CHAPTER FIVE: DISCUSSION
In chapter five, major finding of the study was discussed, testing of hypothesis followed by examination of the data addressing the research question. In addition, the strengths and weakness of the study was explored. Next the implication of the study is presented followed by recommendations for future research and limitations faced as the study being conducted.
5.1 Overview of the study
The study was designed to examine the effectiveness of aromatherapy inhalation for 7 days in reducing depression, anxiety and stress during clinical practice among first year UiTM Nursing students. Numerous research studies have highlighted the relationship between effect of depression, anxiety and stress on nursing student during clinical practice.
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At the beginning of clinical practice period, the researcher introduced the study objective and informed consent process to the first year nursing student of the Universiti Teknologi Mara (UiTM) Puncak Alam. Students who were interested in participating signing an informed consent form. A total of 42 students signed the informed consent and had an opportunity to ask question during initial meeting.
Participants completed the DASS questionnaire (pretest) and were selected into two groups from convenient sampling. As a result, 20 participants in experimental group and 22 in the control group for purposes of data analysis.
5.2 Baseline characteristic of participants
The sample population of this study was composed of first year nursing student from diploma program in UiTM Puncak Alam from both genders who free from taking any relaxation medication. The study groups were homogenous with respect this characteristics, so influenced of these aspect can be generalized for all the nursing students who were evaluated (p = 0.175, p = 0.716).
Summary of the result
Objective number 1
To determine the baseline level of anxiety score in experimental and control group.
The baseline mean score for depression, anxiety and stress in the control group was 16.14±2.765, 13.32±6.658 and 20.36±2.341 respectively and the baseline mean score for depression, anxiety and stress in the experimental group was 15.25±2.359, 13.20±5.917 and 21.65±2.183. An independent t-test at the 95% confidence interval and .05 level of significance was computed to compare the average depression, anxiety and stress score between both groups, and it was concluded that the sampling process effectively produced equivalent groups with respect to depression, anxiety and stress score at baseline, t =-1.112, p = 0.27, t = -0.61, p = 0.952, t = 1.836, p = 0.074. This indicated that the levels of DAS in the two groups were the same at the beginning.
5.3 Baseline DAS score in both group
In this study, for baseline score, both groups was had a moderate level of depression, anxiety and stress (DAS). Possible explanation for the higher prevalence of baseline DAS score among this study population could be due to preparation for practice require more than developing skills in the on campus lab. It entails developing an ability to provide safe and effective care to other human beings in various clinical settings. This components of developing expertise as a student nurse can be very stressful to nursing students and create anxiety.
In health professional education, the clinical perspective is identified as fundamental field for students to learn about practice in the ‘actual’ world (Egan & Jaye, 2009). Prior to the education of health professionals, in particular nurses, has switched from an apprentice-based training model where the regular practice of task and activities are highlighted, to university-based preparation that educated student to understand situation and pursue and wisely use evidence in practice. (Henderson, Cooke, Creedy & Walker, 2012)
The clinical practicum is a significant and essential element of any undergraduate nursing degree. Experiences during clinical placement are effective in shaping student attitudes to learning, practice and professional development (Henderson, Cooke, Creedy & Walker, 2012).
High levels of anxiety can affect student’s learning, performance (Sharif & Armitage, 2004; Moscaritolo, 2009) and in some cases retention within a nursing program (Moscaritolo, 2009). According to Melincavage (2011), students likely to experience anxiety when in any new learning experience and while evolve from novice to expert.
According to Burnad et al. (2008) and Pulido-Martos et al. (2012) they found that witnessing the death of patient, relationship between student and mentor and/or staff, providing care, lack of knowledge and skills, practical and assignment are common clinical stressors among nursing student. Furthermore, nursing student at both novice and experienced level believed that clinical stressor more stressful that academic and external one (related to daily life) and generate more psychosocial responses such as anxiety, cognitive symptoms and depression (Blomberg, 2014). However, previously recognized clinical stress factor are lack of knowledge and professional ability, lack of understanding with history and medical terms, heavy workload, being in an unfamiliar situation, mistakes with patients or handling of technical instruments (Basso Mussoetal.,2008; Chanetal.,2009; Jimenezetal.,2010). This factor might be more frequent in hospital settings. This could clarify why student more likely to experience stress during clinical placement in hospital (Blomberg, 2014).
A study conducted by Goff (2011) found that nursing students has been long perceived by nursing department and students to experience higher levels of stress than other college student. Nursing student believed that they have little leisure time because they needed to study, with assignments and clinical task (Reeve, Shumaker, Yearwood, Riley & Crowell, 2013).
Shriver and Scott-Stiles (2000) found another leading factor to high level of stress is that clinical task demanded nursing student to spend substantial time away from campus and also require them to be responsible for the well being of patients In the other word, these activities take off student from normal social development of their friends (Reeve, Shumaker, Yearwood, Riley & Crowell, 2013).
According to Melincavage (2011), students likely to experience anxiety when in any new learning experience and while evolve from novice to expert.
Objective number 2
To compare mean of post depression, anxiety and stress score level between intervention and control group. The H1o was: There is no difference in level of depression, anxiety and stress score between intervention and control group. An independent t-test at the .05 significance level was computed to compare mean of post depression, anxiety and stress score level between intervention and control group. There was a statistically significant difference in the mean of post depression, anxiety and stress score, t = -2.072, p = 0.045, t = -2.625, p = 0.012, t = -3.232, p = 0.002 respectively. The null hypothesis was rejected. It was concluded that there is a significant difference in level of depression, anxiety and stress score between those students who did not received aromatherapy and those student who received aromatherapy after the intervention.
Both group showed a decreasing in mean score of DAS after the intervention. However, aromatherapy group significantly lower than control group. In the other word aromatherapy was effectively reduced level of DAS in the experimental group after seven day of inhalation. However, although being exposed to water, mean score of control group also show a reduction in posttest compare to pretest. But, it was not significant as aromatherapy group.
Objective no 3
To examine the mean of depression, anxiety and stress score in intervention and control group before and after introducing the intervention. A paired t-test at the 95% confidence interval and .05 significance level was computed to examine mean of depression, anxiety and stress score in experimental and control group before and after introducing the intervention. There was significant different in the mean score of DAS between pretest and posttest among student who received aromatherapy, t = 9.51, p = 0.00, t = 5.39, p = 0.00, t = 11.11, p = 0.00 respectively. The group of student who do not received aromatherapy also significant difference in the mean score of DAS between pretest and posttest t = 4.09, p = 0.001, t = 2.23, p = 0.037, t = 4.87, p = 0.000 respectively. However, mean score of depression and anxiety in the aromatherapy group significantly lower than the control group.
5.4 Reduction of DAS score
In our study, intervention group who received aromatherapy inhalation for 7 days showed significance reduction of DAS score with p value 0.045, 0.012, 0.002. The null hypothesis of the study was rejected because there was a beneficial effects and statistically significant effect from aromatherapy in reducing depression, anxiety and stress score in the sample of nursing students. We accept alternative H1 and H2 since there is difference in level of DAS between intervention and control group and intervention group has showed a reduction in level of DAS after introducing the aromatherapy. Result from this study also supports previous research on effectiveness of aromatherapy (Johnson, 2013).
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This finding is similar to a study conducted among 110 nurses in the hospital. A small bottle containing 3% lavender oil was pinned on their clothes to examine the effectiveness of lavender oil to reduce stress related job among nurses. The study found that there is reduction of the number of stress symptoms for 3 to 4 days in the experimental group after aromatherapy was carried out (Chen, Fang & Fang, 2013).
Another consistent finding from a study by Yuen, Mei and Wing (2014) found that there was significant improvement in the reduction of stress level (p = 0.001) and the reduction of anxiety level (p = 0.044) when compared pre and post aromatherapy inhalation among nursing student in Hong Kong facing final examination.
The result from this study similar to previous study conducted to determine the impact of aromatherapy on the anxiety level of patients experiencing coronary angiography. The study concluded that anxiety level decreased significantly in the intervention group compared with the control group after aromatherapy (P <0.0001) (Tahmasbi, Mahmoodi, Mokhberi, Hassani, Akbarzadeh & Rahnamai, 2012).
However, in this study, participant in control group showed a reduction in the level of DAS after the intervention. This result showed that nursing students seek for other intervention or coping method to overcome the depression, anxiety and stress during clinical practice. A study carried on baccalaureate nursing students in Jordan in their initial period of clinical practice found that needed support and guidance from clinical instructors helped to reduce stress and promote a positive clinical experience. Furthermore, nursing student applied the most common used of coping strategy in relieving stress such as a problem solving behavior followed by staying enthusiastic and conversion of attention from the stressful event to other things was of coping strategies ( Shaban, Khater & Akhu-Zaheya, 2012).
Other than that, another study carried out by Por, Barriball, Fitzpatrick and Roberts (2011) found another factor that relieving stress was emotional intelligence. Emotional intelligence was absolutely related to well-being (p<0.05), problem-focused coping (p<0.05) and perceived nursing competency (p<0.05), and adveresly related to perceived stress (p<0.05). This study also suggested that increased feelings of control and emotional competence assist nursing students to implement active and effective managing strategies when dealing with stress, which in turn enhances their subjective well-being.
The results of this pretest, posttest design study revealed that the effect of aromatherapy oil on depression, anxiety and stress among first year nursing students during clinical practice was statistically significant. Based on previous discussions in this chapter and the rationale for this study, future research is recommended in nursing education with large sample and close room to allow the aroma ventilated in the room. Other as this study has shown the effectiveness of aromatherapy in reducing depression, anxiety and stress among nursing student, this evidence based will be suggested to UiTM Nursing Department to apply this method to nursing student especially during attending clinical practice. Other than that, aromatherapy also can use for nursing student before attending exam especially objective structured clinical examination (OSCE).
5.6 Implication of the study
The implication of the study are that, it can increase awareness to the nursing department about problem of nursing student during clinical practice and the negative effect toward nursing curricular. It also exposed and encourages the lecturer or staff in the nursing department on the utilization of the aromatherapy among nursing student.
The finding of this study can provide a nursing student with stress coping method using aromatherapy. With the use of aromatherapy, student can focus on learning and perform procedure in the clinical area effectively and increasing the quality of patient care.
Furthermore, aromatherapy is a safe, cost-effective, time appreciative intervention that can be implemented in nursing education.
The following limitations were identified during the administration and analysis of the current study to assess the effect of aromatherapy on depression, anxiety and stress among first year nursing students during clinical practice. The purpose of this section is to provide a critical assessment of the study’s limitations.
The primary researcher did not have control over where the duration of inhalation during the intervention due to participants freely to stay in any room instead of their own room. As a result, the duration of inhalation may have contributed to the significance of pre and posttest in the control group. Participant in the control group may stay in the room of participant in experimental group. Thus, the participant was indirectly inhaled the aromatherapy oil. It would be beneficial to place the both group in different block of residential college.
In conclusion, the overall study’s findings were statistically and clinically significant in demonstrating that aromatherapy is able to reduce level of depression, anxiety and stress during clinical practice among first year nursing student. Theses results are similar to those study demonstrated by Johnson (2013) Chen, Fang & Fang (2013) andYuen, Mei & Wing (2014) with the aim to measure the effectiveness of aromatherapy in reducing depression stress and anxiety among nursing student and nursing staff. An extension of this study over a longer time period with a larger sample size and using Randomized Control Trial (RCT) design may provide better results in future studies.
This quasi-experimental study set out to examine the effectiveness of aromatherapy in reducing depression, anxiety and stress during clinical practice among first year nursing student. The result showed that such students perceived moderate level of depression, anxiety and stress prior to attending clinical placement in hospital.
The purpose of reducing depression, anxiety and stress among nursing student is part of strategy to promote effective learning environment especially during attachment in hospital. Depression, anxiety and stress can hinder student’s self confidence to perform nursing care to patient. Other than that, it gives a bad impression toward nursing department as their student unable to show a competency during performs a procedure in the hospital. Since clinical practice is vital element in nursing education, students are believes to apply the basic nursing skills in the clinical areas that enable the application of theoretical knowledge to develop. However, if the students unable to relieve their depression, anxiety and stress, these objectives are unable to be achieve and give a loss to student and nursing department. Therefore, there is a need for nursing department to encourage student to utilize the evidence based-practice especially during attending clinical practice with recommended solution which is aromatherapy inhalation. The research gap has been addressed and the findings showed consistent with previous studies. Research question of this study has been answered and the study null hypothesis was rejected based on the data analysis.
The overall finding showed that aromatherapy has a positive effect in reducing depression, anxiety and stress among nursing student. The finding identified pointed to rejection of study null hypothesis because the use of lavender aromatherapy significantly reduce the level of depression, anxiety and stress in nursing student compared to use of water. Hence, aromatherapy was proven as an effective coping strategy in this study in addition to others in the literature. This result supported previous studies on same setting and population (Johnson, 2013).
It is critical for nursing student to overcome depression, anxiety and stress and aromatherapy can facilitate to relieve these problems. Although sample size in this study was small, there exists quantitative evidence that aromatherapy has a role to play in nursing curricular especially among students attending clinical area. The design and results of this study will hopefully inspired nursing researcher to explore the phenomenon of depression, anxiety and stress during clinical practice and create innovative practices to minimize it in the future. Nursing faculty must continue to create advanced method to facilitate success for student who experience depression, anxiety and stress The increasing diversity of nursing students in age, gender, and ethnicity will continue to grow in future years, and nursing faculty will require more expertise that addresses students holistically (Jeffreys, 2012).
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