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1. What are some sources of stress for college students according to the article
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29DOI: http://dx.doi.org/10.17159/2310-3833/2021/vol51n2a5South African Journal of Occupational Therapy. 2021; 51(2): 29-38Coping Styles and Sources of Stress of Undergraduate Health Science Students: An Integrative Review*Robyn Marcella Henderson**, B. OT (UKZN). https://orcid.org/0000-0003-0806-6541 Community service occupational therapist, Appelsbosch Hospital, KwaZulu-Natal, Durban, South Africa.Odell Chetty**, B. OT (UKZN). https://orcid.org/0000-0002-2594-3166Community service occupational therapist, Addington Hospital, KwaZulu-Natal, Durban, South Africa. Thavanesi Gurayah. B. OT (UDW); M. OT (UDW). https://orcid.org/0000-0001-9005-6355Lecturer, Occupational Therapy Department, School of Health Sciences, University of KwaZulu-Natal, Westville Campus, KwaZulu-Natal, Durban, South Africa. **Undergraduate students at the time of the studyKeywords: stressors, coping strategies, health science students, workload, student support. ABSTRACTBackground and aim: Tertiary education provides many personal and social benefits. However, students, particularly those from professional and health science disciplines are known to face significantly greater stress throughout their undergraduate degrees. In this integrative review sources of stress for students and the strategies they use to cope with the stress are explored.Method: Various databases were searched using common key phrases such as “stressors among undergraduate health science students” and “coping mechanisms utilised by undergraduate health science students”. Thirty-three articles were selected based on predetermined inclusion and exclusion criteria. The content in the articles were analysed to identify themes.Results: Academic stress was the primary source of stress for health science students. Other sources of stress included interpersonal interactions and clinical training. Students primarily used problem-focused strategies to cope with stress. Other strategies included avoidance and the use of social support networks.Conclusion: Health science students experience stress from academic tasks, interpersonal stress and stresses emanating from clinical training. They utilize problem-focused coping strategies, as well as avoidance and seeking social support when faced with stressful situations. Students would benefit from regular screening for stress-related conditions, and interventions to teach them more adaptive ways to deal with stress.INTRODUCTIONHigher education is essential for both personal success and eco-nomic growth. Tertiary education provides social benefits such as the acquisition of advanced knowledge, increased employability and financial stability1. However, successful graduation is a prereq-uisite for these benefits. Challenges to academic success include the complexity, number and timing of assessment tasks, and stress associated with intense studying at a higher education institutionFears concerning the future, leaving behind friends and family, and having a poor work-life balance all take a toll on the mental health of university students2. This was confirmed by Makoni3, who stated that mental health remains a global concern for university students, as psychological distress impacts negatively on academic performance. Stressful factors experienced by students include rigid course structures, insufficient support systems, inadequate finances and conflicting role demands, due to either childrearing, caring for an elderly family member or part-time employment2. Moreover, many students are academically unprepared for higher education, as many are first generation students, who may lack the social capital to succeed4. This is reflected in their poor academic performance such as high failure and dropout rates, and lengthy throughput among others5. This article is based on a review that was conducted by UKZN undergraduate students for the fulfilment of a bachelor’s degree in Occupational Therapy. This review was underpinned by the following questions: 1. What are the sources of stress among undergraduate health sci-ence students? 2. What strategies do students use to cope with stress? METHODAn integrative review of the literature was conducted to under-stand the sources of stress, as well as the coping mechanisms utilised by undergraduate health science students. This method allowed for the inclusion of different types of studies for a holistic understanding of the research phenomenon6. This review was granted exemption from ethics, based on the pandemic, by the University of KwaZulu-Natal. The protocol reference number 00005806 was issued in response to the protocol submitted on 31 March 2020. ISSN On-line 2310-3833Creative Commons License 4.0
30Inclusion criteria:• Articles published between 2000-2020• Articles on undergraduate health science students. • All articles were published in English and had to be full text.Exclusion criteria:• Articles involving medical students were excluded from the review as they are exposed to different stressors, and the demands and duration of their degree was different to that of other health science disciplines. • Articles on postgraduate health science students were ex-cluded as they may be exposed to different stressors, and cope differently.Review processThe review process was done in phases. The following health databases were searched: Microsoft academic, Refseek, Catalogue search, SagePub, SciELO, Semantic Scholar, Science Direct, Google Scholar, Pubmed, Ebscohost and Medline were used. Pubmed and Medline were searched separately. The following descriptors and Boolean phrases were used as key phrases: • undergraduate health science students, • undergraduate occupational therapy students, • coping mechanisms utilised by undergraduate health science students, OR undergraduate occupational therapy students, • stressors among undergraduate health science students, OR undergraduate occupational therapy students • AND sources of stress in undergraduate health science stu-dents OR undergraduate occupational therapy students.The initial searches yielded 60 studies, and the title and abstracts were read in July 2020. The final sample consisted of 33 articles that met the inclusion criteria. The information to be extracted from the studies were defined and categorized, and the full-text articles were read. Data analysis entailed creating a table and extracting the information from all articles into sources of stress and coping strategies. Information was further broken down into themes such as academic, personal, environmental factors and other stressors, as well as adaptive and maladaptive coping strategies. Once all the infor-mation was extracted, the themes were constituted, reviewed, and refined, and a flow chart created. The review process is illustrated in Figure 1 (below).RESULTS Twenty five of the 33 studies were quantitative, six were qualitative, and two were systemic reviews. The studies were conducted in various countries including South Africa, Nigeria, Saudi Arabia, the United Kingdom, the United States of America, and Australia. The studies were focused on the perspectives of occupational therapy, physiotherapy, dental therapy, speech pathology, pharmacy, and nursing students. The articles included in this review are presented in Table I (p31), which are organized according to the numerical order of references. The findings are presented according to the sources of stress and coping strategies utilized by students.Sources of stressThree major sources of stress were identified, which included academic activities, interpersonal/social interactions, and clinical training. Several studies identified academic demands as the most significant source of stress for health science students7-9. Students described examinations and a high workload as the major factors contributing to academic stress10-12. Interpersonal or social stressors with family and peers were cited in 15 studies7,11,13-25. In another study conducted in Saudi Arabia, nursing students identified rela-tionships with hospital staff to be a source of stress26. Stress from clinical training was emphasised by 13 out of the 33 studies7,13,17,18,20,25-32. Poorly staffed clinical departments, fast-paced wards and initial clinical placements were all factors contributing towards the stress of students28. High level patient care was also a prevalent stress factor amongst nursing students13,17,20. Other stressors that were reported less frequently included personal issues, financial concerns, environmental factors, psychosocial issues, and lack of students’ professional skills. Personal stressors consisted primarily of students being stressed about their personal health-related conditions and illnesses7. Financial issues were cited in a study by Gibbons, Dempster and Moutray28, where students revealed that they had to work part-time during their undergraduate studies to support themselves. Environmental factors cited as stress inducing included noisy liv-ing environments13. In terms of psychosocial stressors, final year physiotherapy students described the suffering and death of their patients as a traumatic experience39. Another study revealed that high parental expectations and decreased time to participate in leisure activities contributed to the students’ psychosocial stress10. Lack of professional knowledge was reported as a source of stress in six out of the 33 studies13,17,20,23,25,27. Students felt that they lacked the necessary skills, and that clinical training was not always sufficient40. Other stressors identified in this review were concerns about postgraduate opportunities and career choices7. The frequency with which the stressors were identified in the reviewed studies is illustrated in Figure 2. Figure 1: Flow chart showing the research process.Figure 2: Sources of stress amongst health science students.
31Table I: Description of studies showing title, year, methodology, authors, country and findings of study.Title of the journal articleAuthorsYearSample sizeMethodologyFindingsCountrySources of stress in a phar-macy student population7Garber, M., Huston, S., & Breese, C.2019721 Quantitative: survey using the Perceived Stress Scale.Stressors included aca-demic work, pressure to succeed, relationships, postgraduate opportuni-ties, and financial stress.United StatesPerceived stress and sources of stress among physiotherapy students from three countries8Jacobs, T., Gummesson, C., Nordmark, E., Ansary, D., Remedios, L., & Webb, G.2018626 Quantitative: cross-sectional study design, using the Perceived Stress Scale (PSS), and the Undergraduate Source of Stress Questionnaire (USOS).Academic factors were found to be the most significant, and financial stressors were least significant.Israel, Australia, and SwedenSources of stress and psychological morbid-ity among undergraduate physiotherapy students9Walsh, J., Feeney, C., Hussey, J., & Don-nellan, C.2010125Quantitative: survey using the Undergraduate Sources of Stress Questionnaire and the General Health QuestionnaireStudents experienced academic and personal stressors. 27% of the students presented with psychological morbidity. IrelandA cross-sectional study of stress and its sources among health professional students at Makerere University, Uganda10Amanya, S. B., Nakitende, J., & Ngabirano, T. D.2017258Quantitative:descriptive cross-sectional study design, using the General Health Questionnaire (GHQ-12). Stressors included the academic curriculum (38%), high parental expectations (26.7%) and financial problems (24.4%).UgandaNature of Stress among Health Science Students in a Malaysian University11Othman, C., Fa-rooqui, M., Yusoff, M., & Adawiyah, R.2013248Quantitative:cross-sectional study, using the Medical Student Stress Question-naireFemale students (60%) were more stressed com-pared to male students.MalaysiaSource of stressors and emotional disturbances among undergraduate sci-ence students in Malaysia12Radeef, A.S., Faisal, G.G., Ali, S.M., & Ismail, M.K.2014194Quantitative:Cross sectional, questionnaire-using the Depression Anxiety Stress Scale (DASS-21).Academic stress was most significant, followed by social /interpersonal stressors. MalaysiaAssessment of Level and Sources of Stress Among Allied Health Sciences Students of Bayero Univer-sity Kano: A Comparison Between Clinical and Pre-Clinical Students13Muhammad, D., Ahmad, A., & Usman, J.2019230 Quantitative:Using the MSSQ (Medical Student StressorsQuestionnaire).Academic stress was prevalent, with anxiety (84.5%), depression (64.4%), and stress (56.7%) rates recorded.NigeriaOT students’ experience of stress and coping14Govender, P., Mkhabela, S., Hlongwane, M., Jalim, K., & Jetha, C. G201599Quantitative: descriptive survey design using a de-scriptive stress sur-vey and the Ways of Coping Checklist (WCC).Academic stress was most prevalent, and 7.8% of students were mildly stressed, 49.1% were moderately stressed, 6% were highly stressed, and 0.4% were severely stressed. South Africa
32Title of the journal articleAuthorsYearSample sizeMethodologyFindingsCountryResilience in occupational therapy students15De Witt, P.A., Monareng, L., Abraham, A.A.H., Koor, S., & Saber, R.2019118Quantitative: Descriptive, cross-sectional survey design using the Re-siliency Scale (RS); the Perceived Stress Visual Analogue Scale (PSS) and the Health Behaviours Questionnaire (HBQ).Academic stressors were the most prevalent, as well as social and per-sonal stressorsSouth AfricaReplacing stressful chal-lenges with positive coping strategies: a resilience pro-gram for clinical placement learning16Delany, C., Miller, K. J., El-Ansary, D., Re-medios, L., Hosseini, A., & McLeod, S.20156Qualitative:A resilience pro-gram was designed consisting of four 90-minute sessions. Clinical training was stressful, and students used avoidant coping.AustraliaNursing students’ perceived stress, coping strategies, health, and supervisory approaches in clinical practice: A Slovak and Czech perspective17Gurková, E., & Zeleníková, R.2018275Quantitative:cross-sectional, descriptive study using the Perceived Stress Scale and the Coping Behaviour Inventory.Stressors categorized as clinical, academic and social stressors. Problem focused coping, avoidance, transference and remaining positive were used.Czech Republic and SlovakiaStress and coping styles in Japanese Nursing stu-dents18Yamashita, K., Saito, M, & Takao T20121324Quantitative:using the General Health Question-naire and Brief Coping Orienta-tions to Problems Experienced scales.Academic stressors, interpersonal relationships, and stress from clinical practice. Strategies included social support (61.7%) and avoidant coping (2.7%). Japan Study of stress level in occupational therapy students during their aca-demic curriculum19Kumar, S., & Jejurka, K.2005100Quantitative:study using a 28-item stress questionnaire and Zung’s self-rating scale for depres-sion.First year students experienced greater academic, social and emotional stress. IndiaA literature review on stress and coping strategies in Nursing students20Leodoro J201713 Systemic review Stressors included the care of patients, academics, and negative interactions with staff. Problem solving strategies were used.Saudi ArabiaAlcohol use by occupational therapy students: An exploratory study21McCombie, RP., Ev-ans, A., & Miller, MJ201681Quantitative: using the Modified version of the Michigan alcohol screening test, the Stecker Life Stressors Survey Alcohol use was associated with socialisation. Social support was the primary coping mechanism.United StatesPsychological distress among nursing, physiotherapy and occupational therapy students: A longitudinal and predictive study22Nerdrum, P., & Rustoen, T.2009416Quantitative:using the StudData questionnaire and the General Health Questionnaire Students experienced academic stress and had interpersonal problems.NorwayPsychosocial stress factors among mental health nurs-ing students in KSA23Seham, M201910Qualitative: Inter-pretive qualitative approach involving semi-structured interviewsStressors included the academic environment, social distress, financial constraints, and interper-sonal relationships.Saudi Arabia
33Title of the journal articleAuthorsYearSample sizeMethodologyFindingsCountryExperienced stressors and coping strategies among Iranian nursing students24Seyedfatemi, N., Tafreshi, M., & Hagani, H.2007440Quantitative:descriptive cross-sectional study using the Student Stress Survey and the Adolescent Coping Orientation for Problems Expe-rienced Inventory. Stressors included academic and environmental stress, interpersonal problems, and health concerns.IranStress and coping strate-gies among nursing students: an international study25Labrague et al2018547 (161 Greek students, 153 Filipino students, and 233 Nigerian students)Quantitative:Using The Per-ceived Stress Scale (PSS) and the Coping Behaviour Inventory (CBI).Academic stress was ranked the highest (M=2.46, SD=0.78). Problem focused coping was the most used coping strategy (M=2.68, SD=0.72).Greece, Philippines and NigeriaExamining stress percep-tions and coping strate-gies among Saudi Nursing students26Labrague L.J.201811 quantita-tive studies. Systemic review Academic stress was the most significant stressor. Students utilized active and passive coping styles.Saudi ArabiaHong Kong baccalaureate nursing students’ stress and their coping strategies in clinical practice27Chan, C., So, W., & Fong, D2009205Quantitative:survey using the Perceived stress scale, Physio-Psy-cho-Social response scale and Coping Behaviour Inven-tory.A lack of clinical knowledge, taking care of clients and academic stressors induced stress. Coping strategies included problem solving, transference, avoidance and remaining positive. Hong KongStress and eustress in nurs-ing students28Gibbons, C., Demp-ster, M., & Moutray, M.200816Qualitative:focus group inter-views Students who coped well used support networks and were positive, to-wards programme issuesUnited KingdomStress, coping and satisfac-tion in nursing students29Gibbons, C., Demp-ster, M., & Moutray, M.2011171Qualitative using The General Health Questionnaire. Stressors included academic and fieldwork demands. Coping strate-gies included avoidance and using social support. United KingdomPerceived stressors of oral hygiene students in the dental environment30Gordon, N., Rayner, C., Wilson, V., Crombie, K., Shaikh, A., & Yasin-Harnek-ar, S201689 (3rd year Bachelor of Oral Health students)Quantitative:Using the DES questionnaire; and the Maslach Burnout Inventory (MBI).First and second year students identified theo-retical learning as most stressful, whereas the 3rd year group reported clinical training as most stressful. South AfricaPerceived stress and well-being amongst Dental Hy-giene and Dental Therapy Students31Harris, M., Wilson, J., Holmes, S., & Radford, D.201772 dental hygiene and dental thera-py students, and 80 final year out-reach dental students (as a comparison group)Quantitative:survey using the Dental Environment Stress questionnaire (DES); Depres-sion Anxiety Stress Scales (DASS21); Scales of Psycho-logical Well-Being (SPWB); Valuing Questionnaire(VQ); and the Adult Hope Scale (AHS).Stressors included academic work and field-work practice.United Kingdom
34Strategies used by students to cope with stressStudents used a variety of strategies to help them cope with stress. Problem-focused coping was identified as one of the most used coping strategies14,20,25. Avoidance was another commonly used strategy, which involved students waiting for others to solve their problems, or avoiding teachers, but this approach led to difficulties in clinical training33. Other negative coping strategies that were not health promoting was avoidance (17%), transfer-ence (11%) and substance use by 2% of the sample.Students used social support networks as a strategy for coping, as indicated in eight of the 33 studies14,16,18,21,24,29,33,39. The frequency with which various coping strategies were used by students in the Title of the journal articleAuthorsYearSample sizeMethodologyFindingsCountryStress sources in nursing practice. Evolution during nursing training32Zupiria Gorostidi, X., Huitzi Egilegor, X., Jose Alberdi Erice, M., Jose Uranga Iturriotz, M., Eizmendi Garate, I., Barandiaran Lasa, M., & Sanz Cas-cante, X.200769Quantitative:Using components of the KEZKAK, STAI and demo-graphic question-naires.Stressors included academic and social stressors, and the lack of professional knowledge.SpainPerceptions of stress, time management and coping strategies of speech pa-thology students on clinical placement33Lincoln, M., & Adamson, B.2004Time1: 62 Time 2: 36 Time 3: 48 Quantitative:Using the Perceived Stress Scale and Australian Time and Organization Management Scale (ATOMS). Coping strategies in-cluded problem focused coping, optimism and using social support. AustraliaCauses of Stress and Cop-ing Strategies Adopted by Undergraduate Health Professions Students in a University in the United Arab Emirates34Gomathi, K., Ahmed, S., & Sreed-haran, J.2013212Quantitative:survey using the brief COPE inven-toryStressors included academic and health related stress. Religion and praying were coping strategies.United Arab EmiratesThe role of religiosity, cop-ing strategies, self-efficacy and personality dimensions in the prediction of Iranian undergraduate rehabilita-tion interns’ satisfaction with their clinical experi-ence35Mirsaleh, Y., Rezai, H., Kivi, S., & Ghorbani, R.2010318Quantitative:cross-sectional survey using theIslamic Religios-ity Scale, Ways of Coping Question-naire, General Self-efficacy Scale, NEO Five Fac-tor Inventory, and Satisfaction with Clinical Experiences Questionnaire.Religiosity, problem-fo-cused coping and general self-efficacy were good predictors of satisfaction with clinical internship in rehabilitation students.IranNursing students’ stress and coping strategies dur-ing clinical training in KSA36Waled, A.M., & Badria, M.A.2019125 Quantitative:Descriptive cross-sectional study Stressors included academic stress, a lack of professional knowledge and competitive relation-ships with peers. Saudi ArabiaDealing with stress: Patterns of self-comfort among healthcare stu-dents37Vera Dahlqvist, A. S., & Astrid, N.2018168Qualitative:focus group.Emotion focused styles of coping were used.SwedenPredictors of mental dis-tress among undergradu-ate health science students of Hawassa University, College of Medicine and Health Sciences, Hawassa, SNNPR, Ethiopia: a cross-sectional study38Bedaso, A., Duko, B., & Yeneabat, T.2020309 Quantitative:cross-sectional study design A lack of social support and the excessive use of substances were strong predictors of mental distress.Ethiopia
35reviewed studies can be seen in Figure 3.DISCUSSIONHealth science students experience significantly higher levels of stress as compared to students in other disciplines41. Academic related stress was most prevalent amongst health science students7-9 and appeared to increase over the four-year occupational therapy course, with final year students perceiving it to be the greatest source of stress12. Examinations and an increased workload were most significant10-12, which was attributed to students’ poor time management34. This was reiterated by Mohamadkhani et al42 who stated that efficient time management skills were an important predictor for academic performance, reduced stress levels and increased productivity42. Clinical training was also identified as a source of stress28; due to understaffed clinical settings, high turnover in wards and prob-lematic clinical placements. Garber et al.7 described fieldwork rota-tions to be stressful for pharmacy students, who were concerned about their performance in these experiential rotations. Negative relationships with faculty members were identified as one of the key social stressors7. A poor relationship with staff can result in decreased academic performance, as students find it difficult to approach lecturers or clinical supervisors. Social stress was cited in Gomathi et al.34, who reported that competitive relationships amongst peers was stressful. These competitive interpersonal relationships have been found to negatively impact on students’ available support systems. Family conflicts were also found to compound the stress experienced by students, due to a negative impact on the students’ available support networks21.Gomathi et al.34, reported that the main psychosocial stressors experienced by students were high parental expectations, lack of adequate leisure time, and anxiety about the future, which centred about future unemployment. Psychosocial stresses of students included difficulties in processing the death or suffering of their patients39. Peters et al43, suggested that health providers are constantly exposed to the death and suffering of their clients, which can serve as a subconscious reminder of their own mortality. Students’ health-related conditions were also stress inducing7,13. Students with chronic illnesses, or those who had surgeries found it difficult to manage these additional stressors7. Binge eating disor-ders and obesity were prevalent in first generation students44. These findings were in stark contrast to what has been reported in developing countries, such as South Africa, where many students presented with food insecurity and malnutrition45. Dominguez-Whitehead45 highlighted that South African university students were subjected to food insecurity because of limited funds.Environmental factors such as noisy environ-ments and the climate within the university and clini-cal settings were also stress inducing. Servilha and Delatti46, reported that increased noise levels were a major stressor for undergraduate health science students, which impacted their studies negatively. Fi-nancial stress was another source of stress identified within this integrative review. In one of the studies, it was found that students needed to secure part-time employment to alleviate their financial burdens28. University students with financial stress were likely to present with decreased academic performance, as they struggled to balance work and completing academic tasks47. This continues to be a problem particularly in developing countries, including South Africa, with many students on financial aid. A lack of professional knowledge was the least reported stressor within this integrative review. These students felt that clinical training was inadequate, and that they continued to lack the necessary clinical skills23. Coping strategies of health science studentsStudents used a variety of coping strategies, including problem focused coping and emotion focused coping. It was found that stu-dents with high levels of resilience and optimism tended to respond to stress with adaptive coping strategies, such as task-oriented and active coping, whilst those with high levels of pessimism were likely to use maladaptive strategies, such as disengagement, denial, and venting of emotions. Some of the adaptive strategies included remaining positive and using social support. Other negative coping strategies included avoidance, transference, and substance use to cope with stress.As can be seen in Figure 3, health science students were more likely to utilize problem-focused coping (20%)14,17,20,24-27,34,35,36,41, in contrast to emotional-focused coping (13%)14,16,24,34,35,37,39. Problem focused coping involves taking control of the stressor by either seeking information or assistance in handling the situation, whereas emotional focused coping included avoidance(17%)17,24,25,27,29,33,34,35,36 and seeking social support14,16,18,21,24,29,33,35 (15%). Govender et al14 found that only 2% of occupational therapy students at the Univer-sity of KwaZulu-Natal between the first and fourth year of study used problem-focused coping13. This strategy consisted of identify-ing, planning, analysing potential solutions and taking the necessary actions to solve the problem48. Other studies revealed that health science students employed a range of problem-focused coping strategies such as “managing their time, seeking information and sport and recreational activities, or they employ emotion-focused strategies such as tension reduction strategies, such as exercising, balanced diet, getting enough sleep, and engaging in constructive leisure activities”14.Adaptive coping strategiesRemaining positive was cited in 11 out of the 33 studies included in this integrative review14,17,20,24-27,34,35,36,39. Students were found Figure 3: Pie graph showing coping strategies of students.
36to adopt a positive attitude and mind-set in response to stressful events, confirming the use of hopefulness and optimism as a coping style36. A positive mind-set is likely to prevent students from resort-ing to helpless coping styles. Students were reported to be engaged in problem-focused methods of coping where they actively sought ways to cope with different stressors. Coping approaches included the development of solutions to their problems, and the seeking of assistance from student support services26. Another adaptive coping style identified was seeking social support. Support from family and friends is crucial in enabling a student to successfully integrate into university life, and a poor support network is a strong predictor of mental distress38. This approach entailed students talking about their problems with family and friends48. One study identified 61.7% of nursing students from a cohort of 1324 students who used social support as a means of coping17.Emotion-focused coping was cited in seven out of the 33 articles14,16,24,34,35,37,39, where the individual tried to minimise the stressor, and they felt better, but the problem remained unsolved. Other strategies used by students included remaining positive, transference, and other non-specific methods, such as remaining positive or optimistic,17,27 and substance use.Maladaptive coping strategiesStudents who engaged in avoidance behaviours often participated in activities such as procrastination, substance use and playing video games. These students were unlikely to identify the positive aspects of a situation24, which indicated a negative worldview and tendency to utilise avoidant coping styles. McCombie et al21 postulated that some students used substance use as a coping strategy. Problematic family relationships resulted in a lack of social support, resulting in the increased tendency to use substances. With emotion-focused coping, the stressor is not analysed or resolved, but rather indirectly managed, and may include maladaptive coping strategies, such as substance use, avoidance, or transference, self-blame, denial, mini-misation, sleeping, eating, wishful thinking and keeping to oneself.LIMITATIONSThe limitation in this study was that the researchers were under-graduate students and novice researchers. This could have affected the analysis and information extracted during the integrative review. However, having the project supervised by a more experienced researcher mitigated this limitation.RECOMMENDATIONSBased on the researchers’ analysis, the following recommendations are made:• Health science and other professional degrees are associated with an increased academic workload, due to the clinical train-ing component. Therefore, there is a need for health science disciplines to review their course structures, and the number and timing of assessments, to reduce the stress on students. • Interventions to support students should be emphasised for first year orientation programmes. Thereafter student support services could send out electronic stress questionnaires to students, which could be conducted biannually, at the begin-ning and end of the academic year, allowing support services to screen for any students who may be struggling, and ensure timely support, nuanced to the students’ needs39. Students who experienced the death of a patient can be referred to a psychologist or student counsellor to assist them in coping with this loss. Research has shown that students do experi-ence stress because of their patients’ suffering and death49. Some believe that academic support should be compulsory for health science students, who are often reluctant to at-tend sessions voluntarily50. Moreover, it is recommended that student support services must address the academic and emotional needs of students, and support must be nuanced to the students’ needs.• Workshops aimed at addressing budgeting skills would be useful in assisting students to better manage their finances and reduce financial stress.• The clinical supervisor-student bond may be strengthened during annual workshops for supervisors to ensure students are well supported during their fieldwork blocks. King, Edling-ton and Williams51, suggested that both the student and the clinical supervisor require training to ensure effective clinical supervision.CONCLUSION The purpose of this integrative review was to determine the sources of stress for health science students in undergraduate programmes, and strategies that they used to cope with stress as reported in international published peer reviewed articles. The sources of stress included academic demands, social and personal factors, financial worries, and stress as a result of clinical training. Other stress-inducing factors included environmental influences, psychosocial factors, and feelings of inadequacy in relation to professional knowl-edge. Most students reported the use of problem-focused coping in response to increased stress, while others used maladaptive coping styles, such as substance use and other avoidant behaviours. The multitude of stressors and maladaptive coping necessitates the need for support to be timeously accessed by students. The implementa-tion of online semester check-ins would be beneficial in allowing support services to identify students requiring additional support. Students’ mental health are predictors for how well they will cope in tertiary education, and specifically with the demands of the health science programmes. It is imperative they access timely support, nuanced to their academic and personal needs.AUTHOR CONTRIBUTIONSOdell Chetty and Robyn Henderson conducted the initial article search, information extraction, data analysis, writing, editing and submission of the article. Thavanesi Gurayah conceptualised and supervised the project and edited the final manuscript.Acknowledgements The authors wish to acknowledge the other members of their research team Lerato Xulu, Nelly Zulu, Zama Mzobe and Nqobile Mhlope who assisted in conducting the review. REFERENCES:1. Chan R. Understanding the purpose of higher education: An analysis of the economic and social benefits for completing a college degree. Journal of Education Policy, Planning and Administration, 2016; 6(5): 1-40. https://www.researchgate.net/publication/305228497_Understanding_the_purpose_of_higher_education_An_analy-sis_of_the_economic_and_social_benefits_for_completing_a_col-lege_degree 2. 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CopyrightofSouthAfricanJournalofOccupationalTherapyisthepropertyofOccupationalTherapyAssociationofSouthAfricaanditscontentmaynotbecopiedoremailedtomultiplesitesorpostedtoalistservwithoutthecopyrightholder’sexpresswrittenpermission.However,usersmayprint,download,oremailarticlesforindividualuse.
The content in this document is intended for general informational purposes only and is not a substitute for professional medical advice or treatment for specific medical conditions. No professional relationship is implied or otherwise established by reading this document. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Many of the resources referenced are not affiliated with Craig Hospital. Craig Hospital assumes no liability for any third party material or for any action or inaction taken as a result of any content or any suggestions made in this document and should not be relied upon without independent investigation. The information on this page is a public service provided by Craig Hospital and in no way represents a recommendation or endorsement by Craig Hospital.  Craig Hospital 2015 All Rights Reserved Rev. 1/2015 Publication # 806 Page 1 of 4 Stress Management, Stress Reduction, and Relaxation What Is Stress and How does it Affect Me? Stress is in inescapable fact of life. We’re bombarded daily with challenges ranging from traffic to bills — from deadlines to last minute changes. We’re also faced with a variety of personal problems such as health concerns, poor nutrition, and aging. And we have to deal with our thoughts, which often make us question the wisdom of our decisions, performance, and worth. The answer to why some people manage much better than others with these universal problems has to do with how stress works. Stress is not unexpected bills, a traffic accident, a canceled flight, or getting laid off from your job. Rather, stress results from interpreting those events as dangerous, difficult, painful, or “unfair,” and/or feeling that you don’t have the resources to cope with them. The fact that stress is the result of how we interpret events explains why some people fall apart during a crisis, while others, facing exactly the same situation, rise to the occasion and perform admirably. As Shakespeare wrote: “Things aren’t good or bad, it’s thinking makes them so.” Reacting to various events as threats triggers the “fight or flight” response, which speeds up the heart rate, breathing rate, raises blood pressure, metabolism, and muscle tension. In addition, various chemicals are released that slow down digestion, growth, reproduction, and tissue repair. In other words, chronic stress can be very harmful to your health. The good news in all this is that if stress is the result of how we interpret and react to events, by being more conscious of those events that trouble and upset us and changing the way we interpret and react to them, we can change our levels of stress.
Stress Management, Stress Reduction, and Relaxation  Craig Hospital 2015 All Rights Reserved Rev. 1/2015 Publication # 806 Page 2 of 4 What is Stress Reduction and Relaxation? Simply put, stress management and stress reduction methods include a variety of coping tools used to recognize and assess stress and interpret it in a more positive way. They are tools that are used to release stress and reduce its negative effects on our lives. In general, stress management consists of examining the five steps of the stress process shown below, and then altering your response in order to interrupt the process and reduce the effects. The stress response pattern looks like this: Life Situation: caught in traffic jam; late for work Perceived as Stress: I’m incompetent; boss will be angry; lose promotion Emotional Arousal: irritable, paranoid; poor concentration; overly sensitive Physiological Arousal: elevated heart rate and breathing; sweating Consequences: loss of tranquility, poor performance; stinky Problems arise because people often respond to these emotional stressors with the physical responses mentioned earlier — increased heart and breathing rate, muscle tension and lots of adrenaline — instead of using productive and useable emotional responses. In the process, they usually end up creating both physical and emotional problems. The solution begins with a close examination and keeping track of those situations that cause you stress. Once various situations are identified, knowing exactly how you react and what the consequences are enable you to alter your response in order to maintain a more even keel. In almost every case, effective stress management involves slowing down and staying in the moment, rather than worrying and jumping into the future or remembering and falling back into the past. Many find it useful to determine exactly why certain situations cause them stress, as their assumptions may be ill-founded. But knowing why isn’t always enough. The following methods can help with coping. Common and Popular Stress Management Tools Meditation Meditation consists of attempting to focus attention on one thing — a word, an image, simply counting slowly, or focusing solely on the flow of breath in and out of the body — to the exclusion of all other thoughts. By focusing on only one thing, it’s much more difficult to worry, be afraid, hateful, or angry. This type of focus is also helpful in choosing what thoughts to focus on, as well as insight into persistent patterns of thinking. Yoga Yoga can be done from a chair and not only involves the same level of concentration and focus as meditation, but also improves flexibility — a plus for people with SCI.
Stress Management, Stress Reduction, and Relaxation  Craig Hospital 2015 All Rights Reserved Rev. 1/2015 Publication # 806 Page 3 of 4 Visualization and guided imagery This uses the power of the mind to achieve overall physical relaxation, often by visualizing very detailed peaceful and relaxing scenes. Several studies have documented increased athletic performance with the regular use of visualization. Actors regularly visualize themselves performing before they ever take the stage. More importantly, visualization has been practiced, studied and used with success in people with cancer, chronic pain, and those with headaches, muscle spasms and general or specific anxieties. Progressive relaxation This is the process of methodically tensing and relaxing specific muscle groups throughout the body, beginning with the head and working down, or with the feet and working up. The tensing phase normally lasts five to ten seconds, followed by 20 to 30 seconds of conscious and focused relaxation of the same muscle group. Controlled breathing Controlled breathing focuses on the process of breathing – the full inhalation, the expansion of the belly and the lungs, exhalation, the contraction of the midsection, and all the various physical sensations and sounds that accompany breathing that we normally ignore. Improper or shallow breathing can lead to higher levels of anxiety, depression, muscle tension, fatigue, and headaches. Deep, controlled breathing increases the amount of oxygen taken into the lungs, as well as the amount of carbon dioxide expelled from them, helping the body and mind to work more efficiently and effectively. Various controlled breathing methods are often used for one to five minutes, three to five times a day, or as needed to relieve symptoms or stress. Spinal cord injury may affect full and complete breathing capacity, either directly or as a result of poor posture. Practicing deep, controlled breathing may require reclining or lying down for some, but the benefits of managing stress, calming the body and the mind, and increasing oxygen flow are well worth the effort. These are all very brief descriptions of rather complicated and involved stress management techniques. If you want to learn more it’s recommended that you take a course, or at least read a book or two on a specific technique in order to gain any significant results. Are Stress Management and Stress Reduction Widely Used? The various stress management tools outlined in this brochure – yoga, meditation, controlled breathing, visualization, guided imagery – are used by millions throughout the world as they have been for thousands of years. Some have their origins in the Middle East or Asia, and some are associated with various religions, even though they are now commonly practiced by people of all faiths.
Stress Management, Stress Reduction, and Relaxation  Craig Hospital 2015 All Rights Reserved Rev. 1/2015 Publication # 806 Page 4 of 4 What are the Benefits? There are numerous benefits to be had from reducing and managing stress, beginning with an increase in concentration, a decrease in anxiety, and a reduction in pain. Effectively managing stress often leads to improved health. Stress management programs are drug-free. Most importantly, stress management programs put you in charge and give you a sense of control, which leads to enhanced self-esteem, less likelihood of depression, and an overall improvement in quality of life. The primary cost consideration is an investment of your time. What About Stress Management, Stress Reduction, and Spinal Cord or Brain Injury? All those things which non-disabled individuals find stressful — financial difficulties, employment problems, health problems, issues of dependency, last minute changes, lack of control – are often more prevalent for people with spinal cord or brain injury. That’s the bad news. The good news is that stress management and reduction are possible. What’s The Cost? Many, if not most, stress reduction and stress management programs and methods are either low cost or free. However, stress reduction and stress management programs do require time, effort and commitment, often over a lifetime. In our fast paced lives, we’ve grown accustomed to the immediate gratification of buying things to improve our lives, whether it’s cable and big screen TV, vacations, microwaves, or a prescribed medication for symptom relief. Stress management and stress reduction are no different. “What do you mean I have to do something?” people ask, “can’t I just take a pill?” The short answer is “No.” Be prepared — stress management and stress reduction will require time and effort in order to produce results. How Can I Learn More? You can usually learn basic techniques and principles of stress management for the price of a book or two or an educational audio or video tape. Check out your local library, community or adult education center, community colleges, or recreation or wellness centers, as they often offer various stress management classes. The most important part of any stress reduction and management program is practice and regularity, regardless of whether it’s meditation or counseling or yoga or visualization. All these methods work, but many require months of persistent practice before they can be fully effective and appreciated.
p | 1stress managementQuick Stress ReliefLearn how to use the power of your senses to relievestress on the spot and stay calm, productive, andfocused—no matter what life throws at you.What is the fastest way to relieve stress?There are countless techniques for managing stress. Yoga, mindfulness meditation, andexercise are just a few examples of stress-relieving activities that work wonders. But in theheat of the moment, during a high-pressured job interview, for example, or a disagreementwith your spouse, you can’t just excuse yourself to meditate or take a long walk. In thesesituations, you need something more immediate and accessible.
p | 2One of the speediest and most reliable ways to stamp out stress is to engage one or more ofyour senses—sight, sound, taste, smell, touch—or through movement. Since everyone isdifferent, you’ll need to do some experimenting to discover which technique works best foryou—but the payoff is huge. You can stay calm, productive, and focused when you know howto quickly relieve stress.Social interaction is your body’s most evolved and surefire strategy for regulating thenervous system. Talking face-to-face with a relaxed and caring listener can help you quicklycalm down and release tension. Although you can’t always have a pal to lean on in themiddle of a stressful situation, maintaining a network of close relationships is vital for yourmental health. Between sensory-based stress relief and good listeners, you’ll have yourbases covered.Tip 1: Recognize when you’re stressedIt might seem obvious that you’d know when you’re stressed, but many of us spend so muchtime in a frazzled state that we’ve forgotten what it feels like when our nervous systems arein balance: when we’re calm yet still alert and focused. If this is you, you can recognize
p | 3when you’re stressed by listening to your body. When you’re tired, your eyes feel heavy andyou might rest your head on your hand. When you’re happy, you laugh easily. And whenyou’re stressed, your body lets you know that, too. Get in the habit of paying attention toyour body’s clues.Observe your muscles and insides. Are your muscles tense or sore? Is your stomachtight, cramped, or aching? Are your hands or jaw clenched?Observe your breath. Is your breathing shallow? Place one hand on your belly, the otheron your chest. Watch your hands rise and fall with each breath. Notice when you breathefully or when you “forget” to breathe.Tip 2: Identify your stress responseInternally, we all respond the same way to the “fight-or-flight” stress response: your bloodpressure rises, your heart pumps faster, and your muscles constrict. Your body works hardand drains your immune system. Externally, however, people respond to stress in differentways.The best way to quickly relieve stress often relates to your specific stress response:Overexcited stress response: If you tend to become angry, agitated, overly emotional, orkeyed up under stress, you will respond best to stress relief activities that quiet you down.Underexcited stress response: If you tend to become depressed, withdrawn, or spacedout under stress, you will respond best to stress relief activities that are stimulating andenergizing.The immobilization or “frozen” stress responseDo you freeze when under stress? The immobilization stress response is often associatedwith a past history of trauma. When faced with stressful situations, you may find yourselftotally stuck and unable to take action. Your challenge is to break free of your “frozen” stateby rebooting your nervous system and reactivating the body’s natural “fight-or-flight” stressresponse. Physical movement that engages both your arms and legs, such as walking,swimming, running, dancing, climbing, or tai chi, can be particularly helpful. As you move,focus on your body and the sensations you feel in your limbs rather than on your thoughts.This mindfulness element can help your nervous system become “unstuck” and move on.
p | 4Tip 3: Bring your senses to the rescueTo use your senses to quickly relieve stress, you first need to identify the sensoryexperiences that work best for you. This can require some experimentation. As you employdifferent senses, note how quickly your stress levels drop. And be as precise as possible.What is the specific kind of sound or type of movement that affects you the most? Forexample, if you’re a music lover, listen to many different artists and types of music until youfind the song that instantly lifts and relaxes you.Explore a variety of sensory experiences so that no matter where you are, you’ll always havea tool to relieve stress.
p | 5The examples listed below are intended to be a jumping-off point. Let yourimagination run free and come up with additional things to try. When you find theright sensory technique, you’ll know it!SightLook at a cherished photo or a favorite memento.Use a plant or flowers to enliven your work space.Enjoy the beauty of nature: a garden, the beach, a park, or your own backyard.Surround yourself with colors that lift your spirits.Close your eyes and picture a place that feels peaceful and rejuvenating.SmellLight a scented candle or burn some incense.Experiment with different essential oils.Smell the roses or another type of flower.Enjoy clean, fresh air in the great outdoors.Spritz on your favorite perfume or cologne.TouchWrap yourself in a warm blanket.Pet a dog or cat.Hold a comforting object (a stuffed animal, a favorite memento).Give yourself a hand or neck massage.Wear clothing that feels soft against your skin.TasteSlowly savoring a favorite treat can be very relaxing, but mindless eating will only add toyour stress and your waistline. The key is to indulge your sense of taste mindfully and inmoderation.Chew a piece of sugarless gum.Indulge in a small piece of dark chocolate.Sip a steaming cup of coffee or tea or a refreshing cold drink.Eat a perfectly ripe piece of fruit.Enjoy a healthy, crunchy snack (celery, carrots, or trail mix).
p | 6MovementIf you tend to shut down when you’re under stress or have experienced trauma, stress-relieving activities that get you moving may be particularly helpful.Run in place or jump up and down.Dance around.Stretch or roll your head in circles.Go for a short walk.Squeeze a rubbery stress ball.SoundSing or play a favorite tune.Listen to calming or uplifting music.Tune in to the soundtrack of nature—crashing waves, the wind rustling the trees, birdssinging.Buy a small fountain, so you can enjoy the soothing sound of running water in yourhome or office.Hang wind chimes near an open window.Vocal toningAs strange as it may sound, vocal toning is a special technique that reduces the stresshormones adrenaline and cortisol. Try sneaking off to a quiet place to spend a few minutestoning before a meeting with your boss and see how much more relaxed and focused youfeel. It works by exercising the tiny muscles of the inner ear that help you detect the higherfrequencies of human speech that impart emotion and tell you what someone is really tryingto say. Not only will you feel more relaxed in that meeting, you’ll also be better able tounderstand what he’s trying to communicate.How to tone: Sit up straight and simply make “mmmm” sounds with your lips together andteeth slightly apart. Experiment by changing the pitch and volume until you experience apleasant vibration in your face and, eventually, your heart and stomach.
p | 7Tip 4: Find sensory inspirationHaving trouble identifying sensory techniques that work for you? Look for inspirationaround you, from your sights as you go about your day to memories from your past.Memories. Think back to what you did as a child to calm down. If you had a blanket orstuffed toy, you might benefit from tactile stimulation. Try tying a textured scarf aroundyour neck before an appointment or keeping a piece of soft suede in your pocket.Watch others. Observing how others deal with stress can give you valuable insight.Baseball players often pop gum before going up to bat. Singers often chat up the crowdbefore performing. Ask people you know how they stay focused under pressure.Parents. Think back to what your parents did to blow off steam. Did your mother feel morerelaxed after a long walk? Did your father work in the yard after a hard day?The power of imagination. Once drawing upon your sensory toolbox becomes habit, trysimply imagining vivid sensations when stress strikes. The memory of your baby’s face willhave the same calming or energizing effects on your brain as seeing her photo. When youcan recall a strong sensation, you’ll never be without a quick stress relief tool.Take a break from technologyTaking a short hiatus from the television, computer, and cell phone will give you insight onwhat your senses respond to best.Try tuning into relaxing music instead of talk radio during your commute. Or try ridingin silence for 10 minutes.Stuck in a long line at the grocery store? Instead of talking on your phone, take amoment to people watch. Pay attention to what you hear and see.Instead of checking email while waiting for a meeting, take a few deep breaths, lookout the window, or sip some tea.While waiting for an appointment, resist the urge to text and give yourself a handmassage instead.
p | 8Tip 5: Make quick stress relief a habitIt’s not easy to remember to use your senses in the middle of a mini—or or not somino—crisis. At first, it will feel easier to just give into pressure and tense up. But with time,calling upon your senses will become second nature. Think of the process like learning todrive or play golf. You don’t master the skill in one lesson; you have to practice until itbecomes second nature. Eventually you’ll feel like you’re forgetting something if you don’ttune into your body during challenging times. Here’s how to make it habit:Start small. Instead of testing your quick stress relief tools on a source of major stress,start with a predictable low-level source of stress, like cooking dinner at the end of a longday or sitting down to pay bills.Identify and target. Think of just one low-level stressor that you know will occur severaltimes a week, such as commuting. Vow to target that stressor with quick stress relief everytime. After a few weeks, target a second stressor and so on.Test-drive sensory input. If you are practicing quick stress relief on your commute towork, bring a scented handkerchief with you one day, try music another day, and try amovement the next day. Keep experimenting until you find a clear winner.Have fun with the process. If something doesn’t work, don’t force it. Move on until youfind what works best for you. It should be pleasurable and noticeably calming.Talk about it. Telling friends or family members about the stress-relief strategies you’retrying out will help you integrate them into your life. As an added bonus, it’s bound to startan interesting conversation: everyone relates to the topic of stress.Tip 6: Practice wherever you areThe best part of sensory-based strategies is the awareness that you have control. No matterwhere you are or what you’re doing, quick stress relief is within arm’s reach.Quick stress relief at homeEntertaining. Prevent pre-party jitters by playing lively music. Light candles. The flickerand scent will stimulate your senses. Wear clothes that make you feel relaxed and confident.Kitchen. Ease kitchen stress by breathing in the scent of every ingredient. Delight in the
p | 9delicate texture of an eggshell. Appreciate the weight of an onion.Children and relationships. Prevent losing your cool during a spousal spat by squeezingthe tips of your thumb and forefinger together. When your toddler has a tantrum, rub lotioninto your hands and breathe in the scent.Sleep. Too stressed to snooze? Try using a white noise machine for background sound or ahumidifier with a diffuser for a light scent in the air.Creating a sanctuary. If clutter is upsetting, spend 10 minutes each day to tidy. Displayphotos and images that make you feel happy. Throw open the curtains and let in naturallight.Quick stress relief at workMeetings. During stressful sessions, stay connected to your breath. Massage the tips ofyour fingers. Wiggle your toes. Sip coffee.On the phone. Inhale something energizing, like lemon, ginger, peppermint. While talking,
p | 10stand up or pace back and forth to burn off excess energy, or take calls outside whenpossible.On the computer. Work standing up. Do knee-bends in 10-minute intervals. Suck on apeppermint. Sip tea.Lunch breaks. Take a walk around the block or in the parking lot. Listen to soothing musicwhile eating. Chat with a colleague.Your workspace. Place family photos on your desk or mementos that remind you of yourlife outside the office.Quick stress relief on the goIn traffic. Play music or listen to an audiobook. Take a different route to see somethingnew. Do neck-rolls at stoplights. Sing in the car to stay awake and happy.Public transportation. Take a break from reading, cell conversations, and music to tuneinto the sights and sounds around you. Try noticing something new, even if you’re on thesame old bus ride.Running errands. Wear a special perfume or lotion so you can enjoy it while you rush fromplace to place. Carry a stress ball in your pocket. Take a mental “snapshot” or “postcard” ateach destination.Waiting in lines. Instead of worrying about time slipping away, focus on your breathing.People watch. Chat with the person ahead of you. Chew a stick of minty gum.Authors: Jeanne Segal, Ph.D., Melinda Smith, M.A., and Lawrence RobinsonLast updated: September 2020Get more help40 Ways to Relax in 5 Minutes or Less (Greatist)
p | 11Relaxation – Tips and exercises to help you relax, some of them quickly. (Mind)
MAJORARTICLESelf-leadershipandstressamongcollegestudents:Examiningthemoderatingroleofcopingskills†SherryA.Maykrantz,PhD,CHESaandJefferyD.Houghton,PhDbaSchoolofHealthSciences,SalisburyUniversity,Salisbury,MD,USA;bWestVirginiaUniversity,Morgantown,WV,USAABSTRACTObjective:Stressremainsamajorhealthconcernamongcollegestudentstoday.Consequently,researchonstudentstressisimperative,frombothanorganizationalandanindividualperspective.Thisresearchstudyexploresthemoderatingroleofcopingskillsontherelationshipbetweenself-leadershipandstressamongcollegestudents.Participants:Datafrom643full-timeundergraduatestudentsattendinga4-yearpublicuniversityinthemid-AtlanticregionwerecollectedinFebruary2017andanalyzedusingamoderatedregressionmodel.Results:Theresultsindicateself-leadershippracticesdoreducestudentstresslevelsandthatthisrelationshipismoderatedbystudentcopingskills.Conclusion:Thefindingsfromthisstudydeepenourunderstandingofhowself-leadershippracticesmaydecreasestudentstressandshowcasesself-leadershipasaneffectivetoolforreducingcollegestudentstress.ARTICLEHISTORYReceived20April2018Revised29June2018Accepted19August2018KEYWORDSCoping;collegestudents;self-leadership;stressAccordingtoleadershipexpertBernardBass,“leadershiphasbeenbuiltintothehumanpsychebecauseofthelongperiodweneedtobenurturedbyparentsforoursurvival.”1Fromthebeginning,welearntofollowtheleadershipofourparentsforthesatisfactionofourbasicneeds,suchasfoodandcom-fort.Aswegrow,othersbegintotaketheplaceofourparentsasourleaders.Inthe1980s,leadershipschol-arstookleadershiptoanewlevelbysuggestingthat,inadditiontotheleadershipthatcomesfromothers,onecanandshouldleadoneself.2Self-leadershipisaprocessofself-influencethroughwhichindividualsleadthemselves.2,3Oneofthegreatestchallengesindividualsfaceinleadingthemselvesistheeffectivemanagementofstress.Stressisdefinedas“amind-bodyarousalthatcan,ononehand,cansaveourlivesandontheother,fatiguebodysystemstothepointofmalfunctionanddisease.”4Stressbecomesnegativewhenitsurpassesourabilitytocopeinahealthymanner.Copingcanbedescribedastheabilitywithwhichonehandlesastressfulevent.5Collegesanduniversitiesacrossthenationarefacingaserioushealthproblem,andstressistheculprit.6Whilestressisinevitable,itisbecom-ingmoreandmoreprevalentamongcollegestudents,creatinganincreasinghealthcrisisatournation’scol-legesanduniversities.7,8Stresscancontributetohealthproblemsdirectlythroughphysiologicaleffectslikesleepdisturbances,9depressionandsuicide,10andrecurringorfrequentillness,orindirectlythroughmaladaptivecopingbehaviorslikesmoking,8drugandalcoholabuse,11,12andovereating.Copingis“consideredtobeofcriticalimportanceindetermin-ingwhetherastressfuleventresultsinadaptiveormaladaptiveoutcomes.”13Giventheseriousconse-quencesofstress,theneedtoreducestresslevelsandstrengthencopingskillsisevident.Inresponse,someresearchershavesuggestedthatself-leadershiphasthepotentialtoreducestressandenhancecoping.14Thepurposeofthecurrentstudyistoexaminethemoder-atingroleofcopingskillsontherelationshipbetweenself-leadershippracticesandstressamongcol-legestudents.Nearlyfourdecadesago,leadershiptheoristsCharlesManzandHenrySimssuggestedthatindivid-ualscan“managetheirownbehaviorsbysettingper-sonalstandards,evaluatingtheirperformanceintermsofthesestandards,andbyself-administratingconse-quencesbasedontheirself-evaluations.”15Insteadofleadersexercisingcontroloverpeople,self-leadershipCONTACTSherryA.Maykrantzsamaykrantz@salisbury.edu,SchoolofHealthSciences,SalisburyUniversity,1101CamdenAvenue,Salisbury,MD21801,USA.†ThedatathatsupportthefindingsofthisstudyareavailablewithrestrictedaccessinZenodo:DOI:10.5281/zenodo.1220415.Accesswillbegranteduponanyreasonablerequestfromeditors,reviewers,orotherresearcherswishingtovalidateorreplicateourfindings.2018Taylor&FrancisGroup,LLCJOURNALOFAMERICANCOLLEGEHEALTH2020,VOL.68,NO.1,89–96https://doi.org/10.1080/07448481.2018.1515759
inspirestheindividualtoexerciseinfluenceoverthemselves.Self-leadershipiscomprisedofthethreedistinctcategoriesofstrategies:behavior-focusedstrat-egies,naturalrewardstrategies,andconstructivethoughtstrategies.16Self-leadershipinvolvesavarietyofself-imposed,behavior-focusedstrategiesdesignedtohelpindividualsshapetheirbehaviorsintheper-formanceofnecessarybutunpleasanttasksthatmaybelackinginintrinsicmotivation.2Self-leadershipalsoentailsself-influencestrategiesthatcapitalizeonthenaturallyrewardingaspectsofataskactivity,2whichimpliesthatindividualsperformtasksnotbecausetheyaretold,butbecausetheygenuinelywantto.Thiseffectivelytranslates“should”into“want”intermsoftaskperformanceandbecomesoneofthemainbuildingblocksofself-leadership.Constructivethoughtstrategiesincludepositiveself-talkandposi-tivementalimagery.16Empiricalresearchfindingsacrossdisciplinesrangingfromorganizationalmanagementtosportpsychologyhaveprovidedconsistentsupportforarelationshipbetweencon-structivethoughtstrategiesandenhancedindividualperformance.16Self-leadershiptheoristshaveadvancedconceptualmodelsexploringthepotentialrelationshipbetweenself-leadershipandstress.Forexample,Lovelaceetal.17advancedamodelsuggestingthatwhenpeopleinhighstressworkenvironmentsengageinself-lead-ershippractices,theywillexperiencemorehealthfulregenerationandengagementleadingtogreaterfeel-ingsofcontrolrelativetotheirtasksituation.Workingalongsimilarlines,Houghtonetal14pre-sentedamodelthatsuggests“thateffectiveemotionalregulationandself-leadership,asmediatedthroughpositiveaffectandself-efficacy,hasthepotentialtofacilitatestresscopingamongstudents.”Althoughtheydidnotempiricallytesttheirmodel,theydidgathersomepreliminaryqualitativedataandcalledforfutureresearcherstoexplorethemodelrelationships.RespondingtotherecommendationsofHoughtonetal.,14Wangetal23foundthatself-leadershipisasso-ciatedwithpositivecopingskillsandisinstrumentalinjudgingstressfulsituations.Althoughthisstudyprovidedgoodsupportforshowcasingtherelationshipbetweenself-leadershipandpositivecoping,itonlyexaminedcoping(problem-focusedandemotional-focusedcopingstrategies)andfallsshortinexploringtherelationshipbetweenself-leadership,coping,andactualstudentstress.Atremendousamountofresearchonstressandcollegestudentshasbeenhighlightedintheliterature.Everysemester,theAmericanCollegeHealthAssociation(ACHA)surveyscollegestudentsfromacrossthenation,measuringanarrayofhealthcon-cerns.TheSpring2016ExecutiveSummaryReportdiscussedasurveyof80,139undergraduatestudentsat137publicinstitutions.18Respondentsreportedstress(33.8%)assignificantlyaffectingtheiraca-demicperformance,whichisdefinedbytheACHAasreceivingalowergradeonanexam,project,orcourse,and/ordroppingorfailingacourse.Thisisa3.8%increasefrom2015.Stresswasrankednum-beroneoutof30healthfactorslistedinthe2016report.Alarmingly,overhalfoftherespondents(63%)reportedusingalcoholtocopewithinthepast30days.Furthermore,respondentsindicatedthattheyfeltoverwhelmed(86%),exhausted(82%),sad(66%),andlonely(60%)withinthepast12months.Collegestudentsuseavarietyofmeanstocope,includingbothadaptiveandmaladaptivecopingstrat-egies.11,19Internetusageinvolvingproblematiconlinebehaviorshasbeenexploredasonetypeofmaladap-tivecopingstrategyusedbycollegestudentstodealwithstress.20Bingedrinking(ie,havingmorethan4–5drinksin2hr)isyetanothermaladaptivebehav-iorthathasbeennotedinseveralstudiesasoneofthemorefavoredwaysthatcollegestudentscopewithstress.11,12,21,22Additionalresearchfindingssuggestthatstudentsoftencopewithstressindependently,insteadofutilizingsocialsupport,whichmayleadtomaladaptivecopingbehaviors.8Whilethereisafairamountofresearchoncop-ingandstresstogether,8,12,13,19thereisverylittleresearchonstressastheoutcome,moderatedbycoping.Inaddition,thereislimitedresearchonpre-dictionsofreducingcollegestudentstressusingcopingskillsasaseparatevariable.Thisstudyaimedtofilltheseidentifiedgapsbyexaminingtherelationshipbetweenself-leadershippracticesandstudentstress,usingcopingskillsasamoder-ator.Basedonthetheoreticalandempiricalbasesreviewedabove,weadvancethefollowingresearchhypotheses:H1:Therewillbeanegativestatisticallysignificantrelationshipbetweenself-leadershippracticesandstudentstress.H2:Therewillbeanegativestatisticallysignificantrelationshipbetweenstudentcopingskillsandstudentstress.H3:Studentcopingskillswillmoderatetherelationshipbetweenself-leadershippracticesandstudentstress.90S.A.MAYKRANTZANDJ.D.HOUGHTON
Asummaryofourconceptualmoderationmodeloftherelationshipsbetweenself-leadership,studentstressandcopingisshowninFigure1.MethodsParticipantsAfterIRBapproval,undergraduatestudentsfromapublic4-yearuniversitylocatedinthemid-Atlanticregionwereinvitedviaemailtoparticipateinthisstudy.Atotalof712completedtheonlinesurveyinFebruary2017;however,69casesweredeletedduetomissingdata,resultinginfinalsamplesizeof643.Themajorityoftherespondentswerefemale(76%)whiletheremaining24%weremale.MeasuresSelf-leadership.The9-itemAbbreviatedSelf-LeadershipQuestionnaire(ASLQ)24wasusedtomeas-ureself-leadershippractices.TheASLQisashortver-sionofthe35-itemRevisedSelf-LeadershipQuestionnaire(RSLQ),25whichisthemostwidelyusedandempiricallyvalidatedself-leadershipscale.26TheASLQhasdemonstratedgoodreliabilityandcon-structvaliditythatarecomparabletothepsychometricpropertiesoftheoriginalRSLQ.27,28Sampleitemsinclude:“Iestablishspecificgoalsformyperform-ance,”“WhenIhavesuccessfullycompletedatask,IoftenrewardmyselfwithsomethingIlike,”and“ItrytomentallyevaluatetheaccuracyofmyownbeliefsaboutsituationsIamhavingproblemswith.”TheASLQshowedaCronbachalphaof.73forthecur-rentsample.Coping.The28-itemBriefCOPEInventory29wasusedtomeasurecopingstrategies,withanoverallCronbachalphaof.79forthecurrentsample.However,aftereightitemsweredeletedthefromtheBriefCOPEinventoryduetotherelevanceofthequestions,theCronbachalphadroppedfrom.79to.76.TheBriefCOPEInventoryisashortversionofthe60-itemCOPEinventory,30whichhasbeenusedsuccessfullyinasubstantialnumberofhealth-relatedstudies.29EmpiricalresearchsuggeststhattheBriefCOPEscalecomparesfavorablywiththeoriginalinventoryandisanappropriatemeasureofcopingbehaviors.31BothinventoriesassesscopingbehaviorsacrossfourteendimensionsincludingPositiveReframing,SubstanceAbuse,andSelf-Blame.Sampleitemsinclude:“I’vebeentryingtoseeitinadifferentlight,tomakeitseemmorepositive,”“I’vebeenusingalcoholorotherdrugstohelpmegetthroughit,”and“I’vebeencriticizingmyself.”Studentstress.The10-itemPerceivedStressScale,32whichmeasuresstress-relatedthoughtsandfeelingswithinthepast30days,wasusedtomeasurestudentstresslevels.ThePSSisthemostwidelyusedstressscaleinsocialscienceresearchandconsistentlydemonstratesstrongreliability,validity,andmeasure-mentinvariance.33ThescalereflectedaCronbachalphaof.87inthecurrentsample.Sampleitemsinclude:“Inthelastmonth,howoftenhaveyou…feltthatyouwereunabletocontroltheimportantthingsinlife?”“…feltnervousandstressed?”and“…feltconfidentaboutyourabilitytohandleyourpersonalproblems?”AllsurveyquestionsemployedaLikert-typescaleresponse.DataanalysisWeusedSPSS24withtheadd-onPROCESSmacrototestourhypotheses.34Morespecifically,weusedamoderatedregressionanalysisasthemeanstoempir-icallytesthowthemoderatingvariable(copingskills,M)strengthenstherelationshipbetweenself-leader-ship(X)andstudentstress(Y).Wemeancenteredourvariables,creatingaconditionedvalue,whichisusefulintheinterpretationofthecoefficients.35Mulitcollinearitywasassessedbyscanningacorrel-ationmatrixofthepredictingvariablesinordertoseeifanyofthemwerehighlycorrelated,whichtheywerenot.Inaddition,acollinearitydiagnostictestwasruninSPSStoexaminethevarianceofinflation(VIF).TheresultsconfirmedcollinearitywasnotaproblembecausetheVIFwasverycloseto1andclearlylessthan10.36ResultsTable1showsdescriptivestatistics,reliability,andPearsoncorrelationsforourstudyvariables.Table2displaystheresultsofourmoderatedregression,whichwasusedtotestthehypotheses.Theoverallmodelwassignificant,F(3,639)¼14.8,p<.001,Figure1.Conceptualdiagramofthemoderationmodel.JOURNALOFAMERICANCOLLEGEHEALTH91
R2¼76.Theinteractionwasaddedtothemodel,F(3,639)¼5.97,p<.05,DR2¼01,resultingina1%changeinthemodel.Ourresultsexplain7.6%ofthevarianceduetothevariablesself-leadership,coping,andtheirinteraction.Hypothesis1proposedthattherewouldbeanega-tivestatisticallysignificantrelationshipbetweenself-leadershippracticesandstudentstress.Asimplemod-eratedregressionwasconductedtotestX(self-leader-ship)onY(studentstress),whichrevealedasignificantrelationship,b¼–.143,t(3,639)¼–3.21,p<.001,asshowninTable2.Consequently,Hypothesis1wassupported,withtheresultsindicat-inganegativestatisticallysignificantrelationshipbetweenself-leadershipandstudentstress.Hypothesis2proposedthattherewouldbeanegativestatisticallysignificantrelationshipbetweenstudentcopingandstudentstress.WetestedthesimpledirecteffectofM(coping)onY(studentstress)andfoundasignificantrelationship,b¼.134,t(3,639)¼6.16,p<.000,asshowninTable2.However,Hypothesis2wasnotsupported.Contrarytoourprediction,theresultsindicatedahighlysignificantpositiverelationshipbetweencopingandstudentstress.Hypothesis3pro-posedthatcopingskillswouldmoderatetherelation-shipbetweenself-leadershippracticesandstudentstress.Hypothesis3wassupported,asshowninTable2,whichrevealsaninteractioneffectofXM(self-leadershipcoping)b¼–.012,t(3,639)¼–2.44,p<.014,indicatingthattherelationshipbetweenself-leadershippracticesandstudentstresswasmoderatedbycopingskills.CommentOurfindingsshowanegativestatisticallysignificantrelationshipbetweenself-leadershippracticesandstu-dentstress.Theimportanceofself-leadershipasapotentialtoolformanagingstudentstressisessentialatatimewhenstresslevelsaresteadilyincreasingacrosscollegecampusesnationwide.6,9,18Previousresearchhasestablishedthattherearemanybenefitsrelatedtounderstandingstudentstress.6,9Self-leader-shiptheoryprovidesausefulframeworkforexplainingtherelationshipbetweenself-leadershipandstudentstress,suggestingthatwhenself-leader-shippracticesareused,studentstresslevelsmaybesignificantlyreduced.Ourstudyisamongthefirsttoexaminetherelationshipbetweenself-leadershipandstudentstress.Stressingeneralisverycomplex,butforcollegestudentsitisevenmorecomplexandcanbedetrimentaltotheirhealth.6,9Self-leadershipfacili-tatesmoreandbettercontrol,andwhenstudentshavetheabilitytocontroltheirsurroundingsandtheirownoutcomes,theyaremorelikelytobeabletoeffectivelymanagetheirownstresslevels.Wealsoexploredthehypothesisthattherewouldbeanegativerelationshipbetweencopingskillsandstudentstress.Previousresearchsupportsthishypothesizedrelationship,suggestingthathighcopingskillswouldresultinlowerstudentstress.13However,ourresultsdidnotsupportthishypothesis.Indeed,ourfindingsshowedapositivestatisticallysignificantrelationshipbetweencopingskillsandstudentstress.Essentially,whencopingskillsarehigh,thenhighstresslevelsarereported.Thisfindingcomesasasur-priseandpointstowardtheimportanceinunder-standingthedifferenttypesofcopingskills.Highlevelsofcopingskillscouldindicateeitheradaptive(good)ormaladaptive(bad)copingskills,withthelatterpotentiallyleadingtohigherstresslevels.Understandingcopingskillsinrelationtostudentstressisnotonlytimelybutalsocrucialatatimewhenstresslevelsarerisingandmaladaptivecopingmechanismsseemtobemorewidelyacceptable.Forexample,arecentstudyexaminedcopingstylesamongcollegestudentsanddiscoveredmaladaptivecopingwasthestrongestpredictorofstress,depression,andTable1.Descriptivestatistics,reliability,andPearsoncorrela-tions(n¼643).VariablesMeanStd.deviationCronbach’salphaCorrelationsSLCopingStress1.Self-leadership36.774.21.731–.230–.0841.Coping46.677.92.765.230–.2161.Stress23.164.18.873–.084.216–p<.01.Table2.Modelsummaryandmoderationregression(n¼643).VariablebSEBtpSelf-leadership–.143.044–3.21.001Coping.134.0216.16.000Interaction–.012.005–2.44.014R2.076.000F14.8DR2.010.014DF5.97p<.05.p<.01.p<.00192S.A.MAYKRANTZANDJ.D.HOUGHTON
anxiety.19Thisstudywasinstrumentalinexposingthedangersofmaladaptivecopingonthedevelopingmindsofyoungcollegestudentsandhighlightedtheideathattransitioningtocollegerequirescertaindevelopmentalskillsformanagingnewtasksandnewsurroundings.Collegestudentswhoaren’tequippedwiththeappropriatecopingskillstohandletheirnewlyacquiredself-independencearelikelytoexperi-encehigherstresslevels.Lookingatthesefindingsfromapracticalstandpoint,itseemslikelythatthemorestudentsdealwithstressinanunhealthyormaladaptiveway,suchasblamingandcriticizingthemselves,themorestresstheywillexperience.Likewise,consistentwiththefindingsofNobilingandMaykrantz,37studentswhodealwithstressbyusingalcoholanddrugstocope(maladaptivecoping)willusuallyexperiencemorestress.Ourthirdandfinalhypothesiscontendedthatcopingskillswouldmoderatethestrengthoftherela-tionshipbetweenself-leadershipandstudentstressandtheresultsindicatedthatitdid.AsproposedinFigure2,ourfindingsindicatethattherelationshipbetweenself-leadershipandstressmaybedependentuponthelevelofcopingskills.Whencopingskillsarelow,thereislittlechangeintherelationshipbetweenself-leadershipandstudentstresslevels.However,whenself-leadershipisinvolved,stresslevelsdecline.Infact,thelowestreportedstresslevelsoccurwhenlowcopingskillsarecoupledwithhighself-leadership.Foraveragecopingskills,therewasanominalchangeintherelationshipbetweenself-leadershipandstudentstress.Finally,highcopingskillsshowedthestrongestrelationship,indicatingthathighcopingskillssignifi-cantlyincreasestudentstresslevels.Studentstresslev-elsareatthehighestwhenhighcopingskillsarereportedandtherelationshipbetweenself-leadershipandstressismoresignificantforhighcopingwhencomparedtotheothertwocopinglevels:lowandaverage.Thesefindingsaresignificantbecausetheyindicatethatstudentsarenotcopingwithstresseffectively.Highcopingisassociatedwithhighstresslevels,whichmeanswhenstudentsdonotcopewell,orcopeinineffectiveormaladaptiveways,theirstresslevelsincrease.Indeed,priorresearchsuggeststhatwhenstudentsturntomaladaptivebehaviorssuchasdruguseorbingedrinkingasafavoredcopingstrategy,itonlyspawnsmorestress.12Insummary,ourfindingssuggestthatself-leader-shiptheorymayhelptoexplainhowstresscanbeeffectivelymanagedandreducedamongcollegestu-dents.Ourfindingssurprisinglyrevealedapositiverelationshipbetweencopingskillsandstudentstress,indicatingstudentswhohadthehigheststresslevelsalsohadhighcopingskills.Thisresultmaybeexplainedinpartbymaladaptivecopingprocesses.Studentsmayturntoalcoholordrugsasaneffectivewaytocope,butsuchbehaviorsareconsideredmal-adaptiveanddetrimentaltostudentstressandwell-being.Aprimarypurposeofthisresearchwastoexaminethemoderatingroleofcopingskillsontherelationshipbetweenself-leadershipandstudentstress.Ourfindingsdemonstratedthatcopingskillsdidaltertherelationshipbetweenself-leadershipandstudentstress.Themostsignificantfindinginthemoderatingroleofcopingskillswasthathighcopingskillsresultedinhighstudentstressandsubstantiallyweak-enedtherelationshipbetweenself-leadershipandstu-dentstress.Thefindingsfromthisstudymakeanimportantcontributiontotheexistingliteratureonself-leadership,highlightinghowbeneficialself-leader-shippracticescanbeatreducingstudentstressamongFigure2.Interactioneffects.JOURNALOFAMERICANCOLLEGEHEALTH93
collegestudentsandservingasapotentialcatalystforfutureresearchexploration.TheoreticalimplicationsSelf-leadershiptheorystatesthatindividualswilllead,influence,regulate,andmotivatethemselvestoachievetheirgoal.2,16Ourresultsprovideinsightintohowself-leadershippracticesmayresultinreducingstressamongcollegestudents.Moreover,ourstudyisthefirstintheempiricalliteraturetousecopingskillsasamoderatoronstudentstress,aswellasthefirsttoexaminetherelationshipbetweenself-leadershipandstudentstress.Ourfindingsshowcaseself-leadershipasapotentiallyeffectivetoolformanagingandreduc-ingstudentstress.Self-leadershipofferstheopportun-ityforstudentstotakeresponsibilityforthemselvesandthenotionthatonecanberesponsibleforleadingoneselfthroughlifeisexciting,especiallyintoday’sworld.PracticalimplicationsFromapracticalstandpoint,thisstudyprovidessim-pleexplanationsofhowself-leadershippracticesinflu-encestudentstress.Additionally,thisstudygeneratesusefulexplanationsforvariouscopinglevelsasitrelatestostress.Understandinghowcopingaffectstherelationshipbetweenself-leadershipandstressoffersanopportunityforcollegeadministrators,faculty,andhealthpromotionandwellnessstafftotakeanethicalresponsibilityforthestudents.Oneparticularlyintri-guinginterpretationofourfindingsisthatstudentswhoengageinself-leadershipstrategiesuponenteringcollegemaybemorelikelytomovetowardtheuseofmoreconstructiveandadaptivecopingtechniques,ascomparedtomanyoftheirpeerswhomaybeembrac-ingmoremaladaptivecopingstrategiessuchasbingedrinkinganddruguse.Consequently,ourstudyprovidesincentivesforcollegeleaders,administrators,faculty,andhealthpro-motionandwellnessstafftoimplementself-leadershipinterventionsasameansofdirectlyaddressingstu-dentstressandenhancingpositiveandadaptivecop-ingstrategies.Whileotherinterventionsandprogramsinvolvingmindfulnessandtheevaluationofmind/body38,39havebeensuggestedforhelpingtoreducestressincollegestudents,webelievethatself-leader-shiptraininginterventions,perhapsembeddedinfreshmenorientationorfreshmenexperiencecourses,holdparticularpromiseforbetterequippingstudentsforthestresstheywillencounterduringcollege.Houghtonetal.14providespecificrecommendationsforintegratingself-leadershipintoacademicprogramsandclassesinmanagementandbusiness.Wesuggestthatexposuretoself-leadershipstrategiesasastressmanagementtoolcouldbenefitstudentsacrossmul-tipledisciplines.Indeed,theimplementationofself-leadershipprogramsandinterventionsinacademicinstitutionscouldserveasaprofessionaldevelopmentopportunityforfacultyandstaff,aswellasforstudents.Policiessupportingself-leadershipinterventionstolowerstudentstresslevelsmaybenefitnotonlystu-dentsbutalsotheuniversityaswell.Forexample,loweringstudentstressratesincreasesstudenthealthandperformance,potentiallyincreasingthereturnoninvestmentforthestudent.Aprimarygoalofhighereducationisstudentretentionandimplementingapolicythatencompassestheuseofself-leadershippractices,coupledwithadaptivecopingskills,couldsupportthisgoal.Ourstudysuggeststhatself-leader-shipisrelatedtolowerstudentstressand,moreimportantly,thatself-leadershippracticesinteractwithgoodcopingskills,whichinturnreducesstudentstress.Self-leadershipcouldalsobeeffectiveinfurtherhelpingstudentstodecreaseotherundesirablebehav-iors,suchasself-medicating,bingedrinking,druguse,andpoorstudyskills.Attheinstitutionallevel,self-leadershippracticesamongstudentscouldbeeffectiveinincreasingotherpositiveoutcomesincludingstu-dentretention,academicachievement,andgradu-ationrates.Althoughexaminingtheoverallstressratesofstu-dentswasnotaprimarypurposeofourstudy,thereportedstressratesinourstudydeservesomeatten-tionbecausetheyprovideadditionalincentivefororganizationalleadersinhighereducationalinstitu-tionstobeproactiveinhelpingstudentstoeffectivelydealwithstress.Overall,93.1%ofallrespondentsinourstudyreportedexperiencingsometypeofstresswithinthelastmonth,anextremelyhighfigurebyanystandard.Incontrast,lessthan2%oftherespondentsreportedneverfeelingstressedwithinthelastmonth.Thesefindingsofferanopportunitytodigdeeperintothecauseofhighstress,andmoreimport-antly,intowhatprogramscanbeimplementedtohelpstudentmanagetheirstresslevels.LimitationsTherecommendationsandconclusionsstemmingfromourstudyaresubjecttocertainlimitations.First,copingwasmeasuredasacontinuousmoderating94S.A.MAYKRANTZANDJ.D.HOUGHTON
variable,whichmadeitdifficulttodistinguishadap-tive(good)copingfrommaladaptive(bad)coping.Second,thecross-sectionalresearchdesignonlymeas-uredrespondents’attitudesandbehaviorsrelatedtoself-leadership,copingskills,andstress.Itdidnotaddresspersonalcharacteristics,priorknowledge,and/orexperiences.Nordiditaddressperceivedcompe-tenceorconfidencethatmayaffectindividuallevelsofself-leadershippractices,copingskills,orstresslev-els.Third,thecross-sectionalresearchdesignusedaWeb-basedself-reportingsurveytocollectthedata,whichmayhavepresentedasocialappealbias.Finally,thecross-sectionalresearchdesignusedacon-venientsamplingmethodofcollegestudents;there-fore,theresultsmaynotbegeneralizable.ConclusionBasedonthefindingsfromthisstudy,weadvanceseveralrecommendationsforfutureresearchinvolvingself-leadership,studentstress,andcopingskills.First,consideringthefactthatonly7.6%ofthevariancewasexplainedbyourresearchmodel,futureresearchshouldexploreothervariablesthatcouldexplainadd-itionalvariance.Anothervaluableareaofinquirywouldbetoconductastudyusingqualitativemeth-ods.Qualitativeresearchseekstounderstandpeople’sexperiencesandhowtheirexperienceshelptoexplaincertainphenomena.Expandingonthecurrentresearchbyconductingaqualitativestudywouldallowforamorein-depthunderstandingofhowandwhy:researcherscouldseektodeterminewhystu-dentsarestressedandhowself-leadershipcontributestotheirabilitytomanagetheirstresslevels.Finally,thefindingsfromthisstudycreateanopportunitytoexplorecopinginbothadaptiveandmaladaptiveways(ie,asacategoricalvariable).Severalstudieshaveconcludedthatmaladaptivecop-ingresultsinpooroutcomes,suchasstress,depres-sion,andanxiety.11,19Thecurrentstudyassessedcopingskillsasacontinuousvariable;therefore,theactualbreakdownofadaptiveandmaladaptivecopingbehaviorsisunknown.Additionalresearchcouldbebeneficialinpinpointingthewaysinwhichstudentscopeandcouldaidindevelopinginterventionstocurbtheuseofmaladaptivecoping.Stressstillremainsaprimaryhealthconcernamongcollegestudents;6,9,18therefore,researchaboutstudentstressisimportant.Thisstudyexaminedtheroleofcopingskillsinmoderatingtherelationshipbetweenself-leadershippracticesandstudentstress.Thefindingsfromthisstudydeepenourunderstandingofhowself-leadershippracticesmayeffectivelyreducestudentstressandhighlighttheneedforassistingstudentsindevelopingeffectiveandadaptivecopingskills.Ourresultsshineaspotlightonthehealth-relatedissueofcollegestudentstress,whilesimultaneouslyshowcasingself-leadershipasapoten-tiallyeffectivetoolforreducingstudentstress.Additionally,ourfindingsencouragecollegestudentstorecognizethattheyhavetheabilitytoleadthem-selvesthroughstressfulsituations.Self-leadershipisapractice,askillthatcanbetaught,anditissimpleenoughforanyonetoadopt.Toconclude,self-leader-shiptheoryprovidesanexcellentframeworkforstressreductionthatmaybeemulatedacrossmultipledisci-plinesinhighereducationresultinginhigherlevelsofstudentwell-beingandpersonaleffectiveness.ConflictofinterestdisclosureTheauthorshavenoconflictsofinteresttoreport.Theauthorsconfirmthattheresearchpresentedinthisarticlemettheethicalguidelines,includingadher-encetothelegalrequirements,oftheUnitedStatesandreceivedapprovalfromtheInstitutionalReviewBoardofSalisburyUniversity.References1.BassB.Bass&Stogdill’sHandbookofLeadership:Theory,Research,andManagerialApplications.3rded[e-book].NewYork,NY:FreePress;1990.2.ManzC.Self-leadership:towardanexpandedtheoryofself-influenceprocessesinorganizations.AcadManagRev1986;11(3):585–600.3.NeckC,HoughtonJ.Twodecadesofself-leadershiptheoryandresearch:pastdevelopments,presenttrends,andfuturepossibilities.JManagPsychol.2006;21(4):270–295.4.GirdanoDA,DusekDE,EverlyGS.ControllingStressandTension.SanFrancisco,CA:Pearson-BenjaminCummings;2009.5.FolkmanS,LazarusR.Ananalysisofcopinginamiddle-agedcommunitysample.JHealthSocBehav.1980;21(3):219–239.6.GarettR,LiuS,YoungS.Alongitudinalanalysisofstressamongincomingcollegefreshmen.JAmCollHealth.2017;65(5):331–338.7.C¸ivitciA.Themoderatingroleofpositiveandnega-tiveaffectontherelationshipbetweenperceivedsocialsupportandstressincollegestudents.Estp.2015;15(3):565–573.8.ThomasTM,HodgeFS,Kotkin-JasziS.StressandcopingamongcollegestudentsintheDominicanRepublic.CalJHealthProm.2016;4(1):57–62.9.WallaceD,BoyntonM,LytleL.Multilevelanalysisexploringthelinksbetweenstress,depression,andJOURNALOFAMERICANCOLLEGEHEALTH95
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