LEVEL OF ANXIETY AND STUDENT NURSES CLINICAL PERFORMANCE IN

SPECIAL AREAS

CHAPTER I

INTRODUCTION

Background of the Study

Nurses’ competence in the clinical area is based on the knowledge and skills taught to

them during classroom discussions and skills practices done before they are exposed to the area.

Nursing training is the fusion of theoretical and practical learning experiences that enable them

to acquire the knowledge, skills, and attitudes for providing safe and quality nursing care to the

different clients/patients that they will come across in the clinical area. But what will happen

when the concepts taught in the classroom is inadequate or lacking? What will happen when

they will be asked to assist or do a particular procedure that is unfamiliar to them or is not taught

to them during the skills training? That is where anxiety comes in. Anxiety is said to be contagious

and uncontrollable. It disrupts the student’s concentration, performance and confidence in the

area. According to the American Psychology Association (APA), anxiety is an emotion

characterized by feelings of tension, recurring intrusive thoughts, worry and concerns. Anxiety is

first felt by the nursing students upon finding out where they will be rotated for the semester,

much more when they discover that they will be rotated in special areas such as the emergency

room, delivery room and the operating room. The thought of being in an area where everything

is unpredictable, chaotic and intense gives you the feeling like you’re on pins and needles. Their

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anxiety increases as the day of the rotation is nearer and becomes worst due to the feedbacks of

the students who were previously assigned in the area.

Clinical experience is an important aspect of nursing education as it aids in transforming

the theoretical knowledge into a practice. Special Areas have different procedures than those of

community or hospital ward settings, and students have rare experience of being assigned in

special areas. Students are often faced with challenges during the courses of clinical learning

which makes them feel vulnerable and the fear of making a mistake is present. There are 3 special

areas where student nurses are assigned during their entire life as a nursing student; these are

namely, the Emergency Room (ER), Delivery Room (DR), and the Operating Room (OR).

Emergency Room is defined as the department of a hospital responsible for the provision of

medical and surgical care to patients arriving at the hospital in need of immediate care. (Medicine

Net, 2016). While Delivery Room is defined as an operating theatre or similar room in

a hospital or other medical facility, furnished with suitable equipment and staffed

by physicians, surgeons, or other medical workers, for the purpose of assisting mothers with the

births of their babies. (Wiktionary, 2017). And Operating Room is defined as an operating room

(OR), also called surgery center, is the sterile unit of a hospital where surgical procedures are

performed. (Encyclopedia of Surgery, 2018). Students whether first timer or already had been

exposed in special areas, still experiences anxiety when they are assigned in these clinical

settings; though the levels of anxiety may differ ranging from mild to panic anxiety and depending

to the factors that affect it. Each level of anxiety is manifested in different ways affecting the

psychomotor, emotional and cognitive aspect of the individual experiencing the anxiety.

Therefore, the anxiety level being experienced by students may also differ.

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PURPOSE OF THE STUDY

The primary goal of this study is to identify the different factors that contributes to the

level of anxiety among incoming 4th yr. students exposed in the three areas OR, DR and ER, The

purpose of this research includes the study of the different sources of the different stressors

during clinical practice, the identification of this leading causes may help the students recognize

as to how it affects their anxiety, This study also seeks to investigate on how anxiety affect the

students’ performance in the following areas, The purpose of this study is to increase the

awareness of the existence of stress in nursing students by nurse educators and how they can

respond to it to help diminished students nurses experience of stress. The research also

concentrates on why lack of experience, unfamiliar areas, difficult patients, fear of making

mistakes and being evaluated by faculty members has a great impact on the student’s feeling of

apprehensiveness. The study examines how increase anxiety level interferes with the student’s

stimulation of critical thinking skills and problem solving. The aim of this study is to evaluate how

students perceive their anxiety level throughout their clinical experiences.

OBJECTIVES OF THE STUDY

1. Assess the level of anxiety of the Senior Nursing Students who were previously assigned
in the special area of the following:
a. Zamboanga City Medical Center Emergency Room, Operating Room, Delivery Room,
Birthing.
b. Zamboanga Puericulture Maternity Lying-in Hospital- Emergency Room, Operating
Room, Delivery Room.
c. Mindanao Central Sanitarium General Hospital - Operating Room, Delivery Room.

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 2. Determine if the anxiety level of the students significantly affects the Clinical
Performance in the special areas (Delivery Room, Operating Room, and Emergency
Room)

STATEMENT OF THE PROBLEM

This study aims to answer the following questions:

1. What are the extrinsic and intrinsic factors contributing to the anxiety level of the nursing

students?

2. How does anxiety level affect the clinical performance of nursing students in special

areas?

SIGNIFICANCE OF THE STUDY

The findings of this study will redound for the benefit of nursing students considering that

being exposed to the clinical setting plays an important role in nursing education. The importance

of this study is to determine whether the factors stated contributes to the level of anxiety and

whether the level of anxiety affects the clinical performance of nursing students, with emphasis

to the contributing factors the extrinsic and intrinsic. This will also be a benefit to the college of

nursing, nurse educators and clinical instructors, this will help increase the awareness regarding

the factors that affects the anxiety of nursing students and it will give an idea on how to lessen

the anxiety being experienced to provide a quality health care that is efficient.

SCOPE AND DELIMITATIONS

The focus of this study is to identify the factors contributing to the anxiety level of the

Level 4 Nursing students in WMSU College of Nursing who were exposed in Emergency Room,

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Operating Room and Delivery Room and to whether the level of anxiety affects their clinical

performance in the three special areas. The primary data gathering method used was identical

questionnaires given to each of the respondents. It considers every aspect of the nursing

student’s personal information that has an impact on their clinical efficacy.

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 CHAPTER II

REVIEW OF RELATED LITERATURE

Review of Related Literature

This part of the research chapter covers the different literatures and studies that the
researchers reviewed in connection with the study level of anxiety and nursing student’s
performance in special areas.

Anxiety is a vague feeling of dread or apprehension; it is a response to external or internal

stimuli that can have behavioral, emotional, cognitive and physical symptoms. (Videbeck, 2006)
A person feels his self-esteem or well-being is threatened. Literature reveals that anxiety has a
huge impact on learning. Stress in nursing and in nursing students is a well-documented
phenomenon, but the extent to which it occurs and means of coping with it vary. (Higginson,
2006)

Clinical experience has been always an integral part of nursing education. It prepares
student nurses to be able "doing" as well as "knowing" the clinical principles in practice. The
clinical practice stimulates students to use their critical thinking skills for problem solving. The
Nursing student's experiences in their clinical practice provide greater insight to develop an
effective clinical teaching strategy in nursing education and anxiety as a result of feeling
incompetent, and lack of professional nursing skills and knowledge to take care of various
patients in the clinical setting. In a descriptive correlational study by Beck and Srivastava it was
said that second, third and fourth year nursing students reported that clinical experience was the
most stressful part of the nursing program. Clinical learning is a main part of nursing education.
Students’ exposure to clinical learning environment is one of the most important factors affecting
the teaching-learning process in clinical settings. Identifying challenges of nursing students in the
clinical learning environment could improve training and enhance the quality of its planning and
promotion of the students.

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 Failure to identify the challenges and problems the students are faced with in the clinical
learning environment prevents them from effective learning and growth. As a result, the growth
and development of their skills will be influenced. Many studies have been done on the clinical
environment. Some relevant studies have also been carried out; however, most of them have
focused on clinical evaluation or stress factors in the clinical training. One study showed that
nursing students are vulnerable in the clinical environment and this reduces their satisfaction
with the clinical training. Moreover, the nursing students’ lack of knowledge and skills in the
clinical environment can lead to anxiety.

Extrinsic factors are defined as the factors that are outside the student nurses’ control,
their surroundings and the people present in the environment. Situational factors are extrinsic
and related to the student nurses’ workload and support of the health professionals involved.
These are factors that are not inherent and are acting from the outside the individual.
Intrinsic factors are defined as the factors that originate from within the student nurse.
It comprises that nurse’s attitude and beliefs. These are factors that are not dependent on
external conditions, inherent and are within the individuals body.

According to a study conducted by the Faculty of Nursing & Midwifery of Shiraz University
of Medical Sciences and the School of Nursing of Fasa University of Medical Sciences, three main
themes emerged: ineffective communication, inadequate readiness, and emotional reactions
regarding the challenges of nursing students in dealing with the clinical learning environment.

Ineffective communication has two subcategories: improper treatment and

discrimination. (Improper treatment) In a clinical setting interaction with the clinical instructor,
patient and health personnel is important. When student nurses encounter challenges in dealing
with the environment and the interaction between the people present in the environment it is
said that the way the student is treated affects the clinical learning and performance in the area.
(Discrimination) Students have been expressing their thought about the discriminatory behaviors
they experience in the area. According to what the students claimed, the greatest discrimination
in the clinical setting was apparent in behaviors of patients towards student nurses.

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 Inadequate readiness includes three subcategories of inadequate knowledge, deficient
practical skills, and insufficiently developed communication skills. Many students when going to
the clinical setting may still have insufficient knowledge due to unpreparedness or inadequate
readiness when stepping into the area and providing care and doing procedures. Deficient
practical skills were one of the greatest factors why nursing performance is being affected when
student with deficient practical skills is placed in a situation to do the procedure lack of necessary
skills may increase the anxiety and affect the actual performance. Deficiency in practical skills in
caring for patients and in performing different procedures was a concern of many students in the
clinical setting. Many students mentioned the lack of communication skills as the reason for
deficiency in communicating with the clinical learning environment. It also includes the language
barrier when student nurse and patient doesn’t have a common language they can communicate
with the process of providing care is being disrupted and affected.

Emotional Reactions this includes: stress and inferiority complex. They said that many
students became distressed and overwhelmed in dealing with new experiences within the clinical
learning environment. The presence of stressors in the clinical setting and exposure to new
events cause emotional reactions in students. Inferiority complex is also evident in the student
nurses. The performance of students in the clinical area is greatly affected by difficulties they
encounter especially in their first clinical duty. Factors include relationship with clinical
instructors, misunderstandings arising from group works, hospital policies and requirements,
alterations in contingencies when handling patients and so on. As new members of the
healthcare team, adjustment to different stressors seems to be crucial and student nurses who
was involved in the study somehow feels that they are inferior to the other healthcare team
members.

Mild anxiety is common in everyday life. At this level, you’re likely open-minded, although
stressed. It is a feeling that something is different and requires special attention. Increased
sensory stimulation and helps the individual focus of attention for learning, doing, solving
problems, feel, and protect themselves. Mild anxiety is associated with the tension of everyday
life events. At this level of perception land to widen and individuals will be cautious and vigilant.
Mild anxiety is typically motivational, meaning it helps you focus on seeking a solution to the
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challenge you face. For example, if you're lost in a new place, you might look for a safe place to
ask for directions. Once you get your bearings, your anxiety will likely dissipate quickly. This is
typical of mild, situational anxiety.

Moderate anxiety is a disturbing feeling that something is really different, people become
nervous or agitated. For example, a woman visiting her mother for the first time in several
months and feel that there is something very different. Mom said that the weight down a lot
without trying to reduce it. At this level there is decrease of the perception of the environment,
individuals are more focused on the important thing. At a moderate level of anxiety, you're likely
to focus exclusively on the stressful situation directly in front of you and ignore other tasks. Say
you've taken a child to the playground and lose sight of him. Your singular focus is likely where
the child might be. Once you find him playing with other children, your symptoms subside.

Severe anxiety is experienced when an individual believes that there is something

different and there is a threat: it shows the response of fear and distress. With severe anxiety,
symptoms intensify. Learning a loved one has been in an accident or died unexpectedly, or the
unexpected loss of employment, are examples of situations that can provoke the symptoms.
With severe anxiety, your ability to focus and solve problems is impaired, which can lead to
further anxiety. You may not even be able to recognize or take care of your own needs. Attempts
of others to redirect your attention are likely to be unsuccessful.

DELIVERY ROOM

Nursing students must acquire knowledge of maternal and child nursing from ante-
partum, intra-partum and postpartum periods. After completing a theoretical course, students
must take nursing practice. They also have to prepare knowledge, body, and mind before the
practicum, especially the practice in a delivery room, since delivery is an urgent situation; a
pregnant mother must get help in delivery in time. This is a new experience for nursing students.
There are many factors leading to stress, anxiety, and fear: placement and delivery instrument,
adaptation to university supervisor and mentor, nursing care for pregnant woman with
intrapartum labor pain, mechanisms of labor and complicated nursing for pregnant woman with
complications which requires domain knowledge for the safety of mother and baby. If a nursing

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student cannot adapt themselves to these changes, it will affect their learning and positive
attitude towards the practicum and professional nursing.

The results of the study found that the practical delivery room experience of nursing students
consisted of three issues: 1) stress and coping with stress during practical exercise, 2) changes in
daily routine, and 3) source during practical exercise. (Suwannobol and Suwachan, 2012)

EMERGENCY ROOM

The work in the Emergency Room is complex and intense. The student nurse should be
prepared and watchful for any time to exercise, seeing patients in emergencies, which require
specific knowledge and ability to make decisions promptly. They can unite all the knowledge
learned and used them in a proper and expeditious manner.

Emergency units are an important nursing workspace. It was found that the nurse is
responsible for performing nursing prescriptions, records and procedures, specific from their
category, which is part and control of the unit. The importance of the management,
administration, organization, of quality records for effective communication between the team
was observed, which is a potentiating factor in the health status of the patients’ improvement
and quality in care.

OPERATING ROOM

There are researches that were conducted about the experience of student nurses during
their exposure to the Operating Room.

Student nurses’ dissatisfaction with clinical experiences, due to specific challenges, e.g.:
decreased patient interaction in the intra-operative environment, lack of mentoring, high
complexity of nursing practice (Hughes 2006; Callaghan 2010).

Factors affecting learning during clinical placement is the Clinical environment and Perception of
students. The Clinical environment, involves positive clinical environment fosters learning. (Dunn
& Hansford 1997; Sharif & Masoumi 2005). Perceptions of students has an influence on the
quality and degree of learning taking place (Findik et al. 2015).

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 There are four themes that are reflective of the factors that influenced the quality and
degree of learning encountered in the operating room, and whether, ultimately, the operating
room provided an environment conducive to meaningful clinical learning and performance.

Interpersonal factors: This reflects the interpersonal factors in the operating room. The operating
room presents both enablers and constraints to learning. Interpersonal factors which served as
enablers to learning are acknowledgement and respect from doctors this contributes to feelings
of inclusiveness as part of the team member.

Constraints to learning (Educational Factors): The student nurse feelings of inadequacy. The
anxiety felt before clinical placement, attributed to fear of the unknown and previous negative
encounters. The support being offered by the Clinical Instructor and health personnel also affects
the learning and performance.

Private operating room context. The unpredictable nature of the operating room (which could
exist both in private and public sectors) was perceived as an enabler to learning

Recommendation, reflects the opinions and suggestions made by participants that may enable
learning in the operating room in future. The need for future students to be more positive about
the operating room placement. The need for designated mentors in the operating room, proper
orientation, guidance, preparation, involvement from staff, and improved communication.

The three special areas will be able to run smoothly only if all members of the health care team
will cooperate and do their utmost for the welfare of the patient. It is believed that the
experience on each area is important in the nursing curriculum.

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 Conceptual Framework

RESPONDENTS
Level IV nursing students who were
previously exposed in Delivery Room,
Operating Room and Emergency

FACTORS LEVEL OF ANXIETY

INTRINSIC FACTORS A. Low
1. Self-preparation B. Moderate
2. Actual performance C. High

EXTRINSIC FACTORS CLINICAL PERFORMANCE IN

SPECIAL AREAS
1. Patient
2. Relatives A. Operating Room
3. Clinical Instructor B. Emergency Room
4. Health personnel C. Delivery Room
5. Environment

The respondents for this study will be the incoming level four nursing students of Western
Mindanao State university. The independent variables are the intrinsic and extrinsic factors while
the dependent variables are the level of anxiety and the clinical performance of the students.
The respondents will be given three separate checklists for the three different special areas to
determine their level of anxiety and get the students grades to determine the relationship
between the anxiety and their clinical performance.

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Definition of Terms

Anxiety – is the response to Intrinsic and Extrinsic factors being experienced by nursing students

when they are exposed in Delivery Room, Operating Room and Emergency Room.

Intrinsic factors – refers to the student nurse’s personal actions, and inherent feelings during the

actual performance of the different procedures in special areas specifically Delivery Room,

Operating Room and Emergency Room.

Extrinsic factors – refers to the surrounding of the student nurses and the people present in the

environment. Situations being experienced are also considered extrinsic factors that may affect

the level of anxiety of nursing students during the actual performance of the student nurses in

the special areas.

Level – describes the degree of anxiety being experience by the nursing students when they were

exposed in Delivery Room, Operating Room, and Emergency Room. These level is categorized

into three whether low, moderate or high anxiety.

Low Anxiety – refers to the anxiety felt by the nursing students if they get a total score ranging

from 0-60. Which means that the factors that were enumerated has the least effect on the

anxiety of nursing student’s during their performance.

Moderate Anxiety – refers to the anxiety felt by the nursing students if they get a total score

ranging from 61- 120. Which means that the factors that were enumerated has the moderate

effect on the anxiety of nursing student’s during their performance.

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High Anxiety – refers to the anxiety felt by the nursing students if they get a total score ranging

from 121-180. Which means that the factors that were enumerated has the highest effect on the

anxiety of nursing student’s during their performance.

Clinical Performance – this refers to the performance of the student nurses in the three different

areas. The clinical performance will be shown and seen in the grades acquired by the student

nurses in each area.

Delivery Room – a special area that exhibits procedures such as delivery of the newborn, the

delivery of the placenta and immediate newborn care. It is used as venue to measure the levels

of anxiety of the target population.

Operating Room – a special area that exhibits various surgical procedures wherein the student

nurses act as scrub nurse or circulating nurse. It is used as venue to measure the levels of anxiety

of the target population.

Emergency Room – a special area that caters to immediate cases with various medical

procedures. It is used as venue to measure the levels of anxiety of the target population.

Never – means that the student nurse was not able to experience any anxiety with regards to the
situation that is stated.

Sometimes – means that the student nurse is able to experience anxiety rarely with regards to
the situation that is stated.

Most of the times – means that the student nurse is able to experience anxiety often with regards
to the situation that is stated.

Always – means that the student nurse is able to experience anxiety consistently or regularly
with regards to the situation that is stated.

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 CHAPTER III
METHODOLOGY
Research Design

The research study will be utilizing a non-experimental quantitative descriptive

correlation method, it involves identifying and understanding the nature of the phenomena and
correlational studies examines the extent of relationship between variables. This method will be
use to describe the intrinsic and extrinsic factors affecting the level of anxiety in special areas and
its relationship toward the clinical performance among nursing students of Western Mindanao
State University, Zamboanga City.

Research Locale

The research study will be conducted in Western Mindanao State University which is
considered as one of the most outstanding university in Zamboanga City, specifically in the
college of nursing located at Normal Road Barangay Baliwasan Zamboanga City. We considered
three special areas which includes ER, OR, DR, Birthing at Zamboanga City Medical Center (ZCMC)
located at Dr. Evangelista St. Sta. Catalina, and OR, DR at Zamboanga Puericulture Maternity
Lying-in Hospital located at Brillantes St. and lastly OR, DR at Mindanao Central Sanitarium at
Pasobolong, Zamboanga City.

Sampling Technique

The research group will conduct a study with the use of non-probability sampling method
specifically the purposive-convenience sampling. A non-probability sampling is a sampling
process in which a sample is selected from the members of population through a non-random
method, while purposive sampling is a type of non-probability sampling where in subjects are
consciously selected to be included in the sample population based on certain qualities for
purposes of the study. The researchers are going to gather a list of respondents that can qualify
for our research topic and those nursing students who are available during the time of the
implementation, this will be accomplish by gathering the list of students who are previously
rotated in the three special areas (Delivery Room, Operating Room and Emergency Room).

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Sample Population

The study population for this research study is going to be the 4 th year nursing students
of Western Mindanao State University. The students in this study should be previously assigned
in the three special areas which are the Emergency Room, Operating Room, Delivery Room.

Inclusion Criteria

The respondent must be:

 4th year Nursing students of Western Mindanao State University

 Assigned in Zamboanga City Medical Center - Emergency Room, Operating Room,
Delivery Room, Birthing.
 Assigned in Zamboanga Puericulture Maternity Lying-in Hospital- Emergency Room,
Operating Room, Delivery Room.
 Assigned in MCS General Hospital - Operating Room, Delivery Room.
 Willing to participate all throughout the research study
 Willing to give their grade on the three areas

Exclusion Criteria

If the 4th year nursing student of Western Mindanao State University wasn’t previously
assigned or rotated in at least one of the three special areas (Delivery Room, Operating Room
and Emergency Room), then he or she will not be qualified as a possible respondent for the
research study. If the respondent will not agree to participate in the research or doesn’t want to
give his or her grades in the said area areas then he or she will be excluded as a respondent for
the research.

Plan for Data Collection

After the approval of the ethics committee, we will identify the respondents by instructing
the class president of every section of the upcoming 4th year nursing students (sections A, B, C,
D) to gather the names of the students who were assigned to all of the following special areas:

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Emergency Room, Operating Room and Delivery Room considering the willingness of the
students to participate in the study.

Plan for Data Analysis

The method of gathering will be a 45 items scale questionnaire through a convenient

purposive sampling. The list of nursing students that will be gathered is going to serve as the
baseline data on how many respondents will be able to participate in this research study. To
analyze the data that will be gathered computation of the weighted mean will be utilized.

Ethical Considerations

In the time of the conduct of the study, each participant will be given an informed
consent, whereby confidentiality of the information that will be gather is stressed out. Nursing
students who are willing to be part of the study will only be the ones given an informed consent,
questionnaire, and allowed to participate. Researchers will allow the respondents to answer the
questionnaire without time pressure. The principles namely respect to human dignity and
beneficence will be observe. Respect for the human dignity involves the right of the respondent
to self-determination wherein there is freedom from coercion of any type and the respondent
will be able decide voluntarily whether to participate in the study. The participant also has the
right to ask questions, to refuse to be part of the study and to withdraw from the study even if
he or she is in the middle of answering the questionnaire. The right to full disclosure is also under
the Respect for human dignity, wherein information regarding the study which includes the
significance, objectives, benefits will be provided by the researchers to the target respondents.
Every section of the questionnaire will be explained concisely to them. The student nurse will be
considered qualified to participate only if he or she agrees to answer the said questionnaire.
Beneficence is also highlighted where in the researchers will promote the welfare of the research
participant while minimizing the harm and maximizing the benefits.

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