Ashley, Dick, Unger, Yu, & Zimmerman

Student Stress and Coping Mechanisms

Student Stress and Coping Mechanisms Michelle Ashley, Elisa Dick, William Unger, Michael Yu, and Rachel Zimmerman Touro University Nevada

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Student Stress and Coping Mechanisms

The experience of stress contains the capacity to cause great harm, or conversely, generate significant productivity. What decides the influence of stress on an individuals life is the effectiveness of ones coping mechanisms. High levels of stress are considered prevalent in college and graduate students, and various coping methods may be viewed to have positive or negative consequences on the students wellbeing. Students in rigorous medical or health-related academic programs often endure stress for long periods of time. As students in a medical and allied-health centered university, we are interested in the experiences of students who have experienced stress and employed a variety of coping mechanisms in response. The purpose of this qualitative research study is to explore student stress and coping mechanisms from the perspective of Touro University Nevada students through a phenomenological approach. The phenomenon of coping is defined as the ways that students deal with stress. This topic is of importance because stress is experienced frequently, and can lead to unhealthy coping strategies. Additionally, it is important to gain insight in order to determine effective solutions to stress. Findings may contribute to university-wide seminars or workshops that educate on positive coping and stress-management techniques. The present study aims to investigate: How do Touro University Nevada students cope with stress? Literature Review College and graduate students in healthcare programs are faced with demanding didactic coursework, clinical fieldwork requirements, and frequent exams, all of which can lead to high stress levels. Students reported that taking and studying for exams, grade competition, and mastering large amounts of content in a small amount of time contributed to their greatest source of stress (McKean & Misra, 2000). In conjunction with specific academic stressors, the

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Student Stress and Coping Mechanisms

decreased amount of leisure time available may negatively influence coping mechanisms (Shaikh et al., 2004). Various coping strategies have demonstrated effectiveness in decreasing stress levels in healthcare students. Rizzolo, Zipp, Stiskal, and Simpkins (2009) found that occupational therapy masters and physical therapy doctorate students who spent 30 minutes either participating in yoga, watching a humorous television show, or reading material not related to academics experienced lower blood pressure, heart rate, and decreased stress levels. Additionally, a sample of Pakistani medical students reported the most frequent coping strategies to be spending time with friends, followed by sleep, music, sports, and isolation (Shaikh et al., 2004). Furthermore, McKean and Misra (2000) found that students who incorporated time management techniques, and participated in leisure activities exhibited a reduction in stress and anxiety levels. Though several coping strategies have demonstrated positive outcomes in regards to decreasing stress, certain behaviors have been correlated with higher stress levels. Specifically, novelty-seeking behavior, avoidant coping strategies, and lack of active cognitive and behavioral approaches are associated with high stress levels (An et al., 2012). Although stress commonly manifests through poor physical health, anxiety, or depression, a moderate level of stress can positively impact a students academic experience. In a sample of baccalaureate occupational therapy students, 86% of students reported examinations, amount of class work, lack of free time, long hours of study, and grades to be top stressors. However, 62% of subjects reported that the stress they experienced strengthened their commitment to their professional education (Everly, Poff, Lamport, Hamant, & Alvey, 1994). In this case, the ability of students to perceive their stress constructively serves as a coping mechanism.

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Student Stress and Coping Mechanisms

Stress is commonly considered to be the forces from the outside world impinging on the individual (Shaikh et al., 2004). From a medical perspective, stress is expressed through elevated heart rate and blood pressure (Rizzolo, Zipp, Stiskal, & Simpkins, 2009). Nevertheless, stress need not be harmful if proper coping methods are utilized. Like stress, coping mechanisms are not inherently positive or negative; rather, they are any method chosen to manage stress. Previous research has focused on the effects of various coping mechanisms on the experiences of stress in students. However, descriptions and narratives of students facing stressful situations and choosing coping mechanisms are limited. The present study explores Touro University Nevada student perceptions of stress and coping mechanisms with intent of developing understanding on the topic. Significance in findings may contribute to universitywide seminars or workshops that educate on positive coping and stress-management techniques. Methods Research Design Due to the personal nature of our research question, a qualitative study was deemed most appropriate using a phenomenological approach. The structure of a quantitative study could possibly overlook details of personal experiences and accounts that relate to the research topic. We opted to use personal interviews to allow participants an opportunity to elaborate on personal effects of stress, as well as their chosen coping methods. Participants Students of Touro University Nevada were recruited through a university-wide email (see Appendix A) requesting volunteers for a stress-related study. This convenience sample was composed of five males and four females between of the ages of 24-57. Included were five osteopathic medicine, one physical therapy, two nursing, and one occupational therapy students.

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Student Stress and Coping Mechanisms

When briefing the participants, the researchers explained the purpose of the study, as well as the concept of qualitative research in order to encourage active participation. Verbal permission to record each interview was obtained from each participant. Each participant was ensured that privacy and confidentially would be honored through assigning code names in the final written report. Interviews lasted between five and fifteen minutes. Data Collection Researchers informed the participants that the interview was going to be transcribed in order to encourage participants to elaborate on their personal experiences. Interviews were conducted on campus in private study rooms. Three primary questions formed the main structure of each interview; however, each interviewer asked follow-up questions that were individualized to the participants responses. The following questions were asked: 1. Describe your stresses as a student at Touro University Nevada. How did those experiences make you feel? 2. What coping mechanisms did you implement to deal with your stress? 3. Did your coping mechanisms help you deal with your stress? Interviews took place from early December through early January at Touro University Nevada, in person. Due to the nature of this study, surveys and questionnaires were not required. Data Analysis The data were organized through the use of written transcripts of each interview, all of which were shared amongst the researchers. Content analysis was chosen as the method of analyzing the data, and was selected for its ability to systematically determine the occurrence of common themes across multiple participant interviews. As the goal of this study was to discern

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how Touro students experienced and coped with stress, a systematic approach was appropriate and practical. Categories of codes were determined inductively through the use of the participants own words, and deductively through the use of two categorical archetypes: stressors and stress relievers. Initially, an open coding technique was implemented to produce codes which represented the variety in the participants experiences of stress and stress relief. Once these base codes had been established, they were then grouped and sorted into the broader subcategories of stressors and stress relievers. This was done using axial coding, which involves organizing data into categories and subcategories which influence the phenomenon being studied (see Appendix A). It should be noted that two subcategories, Preparedness and Rest and Sleep, were grouped into both the stress and stress relief categorical archetypes. This was due to the common occurrence in participants experiences; either a lack of or sufficient amount of preparedness or sleep would result in stress or stress relief, respectively. Once the subcategories had been established, their occurrences were then tallied amongst the nine interviews to determine any patterns. One such example of this coding scheme is seen through the process by which the subcategorical code of Disruptive Thinking was generated. This code was synthesized by grouping the more specific themes of Mind Racing, Overwhelmed, and Age Stigma. The following is a selection of text from [*Ginny (name changed)*]s interview in which the theme of Overwhelmed was identified, Even though I studied every day and kept up with the material, I still feel like I had to cram because theres just so much. It was really overwhelming. It was very, very frustrating (see Appendix F). Findings

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Student Stress and Coping Mechanisms

Two particular patterns emerged from the participants responses, in terms of the type of stresses and coping mechanisms. The first pattern was the subcategory of Preparedness. All of the participants cited preparedness to be a stressor or stress reliever, which included time management, anxiety, anxiety from being unprepared, and stress from the unknown. The second pattern observed was the subcategory of Healthy Lifestyle. All of the participants shared experiences associated with this subcategory, as one of their coping mechanisms included exercise, sports, healthy habits, and eating well. The data analysis revealed several themes common among the participants. It was found that the majority of our interviewees had comparable stressors, such as difficult schoolwork, preparedness, and lack of sleep. This was not unexpected, as many graduate programs are challenging, and require a tremendous amount of time and dedication to succeed. One participant described her schoolwork as being so difficult that she got to the point where she had to be okay with the idea of failing (see Appendix K). The theme of preparedness was illustrated by a participant when she stated that its just really frustrating because I want to learn everything but theres just so much of it that there is no way to learn it all the first time around (see Appendix F). Sleep was another theme, and one participant mentioned that during first and second semester, I had anxiety all the time, I wouldnt sleep, I wouldnt do anything (see Appendix H). Additionally, the theme of a healthy lifestyle was present in every participants interview. One participant stated, In general, to reduce stress I exercise. I do surfing contests which is kind of my relaxation thing (see Appendix D). Another participant stated that exercise helps a lot and many people at Touro seem to be pretty well with their physical fitness levels (see Appendix G).

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Student Stress and Coping Mechanisms

Researchers coded transcripts from the interviews they conducted for key words and patterns, which were then discussed as a group. A consensus was reached regarding the prevalence of the common themes of Preparedness and Healthy Lifestyle. Through this process, all reached agreement that various strategies were identified in answering the question of how students at Touro University Nevada deal with stress. As stated previously, our research had three primary questions that pertained to the types of stresses experienced by the participants, and the coping mechanisms they utilized. It was found that there were four categories of stressors: disruptive thinking, preparedness, challenging academics, and rest and sleep. These stressors were managed by the participants through six categories of coping mechanisms: healthy lifestyle, perseverance, social relationships, recreational activities, spirituality, and unhealthy habits. All of the participants indicated that their coping mechanisms did alleviate their stresses. For example, one participant noted that he failed one of his tests and felt really stressed, so he began to manage his time better and get more rest. As a result, he felt less stressed and began to perform better on his tests. Another participant described experiencing stress and anxiety around exam time, which caused her to have difficulty falling asleep. To cope with her stress and anxiety, she decided to listen to nature sounds each night, which helped her go to sleep. Findings of this study were similar to the ones found in previous published research. For example, a study by Rizzolo et al. (2009) found that participation in yoga and watching a humorous television show were effective coping strategies that helped to lower stress levels. However, Rizzolo et al. (2009) also found that reading material not related to academics helped lower stress, which was not found in this research. Additionally, a study by Shaikh et al. (2004) found similar coping strategies, such as spending time with friends, sleep, music, and sports.

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Student Stress and Coping Mechanisms Conclusions

It is a common perception that graduate students experience stress, and this study sheds light by exploring the accounts of nine Touro students. Although stress levels were found to be high amongst all participants, coping mechanisms resulted in effective stress management in most circumstances. Although efforts were made to promote participant comfort and confidentiality, it is acknowledged that participants may have withheld some information pertaining to negative coping mechanisms, due to social desirability bias. Most participants appeared to exhibit a level of self-awareness in regards to their personal levels of stress, and which coping strategies were effective. As it has been found in previous research, certain individuals will respond well to exercise (Shaikh et al., 2004), and others to entertainment (Rizzolo, Zipp, Stiskal, & Simpkins, 2009). Since the approach of this study was phenomenology, it is important that the participants could understand and articulate their experiences with stress. The axial coding of the data analysis elucidated the themes that surfaced in the findings. Future research can expand upon the results of this study by exploring the coping mechanisms used by students in other professional disciplines. The effectiveness of on-campus stress management programs can be examined in further research, as well. An understanding of the phenomenon of stress is pertinent not just to students, but to the professionals they will become in the future.

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Student Stress and Coping Mechanisms References

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An, H., Chung, S., Park, J., Kim, S.Y., Kim, K.M., & Kim, K.S. (2012). Novelty-seeking and avoidant coping strategies are associated with academic stress in Korean medical students. Psychiatry Research, 200(2/3), 464-468. doi: 10.1016/j.psychres.2012.07.048 Everly, J.S., Poff, Lamport, N., Hamant, C., & Alvey, G. (1994). Perceived stressors and coping strategies of occupational therapy students. American Journal of Occupational Therapy, 48, 1022-1028. McKean, M., & Misra, R. (2000). College students academic stress and its relation to their anxiety, time management, and leisure satisfaction. American Journal of Health Studies, 16(1), 1-12. Rizzolo, D., Zipp, G. P., Stiskal, D., & Simpkins, S. (2009). Stress management strategies for students: The immediate effects of yoga, humor, and reading on stress. Journal of College and Teaching & Learning, 6(8), 80-88. Shaikh, B.T., Kahloon, A., Kazmi, M., Khalid, H., Nawaz, K., Khan, N.A., & Khan, S. (2004). Students, stress and coping strategies: A case of Pakistani medical school. Education for Health, 17(3). 346-353.

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Appendix A Recruitment Email 11/28/2012 Michelle Ashley <OT14.Michelle.Ashley@nv.touro.edu> Looking for volunteers to participate in a research study on Touro students and stress. We would appreciate just 15 minutes of your time for an interview- get your voice heard, and enjoy some yummy homemade cookies! Please reply if you can spare a few minutes for a good cause, the more participants we get the better we can understand our diverse student population. Sincerely, Michelle Ashley, Elisa Dick, William Unger, Michael Yu, & Rachel Zimmerman OT 14 Qualitative Research Class

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Student Stress and Coping Mechanisms Appendix B

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Coping Mechanism Coding KEY: Light green: Disruptive Thinking Yellow: Preparedness Teal: Challenging Academics Red: Healthy Lifestyle Turquois: Rest and Sleep Cedric: Stress: time management, mind racing Relief: exercise, perseverance Lily: Stress: anxiety from being unprepared Relief: accepting outcomes, talking with others, exercise, recreational distractions James: Stress: difficult schoolwork, anxiety from being unprepared Relief: Talking with others, stress as a motivator, exercise, sports, spirituality Ginny: Stress: anxiety from being unprepared, overwhelmed, lack of sleep Relief: Sleep, exercise, pets, recreational distractions Ron: Stress: time management, overwhelmed Relief: perseverance, positive attitude, mindfulness, exercise, meditation, talking with others, drinking alcohol, recreational distraction, finding balance, healthy habits Harry: Stress: difficult schoolwork, time management, Dark Green: Perseverance Purple: Social Relationships Gold: Recreational activities Grey: Spirituality Blue: Unhealthy habit

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Relief: seeking help, sleep, taking breaks, time management, exercise, going out, recreational distraction, accepting outcomes, spirituality, relationships, Cho: Stress: time management, Age stigma, Relief: exercise, rest, eating well, spending time with spouse, spirituality, meditation, prayer, recreational writing Luna: Stress: anxiety, lack of sleep Relief: exercise, relaxing sounds, going out, taking a drive Neville: Stress: time management, anxiety, stress from the unknown Relief: entertainment, eating junk food, stress as a motivator, exercise, read scripture,

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Student Stress and Coping Mechanisms Appendix C

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Name: Harry Age: 29 Program: DO15 Marital Status: single E: I want to talk about how school has been for you in terms of stress H: Its very stressful. Theres a lot more time I have to put into it. A lot more detail, and just a lot more classes than you would normally have say in undergrad you do between 16-20 credit hours. Medical school its condensed and probably between 20-24 credit hours per semester. Its just a lot more E: How many classes do you have at once? H: Like during a day? E: During the semester H: Right now we have 6, thats not including the labs though. Its the same classes every block, just more material. Thats the hardest part. E: How did your first year go when you first started medical school? Like adjusting to that schedule in terms of stress and coping? H: It was really stressful. I failed one test, and then I went to OASIS and they helped me, like gave me some tips and some pointers on how to spend my time, the importance of getting rest before you take your test. All of those helped and then after that I didn't fail any more tests so I kinda picked up on what you needed to put into each subject and its just like undergrad, some things are more important than other subjects. Overall, you have to manage your time very well. E: So after that first semester, things kinda got better for you? H: Yeah. It didnt get easier but I was able to handle it and manage to not get too stressed out. It got better. Second year is even harder. Its more interesting, more clinically relevant. Its just a lot harder the classes that you have second year. Working with pharm and then path, pathology, and micro. They all correlate with each other and they all focus on different aspects. With micro you do antibodies and with path you figure out whats going on and then pharm is how you treat it. So you have the same material but its all from different aspects, like youre getting three opinions on the same thing. Like to compare it to religion, you get one from a Christian, one from a Muslim, and one from a Jew. They all have different views on how you attack it. Thats the hardest part I think.

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E: I love that analogy. So going back to first semester, when you were having a tougher time, what were some of your coping mechanisms that, like were you not sleeping enough and feeling tired, were you taking naps, were you working out, eating, drinking, like those kinds of things. H: First semester the hardest part was I wasnt able to manage all the things that were required of me. I kept stressing and thinking I havent done this, I havent done that because youre not going to be able to cover everything so you have to pick and choose and prioritize which ones are more important, how much time you have to allocate to each of the different subjects. How much you have to cut back on extracurriculars like working out or going out, things like that. That was the whole learning process the first semester, figuring out where I can do this or that. And then coping methods, if Im very stressed out Ill just stop. E: Like stop studying? Do something else? H: Change it up . I like to cope a lot more than I like to put myself out there. So I would go watch TV or go play sports or do something, and I would just step away from the studies for a little bit. Just take a break. Im not a gunner, so I wont be pushing until 2 or 3 in the morning, trying to get everything in, to know every little detail. I tend to be the one that just manages so I can do well enough where I feel like Im okay. From my experience I have to do a little more to get to where I have a B. Getting a C is really bad for me and for most of my classmat es, its pretty much like failing, so I try to stay with the class average, which is a B, around that area. For me, I have to do a little bit more to stay in that range. You still work hard but play hard at the same time. E: Can you tell me about what kinds of sports you like to play? How that makes you feel when youre stressed out? H: I play basketball, I like to work out, I do Crossfit. E: At that place down the street? H: Yeah, my classmate, its his gym, we get a little discount and go there, workout. I need to get out from being in the classroom all day. E: How does that make you feel, like if youre really stressed out and then youre on your way to Crossfit, and then after youve done it, how do you feel? H: Sometimes Im more stressed to do crossfit then I am in class, haha E: Its really hard, right?! H: Its intense and they put the workouts up beforehand so you know certain days youre going to be struggling. Like this is one I dont like to do, the rope climb. Last week we did 25 of them

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in one workout, I didnt do well in that. But I like to do yoga, and I understand that youre the yoga teacher [side conversation about yoga at Touro] E: Tell me about some other things you do if youve had a really hard week and its Friday night, what do you like to do? H: I like to go out. No studying, just get your mind off of the books for a little bit. Which never happens because the people that youre going out with is the people that youre with all the time, your classmates. You really dont have any time for a social life outside of school, so most of the people you hang out with are your classmates, theyre the ones you can keep close contact with. I do go to my church, so thats another outlet. E: Oh good so thats a totally differentH: Yeah thats a totally different circle, although some of my classmates go to the same church. Other than that, family. I live pretty close to here, like an hour from here. Family, friends, church, sports. E: So what if youre just studying and you know you dont have time to take a break now but youre really stressing about some material, what would you do? H: If I was really stressing, the only reason to be really stressing is because youre not understanding it as much as you want to. So my thing is that if I study for 15 minutes, I take 10 minutes to take a break. I guess I take a lot more breaks than I should. []

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Student Stress and Coping Mechanisms Appendix D

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Name: James Age: 34 Program: DO15 Marital Status: Married w/ children Mike Y: How is your program going so far? J: So far its good. Its difficult, but it was expected. MY: So now I want you to think of a time you were stressed here at Touro University. How did it make you feel? J: My first exam we had anatomy and I did not study as much as I needed and I had a lot of anxiety the night before the test. It was hard to sleep. For me, when I get stressed out, I get a lot of anxiety. MY: Did your family help in dealing with your stress? J: Yeah definitely, I talk to my wife and explain to her about my situation and she usually has good consoling words to help me. MY: So what are your specific coping strategies to deal with your stress? J: When it comes to studying, when I am stressed I just try to work harder. In general, to reduce stress I exercise. I do surfing contests which is kind of my relaxation thing. And on breaks, I go down to San Diego to go surfing. MY: Oh is that your hometown? J: Yeah. And then for me, spirituality is a big part of managing my stress. I make sure to incorporate that into my life. MY: Well thank you so much. J: No problem.

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Student Stress and Coping Mechanisms Appendix E

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Name: Cedric Age: 27 Program: DO15 Marital Status: Unknown Rachel Z: So your name is Cedric? C: correct RZ: can I ask how old you are? C: 27 RZ: 27. and youre in the DO program? C: yes RZ: okay. And are you married? C: single RZ: What year of the program are you in? C: 4th year, so 13 RZ: If you can, can you just think about a time where you were stressed in any of your years as a student at Touro, if really can be any time as a student C: I guess between 2nd and 3rd year between boards, taking the USMLE and complex. Because we didnt have enough time, so it was a balance as to what I needed to do and how much I needed to study. It was a big time crunch. RZ: Okay, so how did it make you feel? Did it make you feel anxious or you know nervous, where you kind of okay feeling stressed? C: Nervous, I guess. Your mind is racing all the time, because youre like maybe Im not doing enough, so youre like constantly thinking of things in your head. Its kind of you knowRZ: Okay, and what did you do during that time to relieve stress? C: I worked out, like ran. I tried to get away from the library when I could, because usually I just spent the whole day in the library studying for boards. RZ: Okay. And what do you do in other situations when youre stressed? C: I try to work through it.

Ashley, Dick, Unger, Yu, & Zimmerman RZ: What does that mean?

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C: Try to trudge on through it. Try to work really hard on what I need to get done, so I can be done with it. RZ: Okay C: So I would like, make it seem like a goal in the future. Well, like a deadline, like these are the things I need to get done before that deadline, so that helps me. RZ: Okay. And do you feel like what you do is effective or do you think there are ways you could improve your coping mechanisms? C: Im sure there are probably better ways or less time consuming ways to do it. I think trudging through it, is probably not the best thing, but thats worked for me. RZ: But you feel like youre getting it done? C: Yes. But I mean, Im sure there are probably better ways to manage it. I dont know, it works for me. RZ: Do you see anyone around you doing different things? C: Some people like, they eat, I dont know, just different things. RZ: thats common C: Some people eat a lot, I dont know. I see eating a lot. RZ: Okay. And do you see your stress levels going down, like as you start to finish school or I mean is your stress right now mainly because of school? C: Yes, mainly just because of residency interviews and trying to figure out where Im going to go next year and where Im going to finish my training RZ: Okay. Alright well thats really it. We really appreciate it.

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Student Stress and Coping Mechanisms Appendix F

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Name: Ginny Age: 24 Program: DO15 Marital Status: Single

Mike Y: Think of a time you were stressed here at Touro University. How did it make you feel? G: During exam week it feels overwhelming when you actually realize how much material you covered in class. Even though I studied everyday and kept up with the material, I still feel like I had to cram because theres just so much. It was really overwhelming. It was very very frustrating. G: Last year I usually got 2 hours of sleep and what not and it ended up being way too much. I couldnt function well. But this year I tried to limit that and get a set minimum number of hours of sleep to try to get my body some rest. MY: So in terms of stress level? G: Yeah, it was very very stressful. Right now its much more stressful than first year. During first year it feels like you learn the basics, but now were learning things that we have to know to be a physician. So if youre not learning it, you feel like youre not going to be a good physician. Theres just so much to memorize and stuff. Its just really frustrating because I want to learn everything but theres just so much of it that there is no way to learn it all the first time around. It gets to be really frustrating. G: Last year I did not have time to exercise or eat very well. I just grabbed whatever I can to eat so I can get back to studying. First semester I gained weight and felt groggy. But since January, I got much better with that. I changed my perspective on sleeping. I know that its not worth it if I dont feel well or cant function well because of lack of sleep. I make sure to sleep. I personally know people who do crazy things and do not sleep. MY: So what are your specific coping strategies to deal with your stress? G: Couple of months I started going to the Cross Fit gym. Its a gym right by school. Its a good outlet. And a couple of months ago, I got a puppy. Its really good to take a break and play with her. Sometimes I watch TV like basketball or something. MY: What else do you watch? G: I watch basketball, comedy, or medical drama. Greys Anatomy, Big Bang Theory, New Girl, and other shows.

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MY: Wow, you watch a lot of shows, thats good! G: Yeah, I usually watch the 20 minute shows online when I eat or want to take a break. MY: Well thats it for today. Thank you for your time!

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Student Stress and Coping Mechanisms Appendix G

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Name: Ron Age: 26 Program: DPT14 Marital Status: Single R: Obviously it gets a little more intense more towards midterms and finals week but Id say a fair time between regulating time and extracurricular activities. Academics going to stress us out to the max. I can say for myself and my classmates it gets pretty beat up. You get pushed to the edge. I feel like Im there right now. Elisa D: You are kinda getting to midterms? R: Right exactly, so we have a couple weeks left, so this right now is the grind, so the next 4 nights are going to be a big terror. But everyone seems to push through it. Staying positive is always a good things to reduce stress. ED: Yeah, okay. So what kind of things do you do when you feel stressed out? R: Weve actually been learning a lot of, theres cognitive behavior therapy weve been doing. Some mindfulness, getting the right mentality and state of mind. Also obviously exercise helps a lot and a lot of people at Touro seem to be pretty well with their physical fitness levels, so thats always an anxiety reducer. And otherwise a positive atmosphere and environment always helps because once you get in that negative state of mind you can go up and be more anxious and be stressed out to the max. ED: When you do go to that bad place and youre way stressed out, what can you do to pull out of it? R: I guess a top issue in behavior therapy and meditation, but in that moment, anything from deep breathing exercises to reaching out to someone else, but its hard because it can consume you pretty bad, pretty brutally right there. Take a minute to close your eyes and do some breathing exercises will help out a little bit, at least for me personally. ED: Cool R: Yeah, but otherwise go for a run and try to spurt it out of your system. That always helps a little bit too. I ED: Do you ever use coping mechanisms that you perceive as less positive? You know, like youre really stressed out and just watch TV or go drink or R: Yeah definitely, I do some binge drinking every now and then, social drinking, whatever helps alleviate something, but then alcohol is a depressant so it makes it worse usually. But that

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always helps alleviate some anxiety if youre feeling a little anxious that helps a little bit sometimes. But I guess playing in front of the TV and watching HBO for 12 hours straight, that will do it too. But if you watch Game of Thrones you will know its not anyones choice, I started watching that too. Being a couch potato, thats a fact that comes to play too. ED: Do you find you can find a balance between the two? R: Yeah, definitely. You definitely find a balance between the two. If ones not more consuming than the other. And I guess thats a fine line to find. I think that in stressful times like during exams one will take over the other, so right now maybe the lounging and the TV and maybe a little of the drinking on the side might start taking over, but just getting some outside help from your friends to start going the other direction always helps. As you can see because Im covered in sweat right now. Id say more positive outcomes than negative. Or positive things to reduce stress. ED: Those are more prevalent? R: More prevalent, yeah 80-90% of the time. ED: Did you have some of these coping mechanisms before you came to Touro? R: Definitely. Ever since before high school any kind of exercise, they go with you. Less of the negative coping strategies, more of the positive ones, and over time you find that exercise and then a good diet, eating healthy relieves a lot of stress- a lot. And smoking cessation and stuff like that. A healthcare provider- yeah I used to smoke too and I got rid of that and it helped a lot. ED: Thats fantastic! Thanks for all your input. If you have any advice for people who are trying cognitive behavior therapy, who are new to it? You talked about the deep breathing, starting simple? R: Yeah, start simple, take 5 minutes even before you go to bed or when you wake up in the morning because a lot of people have a lot of stress. As soon as they wake up they begin feeling apprehensive, or right before they go to bed they shut their brain off. Take 5 minutes, when youre really tired in class but when you want to go to sleep at nighttime thats when all your thoughts start (muffled). Try if you can imagine a light switch or a dimmer even because some people cant switch it off. I like to imagine it dimming a little bit. And it goes down and it kinda helps and youll realize you are breathing a little easier and deeper. And then you wake up and its the next day! And you start all over again. ED: Oh sounds great, thank you! Anything else you want to add? R: Just keep down the smoking and have a positive atmosphere with your friends around you helps too.

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E: Your peer relationships, support from them? R: Exactly and no matter what remember that this is another day, things are okay. Live in the moment and do not let stress consume you, try to be positive about it. It helps significantly, even the smaller things.

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Student Stress and Coping Mechanisms Appendix H

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Name: Luna Age: 25 Program: Nursing Marital Status: Single Michelle A: Your name is Luna L: Yes MA: The purpose of this is that were trying to do a qualitative class project to see the stress level of Touro students. Are they getting stressed? What happens when they get stressed? And the coping mechanisms they use when under stress. A couple examples would be working out, eating, going out. So, think of times where you feel like you experience more stress, is it all the time or just during exams and what do you do when you feel stressed? L: Im from out of state, so moving here was really stressful. Getting settled in within the first two semesters was probably the most stress Ive ever had in my entire life. Im not a stressful person, Im always the most laid back one and I had the biggest anxiety. MA: Really L: Yes. During my 1st and 2nd semester, I had anxiety all the time, I wouldnt sleep, I wouldnt do anything. My first semester I worked out almost every day. MA: Okay L: And then as my stress level would decrease, Im like oh forget it, I dont need to work out, Ill just hangout. Now when I do get stressed its just around exams time. Usually I dont sleep because of the stress. MA: Okay L: And so when that happens I usually, I dont know, I try to- I found this app on my phone that I have now that has all these nature sounds and that helps me sleep a lot. Its never helped me before, but its helped me a lot now. MA: I have something similar to that L: Then theres also school stress plus stress in general, family and whatever else MA: Was this your first time away from home? L: No. I moved away my freshman year of college, but then went back home

Ashley, Dick, Unger, Yu, & Zimmerman MA: And wheres your family at? N: Hawaii MA: Okay L: So, that whole move was really stressful.

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MA: Do you feel like with clinicals is it equally as stressful as when you just had didactics? Or now when you have clinicals mixed in with schoolwork, does it seem any different or is it just like exams that are stressful? L: I think its more exams. For our clinical practice its more hands on so we dont have too much homework or preparation for it. So, I think it just exams for our class. For clinicals we just show up and show what were supposed to already know. But we get tested before we go into clinicals. MA: Okay L: Going in and performing the things were supposed to perform, that nervous. Right now in our clinicals we have worksheets to fill out asking what are the three things you want to do today and they make sure you get it done before you leave. So we have to figure out how were going to do it and plan accordingly, so that has been more stress than some of the other clinical settings Ive been in. MA: Alright. So mostly just working out and nature sounds L: Yes. And I think going out, not going out, out but just getting out of the house even if I have to drive. Just take a drive somewhere MA: Have a little break L: Yes. Cause even like sometimes now my eyes have been getting really sore from reading and constantly being on the computer, I cant even focus on the tv, the tv doesnt help. So I just need to get out MA: Okay. Well thank you for your time, we really appreciate it

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Student Stress and Coping Mechanisms Appendix I

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Name: Cho Age: 57 Program: Nursing Marital Status: Married Michelle A-Were looking at the type of stress you have at school and then how you cope with it and manage it Cho-Factors that affect me in school are the amount of reading I have. Im 57, so my age is a factor for me in terms of making me feel like I wont be able to handle as much as my younger peers. Its a stigma I have in my own mind. Time management is the biggest thing for me. I have a family, so finding the optimal time to study is important. My children are independent, but both live at home so I have a predetermined familial schedule on top of my school schedule. MA- So if you start experiencing stress, what do you do to help cope with that? C- I work out when Im able to; I have to rearrange my schedule to allow time for it. I have a 45 minute commute, so its hard to find time between that and other obligations. MA- do you use any relaxation techniques or do activities with your family to help you deal with stress? C-I try to get plenty of rest and eat well. I go on walks with my husband every other day, to help me unwind and get my mind of school. I also have a strong spiritual belief system, so I meditate and pray, and that helps me make sense of lifes challenges. I also write. Writing has always been very inspirational and fun for me and allows me to let out my thoughts. It activates the part of my brain that engages the rest of my thinking, so it is very energizing for me. It makes the other studies easier, it uses both hemispheres. MA- Do you feel any additional stress now that youre doing clinicals? C- The hours are very draining, but I dont find it to be more stressful. Theyre equally stressful, but its a good stress. It allows you to practically understand what you have been learning about it class. And I find it very fulfilling.

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Student Stress and Coping Mechanisms Appendix J

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Name: Neville Age: 24 Program: Occupational Therapy Marital Status: Single William U: Im going to ask you just a couple of questions about how stress has been a part of your life as a graduate student. First, think about a time that you were a student at Touro and experienced stress. How did it make you feel? N: I was stressed over the weekend, and I was stressed because I was told by my superiors in the military that I would need to do training up in Alaska for two weeks during finals week. This mainly made me feel frustrated because neither side would budge, and now were at an impasse. Wu: So kind of trying to juggle your life outside of school with the military and then your school schedule? N: Yeah, just juggling between the two. WU: What about another time during the academic year during coursework where you didnt have any conflicts with the military, but instead there was something within school that caused you stress? N: Well, finals week is always stressful. I wouldnt say I cant really function, but I maybe dont eat as healthy during that week and probably dont exercise as much as I should. WU: What things about finals week cause you stress? N: I think its just the amount of everything, because you have the four or five tests over four or five days and projects and all that. WU: So how did you feel trying to prepare for this most recent midterm? N: This one wasnt wasnt as stressful as the first midterm. I felt a little bit anxious, ready to get it done. Felt like I had a lot on my plate. WU: So when you do feel stressed out, what types of things do you do to make you feel less stressed? What types of things do you do to make you feel a little bit calmer? N: I normally listen to music, and my diet usually changes during finals. Ill eat a lot more fatty foods, more comforting foods. I probably should work out more, but thats normally when I dont work out because I just want to get through all of the stuff. I feel like working out more would definitely help out, because it normally decreases my stress. WU: Do you find you put those kinds of activities adie during finals? If so, why? N: Yeah, I normally put them on the back burner because I have so much to do in so little time. When it comes down to it theres not enough time for all of that. If I dont manage my time and have procrastinated, it all builds up at the very end.

Ashley, Dick, Unger, Yu, & Zimmerman WU: Do you think the stress helps you at all?

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N: I think I work a little bit better when I am stressed. I think my mind is a little bit clearer and sharper because I know I have to perform. WU: When you do work out or eat the junk food you mentioned earlier, how exactly does it affect your stress level and make you feel? N: Well, when Im eating the junk food it tastes good, but afterwards I dont feel as sharp as I normally would. I feel a bit slower with all the food thats heavy and not very good for you. With working out, I feel like it wakes me up and brings me to higher level of cognition. It kind of heightens my awareness. WU: What about in an acute moment of stress, such as in the middle of an exam, do you ever feel any sort of test anxiety? N: Maybe a little bit, but I usually feel that more beforehand than during. I like to try to come into a test relaxed. Normally the last half hour before Ill read my scripture or watch a comedy show. When Im relaxed I feel like I can remember more clearly versus when Im stressed I can have a harder time thinking clearly. I like to go into the library or into a study room where Im away from other people who will be taking the test, because that can create kind of a stressful environment. WU: As a final question, what would you say is the most stressful situation youve experienced since you started at Touro? N: Probably the first midterms because I didnt really know what to expect. Not knowing what to expect definitely made it more stressful.

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Student Stress and Coping Mechanisms Appendix K

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Name: Lily Age: 27 Program: DO15 Marital Status: Single

Mike Y: Think of a time you were stressed here at Touro University. How did it make you feel? L: My last exam I almost broke down because I was sick before an exam. I was so behind in the material and I thought I was never going to finish. I got the point where I had to be okay with the idea of failing for me to calm myself down. I talked to my boyfriend and he said its ok to fail and that its not the end of the world and that made me feel better. MY: Any other strategies to cope with your stress? L: For me, the best coping mechanism is talking to anyone outside of school. I try to exercise. I also try not to think about school by putting on music and cooking. MY: Ok, thats it for today. Do you have any questions? L: No. MY: Ok, thank you for your time. L: No problem.