i n g . S t . L o u i s : Mosby. B i l l i n g s , A. & Moos, R. (1981). The r o l e of coping responses and s o c i a l r esources i n a t t e n u a t i n g the s t r e s s of l i f e events. J o u r n a l of B e h a v i o r a l  Medicine. 4_, 131-157. B r a i l e y , J . (1983). Issues i n coping r e s e a r c h . Nursing  Papers. 16, (1), 5-13. Brundage, D. & MacKeracher, D. (1980). Adult l e a r n i n g p r i n c i p l e s and t h e i r a p p l i c a t i o n to program  p l a n n i n g . Toronto: M i n i s t r y of Education O n t a r i o . 75 C a l l i n , M. (1983). Going back to s c h o o l . The J o u r n a l of C o n t i n u i n g Education. 14. ( 4 ), 21 - 2 7 . Camooso, C , Greene, M., & R e i l l y , P. (1981). Students' a d a p t a t i o n a c c o r d i n g t o Roy. Nursing Outlook. 29., 108-109. C h i r i b o g a , D. & B a i l e y , J . (1986). [ S t r e s s P r o j e c t at U n i v e r s i t y of San F r a n c i s c o . ] Unpublished manuscript. Canadian Nurses A s s o c i a t i o n . (1987). E n t r y to p r a c t i c e . Canadian Nurses A s s o c i a t i o n Newsletter. 3 ( 2 ) . F e l t o n , B., & Revenson, T. (1984). Coping with c h r o n i c i l l n e s s : A study of i l l n e s s c o n t r o l l a b i l i t y and coping s t r a t e g i e s on p s y c h o l o g i c a l adjustment. J o u r n a l of C l i n i c a l and Counseling Psychology. 52 (2), 343-353. Fleishman, J . (1984). P e r s o n a l i t y c h a r a c t e r i s t i c s and coping p a t t e r n s . J o u r n a l of Health and S o c i a l  Behavior. 25, 229-244. Folkman, S. & Lazarus, R. (1980). An a n a l y s i s of coping i n a middle-aged community sample. J o u r n a l of  He a l t h and S o c i a l Behavior. 21, 219-239. Folkman, S. & Lazarus, R. (1985). I f i t changes i t must be pro c e s s : Study of emotion and coping d u r i n g three stages of a c o l l e g e exam. J o u r n a l of  P e r s o n a l and S o c i a l Psychology. 48, 150-170. 76 Folkman, S., Lazarus, R., Gruen, R., & DeLongis, A. (1986). A p p r a i s a l , coping, h e a l t h s t a t u s , and p s y c h o l o g i c a l symptoms. J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology. 50, 571-579. George, V. & Owen, L. (1983). P e r s o n a l i t y a t t r i b u t e s of RN students and female c o l l e g e s t u d e n t s . J o u r n a l of Psychology. 115, 221-231. Georgiadou, F. (1986). S t r e s s e s and s t r e s s r e d u c t i o n mechanisms of graduate students at U n i v e r s i t y of Washington School of Nursing. Unpublished manuscript. Green, C. (1987). M u l t i p l e r o l e women: The r e a l world of the mature RN l e a r n e r . J o u r n a l of Nursing E d u c a t i o n . 2£ (7), 266-271. Hale, S. & Boyd, B. (1981). Accommodating RN students i n bac c a l a u r e a t e n u r s i n g programs. Nursing Outlook. 29, 535-540. Haan, N. (1977). Coping and defe n d i n g . New York: Academic Press. Hart, G., Crawford, T., & Hicks, B. (1985). RN to BN: B u i l d i n g on educ a t i o n and experience. The Canadian Nurse. 81 (5), 22-23. H i l l s m i t h , K. (1978). From RN to BSN: Student p e r c e p t i o n s . Nursing Outlook. 26, 96-102. H i r a k i , A., & P a r l o c h a , P. (1983). Returning to s c h o o l : The RN to BSN handbook. Toronto: L i t t l e Brown & Co. 77 Jackson, M. (1984). E n t r y c h a r a c t e r i s t i c s of post-RN st u d e n t s : I m p l i c a t i o n s f o r the f u t u r e . The Canadian Nurse. 80 (9), 20-25. Jacobson, S. F. & McGrath, M. (Eds). (1983). Nurses under s t r e s s . New York: Wiley. Kazdin, A. & Straws, M. K. (1976). Assessment of behavior of the m e n t a l l y r e t a r d e d . In M. Hersen & A. M. B e l l a c k (Eds.), B e h a v i o r a l assessment: A p r a c t i c a l handbook. New York: Pergamon P r e s s . K i r k , C. & Dorfman, L ( 1 9 8 3 ) . S a t i s f a c t i o n and r o l e s t r a i n among middle-age and o l d e r r e - e n t r y women stu d e n t s . E d u c a t i o n a l Gerontology. 9_> 15-29. Kobassa, S. C. (1979). S t r e s s f u l l i f e events, p e r s o n a l i t y , . and h e a l t h : An i n q u i r y i n t o h a r d i n e s s . J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology. 37, 1-11. Kramer, M. (1974). R e a l i t y shock: Why nurses leave n u r s i n g . S t . L o u i s : Mosby. Lazarus, R. (1966). P s y c h o l o g i c a l s t r e s s and the c o p i n g p r o c e s s . New York: McGraw-Hill. Lazarus, R. & Folkman, S. (1984). S t r e s s , a p p r a i s a l and c o p i n g . New York: S p r i n g e r . LeCompte, M. & Goetz, J . (1982). Problems of r e l i a b i l i t y and v a l i d i t y i n ethnographic r e s e a r c h . Review of E d u c a t i o n a l Research. 52 (1), 31-60. 78 MacMaster, E. (1979). Sources of s t r e s s i n u n i v e r s i t y n u r s i n g s t u d e n t s . Nursing Papers. 11 (4), 87-97. McCrae, R. & Costa, P. (1986). P e r s o n a l i t y , coping, and coping e f f e c t i v e n e s s i n an a d u l t sample. J o u r n a l  of P e r s o n a l i t y . 54 (2), 385-405. Menaghan, E. (1983). I n d i v i d u a l coping e f f o r t s and f a m i l y s t u d i e s : Conceptual and methodological i s s u e s . In H. McCubbin, B. Sussman, & J . P a t t e r s o n (Eds.), S o c i a l s t r e s s and the f a m i l y (pp. 113-135). New York: Haworth P r e s s . Menninger, K. (1963). The v i t a l balance: The l i f e  process i n mental h e a l t h and i l l n e s s . New York: V i k i n g . Osipow, S., Doty, R., & Spokane, A. (1985). O c c u p a t i o n a l s t r e s s , s t r a i n , and coping across the l i f e span. J o u r n a l of V o c a t i o n a l Behavior. 27, 98-108. Osipow, S. & Spokane, A. (1981). P e r s o n a l S t r a i n Q u e s t i o n n a i r e , Form E-2. Columbus: Marathon P r e s s . Parkes, K. (1984). Locus of c o n t r o l , c o g n i t i v e a p p r a i s a l , and coping i n s t r e s s f u l e p i s o d e s . J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology. 46 (3), 655-668. Parkes, K. (1985). S t r e s s f u l episodes r e p o r t e d by f i r s t -year student nurses: A d e s c r i p t i v e account. S o c i a l  Science and Medicine. 20 (9), 945-953. 79 Parkes, K. (1986). Coping i n s t r e s s f u l e p i s o d e s : The r o l e of i n d i v i d u a l d i f f e r e n c e s , environmental f a c t o r s , and s i t u a t i o n a l c h a r a c t e r i s t i c s . J o u r n a l of  P e r s o n a l i t y and S o c i a l Psychology. 51(6), 1277-1292. P e a r l i n , L. & Schooler, C. (1978). The s t r u c t u r e of copin g . J o u r n a l of Health and S o c i a l Behavior. 19., 2-21. Pe r r y , A. (1986). Reentry women: Nursing's c h a l l e n g e . Nurse Educator. 11 (3), 13-15. Queen, P. (1984). R e s o c i a l i z i n g the degree-seeking RN: A c u r r i c u l u m t h r e a d . J o u r n a l of Nursing E d u c a t i o n . 23 (8), 351-353. Roehl, J . & Okun, M. (1984). Depression symptoms among women r e e n t e r i n g c o l l e g e : The r o l e of negative l i f e events and f a m i l y s o c i a l support. J o u r n a l of  Co l l e g e Student P e r s o n n e l . 25, 251-254. Sabina, D. (1985). What are the needs of the mature RN student? The Canadian Nurse. 81 (5), 32-33. Sands, R. & Richardson, V. (1984). Education and mental h e a l t h f a c t o r s a s s o c i a t e d with the r e t u r n of mid-l i f e women to s c h o o l . E d u c a t i o n a l Gerontology. 10_, 155-170. S c o t t , N. (1980). Returning women: A review of r e s e a r c h  and d e s c r i p t i v e s t u d i e s . ERIC Document S e r v i c e No. AD 191346. Washington, D.C: ERIC 80 Shane, D. (1980). The r e t u r n l n g - t o - s c h o o l syndrome. Nursing. 10, 86-88. Shane, D. (1983). Returning to s c h o o l : A guide f o r nurses. Englewood C l i f f s , New J e r s e y : P r e n t i c e - H a l l . Smith, S. P. & Reeves, N. (1984). Returning to school? Energy management co u l d h e l p . . . l i f e as a n u r s i n g b a c c a l a u r e a t e student. RNABC News. 16 (1), 14-15. SPSS. (1983). SPSS:X users' guide. New York: McGraw H i l l . S t a t i s t i c s Canada. (1986). Revised r e g i s t e r e d nurses data survey. Ottawa: author. S t e h l e , J . (1981). C r i t i c a l care n u r s i n g s t r e s s : The f i n d i n g s r e v i s i t e d . Nursing Research. 30 (30), 182-186. Tanck, R. & Robbins, P. (1979). A s s e r t i v n e s s , locus of c o n t r o l and coping behaviors used to d i m i n i s h t e n s i o n . J o u r n a l of P e r s o n a l i t y Assessment. 43_ (4), 396-400. White, J . (1981). Role S t r e s s : A d e s c r i p t i v e study of the  types, dimensions, and management of r o l e s t r e s s i n  Master's of Science i n Nursing s t u d e n t s . Unpublished master's t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C. 81 White, J . , & Luna, A. (1983). Nonnurse a d u l t students r e t u r n t o s c h o o l . In D. Shane, Returning to s c h o o l :  A guide f o r nurses (pp. 277-287). Englewood C l i f f s , New J e r s e y : P r e n t i c e - H a l l . Whitman, N., Spendlove, D., & C l a r k , C. (1984). Student  s t r e s s : E f f e c t s and s o l u t i o n s . ASHE-ERIC Higher Education Research Report No. 2. Washington, D.C: ASHE. Wilson, H. & Levy,' J . (1978). Why RN students drop out. Nursing Outlook. 26_, 437-441. Wooley, A. (1978). From RN to BSN: F a c u l t y p e r s p e c t i v e s . Nursing Outlook. 26, 103-108. Zorn, J.M. (1980). A r e s e a r c h p r o f i l e of today's b a c c a l a u r e a t e n u r s i n g student. J o u r n a l of C o n t i n u i n g Nursing E d u c a t i o n . 11, 7-9. Zutewskyj, T. & Davis, L. (1985). Sources of s t r e s s i n t h i r d year b a c c a l a u r e a t e n u r s i n g s t u d e n t s . Nursing Papers. 17 (3), 75-85. 

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