Perceived Stress Levels and Stress Management Among Paramedical

Students Lyceum of the Philippines University:

Towards Stress Management Enhancement
Maribel D. Mayuga-Barrion, DDM, MAT

It is recognized that stress is a normally occurring part of life. Selye was the first
to describe the term "stress" as a state produced within an organism subjected to a
stimulus perceived as a threat (Selye, 1957). He spoke of stress as a condition that
occurs commonly in response to any adaptive response within the body. He defined
stress as ". . . a state manifested by a specific syndrome which consists of all the non-
specifically induced changes within a biologic system" (Selye, 1950). In other words,
stress can refer to a wide range of physiological changes caused by physical or
psychological components or a combination of these. College students, especially
freshmen, are a group particularly prone to stress due to the transitional nature of
college life. They must adjust to being away from home for the first time, maintain a high
level of academic achievement, and adjust to a new social environment.
College students, regardless of year in school, often deal with pressures related to
finding a job or a potential life partner. These stressors do not cause anxiety or tension
by themselves. Instead, stress results from the interaction between stressors and the
individual's perception and reaction to those stressors. The amount of stress
experienced may be influenced by the individual's ability to effectively cope with stressful
events and situations. If stress is not dealt with effectively, feelings of loneliness and
nervousness, as well as sleeplessness and excessive worrying may result. It is
important that stress intervention programs be designed to address stress of college
students. However, in order to design an effective intervention, the stressors specific to
college students must be determined. (Ross, 2010)
The dynamic relationship between the person and environment in stress
perception and reaction is especially magnified in college students. The problems and
situations encountered by college students may differ from those faced by their non-
student peers. The environment in which college students live is quite different. While
jobs outside of the university setting involve their own sources of stress, such as
evaluation by superiors and striving for goals, the continuous evaluation that college
students are subjected to, such as weekly tests and papers, is one which is not often
seen by non-students. The pressure to earn good grades and to earn a degree is very
high. Earning high grades is not the only source of stress for college students. Other
potential sources of stress include excessive homework, unclear assignments, and
uncomfortable classrooms. In addition to academic requirements, relations with faculty
members and time pressures may also be sources of stress. Relationships with family
and friends, eating and sleeping habits, and loneliness may affect some students
adversely.
Many specific events and situations have been implicated as stressors for
paramedical students, more research is needed to investigate the nature of these
stressors for paramedical students, and which stressors are most prevalent in their lives.
It is unclear whether most stressors result from interpersonal relationships or academics.
In addition, this research is needed to clarify whether these stressors are mostly daily
hassles or major live events. The purpose of this study was to determine what sources
of stress are the most prevalent among paramedical students, and to examine the level
of these stressors. (Shaikha, 2004).
According to Ross (2010), College students are no strangers to varying degrees
of stress. Reports suggest that the university environments are different from other
settings, yet levels of stress are no less serious.
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Ramsey, Greenberg, and Hale (1999) surmised that the college experience may
be the most stressful years in one's life. A needs assessment at the University of
Maryland found that stress and tension was the second greatest health concern of
college students following fitness. Very little research has been done to find out what
college students are doing about these high levels of stress. An equally modest amount
of research has been done to learn how effective are the techniques used by college
students to reduce stress levels.
Stress on college campuses is high, but students may not be aware of more
effective ways to reduce stress. For example, in a recent review of literature of
substance use and abuse (Prendergast, 2004) reported that "college students are more
likely to drink and to drink at high levels than are young adults who are not in college."
The means for relaxing may be temporarily effective for reducing stress levels, but there
are consequences associated with regular drinking that are not always desirable
(Fromme & Rivet, 2004).
Existing research provides limited information on stress and its management
among college students. Accurate information regarding stress, its primary sources and
effective ways to deal with it specific to college students would allow university health
educators, counseling centers, and student wellness centers to target specific need
areas more effectively on campuses across the country.
Dental students often report high levels of stress. Even though many studies
have been conducted on this issue, we still lack a global understanding of how dental
students experience and deal with stress, making it difficult for dental educators to
improve this situation.
Stress has been defined as the strain that accompanies a demand perceived to
be either challenging (positive) or threatening (negative) and, depending on its appraisal,
may be either adaptive or debilitating. Stress can act as a creative force that increases
drive and energy, but once it reaches a certain degree, the results can be negative. In
the working lives of dentists, stress has been reported to be considerable, and there has
been increasing interest in stress management programs for dentists. Whether the
experience of stress in dental students leads to stress in working dentists is not known.
There is, however, some evidence linking stress in medical students and future risk for
depression.
A recent systematic review of psychological distress in medical and dental
students concluded that perceptions of stress are correlated with depression, anxiety,
somatic symptoms, and health problems and are predictive of future risk for depression.
In health professions students it has been a subject of much research interest. It is
therefore important to study the experience of stress in dental students and to identify
ways to manage it. (Sanders, 2002).
Stress can also be defined as the biological reaction to any adverse internal or
external stimulus—physical, mental or emotional—that tends to disturb the organism’s
homeostasis. If the compensating reactions are inadequate or inappropriate, they may
lead to disorders. However, stress is not all bad. Certain stressors inspire people to make
a greater effort; for example, a particularly demanding patient may motivate a dentist to
work at an exceptionally high level, resulting in the creation of a highly esthetic and
natural-looking restoration. Some stressors can stimulate people to grow professionally
and personally, learn or improve. Stress is really an essential part of our lives.
We, as species, survive on this planet because we can maintain a normal,
balanced internal environment, called homeostasis. Any threat to the system, perceived
or real, which may disrupt this homeostasis will produce many physiological reactions in
several systems of the body. The purpose of these reactions is to resist these changes
from taking place. These threats or stressors may be physical, psychological or
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psychosocial.
Stressors vary, that is, what may be stressful to one person may be perceived as
no threat whatever to another person. Additionally, what may be stressful for a person at
a particular point in time may not be perceived as stressful at another (Ross, 2010).
Research on stress among dental students developed from the idea of
investigating their perceptions of stress in relation to experiences burnout as well as their
general psychological well-being. Much research on stress among dental students
centered on the sources of stress within the dental training environment, which include
completing graduation requirements, achieving good examination grades, fear of failing
the course, approachability of staff, patients’ being late or not showing for their
appointments, and fear of facing parents after failing in the board exam. While it should
be recognized that environmental stressors can be modified to support a more conducive
learning environment, the question as to why some students cope better with these
stressors than others remains relatively unexplored. (Newton, et al., 2006)
With the aforementioned, the researcher believes that paramedical courses are
very stressful in nature. Students had difficulties in handling stressful situations like
examinations and doing clinical and subject requirements. Thus, the researcher had an
idea of conducting this research to investigate the paramedical student’s perceptions of
stress in relation to their everyday experiences and psychological well-being.
Furthermore, the researcher believed that this study will have significant to the
faculty members and clinical instructors by providing an insight in increasing the
emphasis of stress management in health education. On the other hand, students would
have more insights on how to be more responsible for the stress they experience and
would have better understanding on the role of stress management in their chosen
career.

Objectives of the Problem

In the study, the research was anchored by the following objectives:

1. To know the perceived major source(s) and levels of stress among paramedical
students.
2. To determine stress management activities as practiced by respondents.
3. To find out if there is a relationship between the levels of stress and stress
management activities of the respondents.
4. To propose program that will enhance the stress management activities of
paramedical students.

Literature Review

During the course of life, stress is encountered at varying levels, some in high
levels, and some in low. Stress is the result of placing undue expectations or desire,
creating images of the self and trying to live up to the image that has been created by
the significant others. When compare one’s that of reality, opposing forces are created.
Hence, the mind tries to match the created image with the current situation.
Stress can be made worse by other people’s expectations, and being human we
always care what others think of us, even though we tell ourselves that we do not. We
try to change ourselves so that other people, regardless of whether they care, can
accept us or not. Therefore the motive /objective of this study is to know the following
aspects.(Flach, 2003).
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The word 'stress' is defined by the Oxford Dictionary as "a state of affair involving
demand on physical or mental energy". A condition or circumstance (not always
adverse), which can disturb the normal physical and mental health of an individual. In
medical parlance 'stress' is defined as a perturbation of the body's homeostasis. This
demand on mind-body occurs when it tries to cope with incessant changes in life.
According to Flach (2003), A 'stress' condition seems 'relative' in nature. Extreme stress
conditions, psychologists say, are detrimental to human health but in moderation stress
is normal and, in many cases, proves useful. Stress, nonetheless, is synonymous with
negative conditions. Today, with the rapid diversification of human activity, we come face
to face with numerous causes of stress and the symptoms of stress and depression.
It is an interaction between the person and their (work) environment and is the
awareness of not being able to cope with the demands of one’s environment, when this
realization is of concern to the person, in that both are associated with a negative
emotional response.
Stress is the reaction that people have when they worry that they can't cope with
the pressures or other types of demand placed upon them. Stress can be described as
the adverse reaction people have to excessive pressure or other excessive demands
placed on them. It is one’s reaction to external events and it can be positive or negative
depending upon how one reacts. It is the general wear and tear of the body machine that
takes place due to extra demands put on it. In other words stress can be defined as
“body’s nonspecific response to any demand made on it”.
It is the inability to cope with a real or imagined threat to one’s mental, emotional,
physical, social, economic, and spiritual well being which results in a series of
physiological responses and adaptations. It is generally believed that some stress is
okay (sometimes referred to as "challenge” or "positive stress") but when stress occurs
in amounts that you cannot handle, both mental and physical changes may occur and
thus everyone reacts to stress in different ways.
In a challenging situation the brain prepares the body for defensive action—the
fight or flight response by releasing stress hormones, namely, cortisone and adrenaline.
These hormones raise the blood pressure and the body prepares to react to the
situation. With a concrete defensive action (fight response) the stress hormones in the
blood get used up, entailing reduced stress effects and symptoms of anxiety.
When we fail to counter a stress situation (flight response) the hormones and
chemicals remain unreleased in the blood stream for a long period of time. It results in
stress related physical symptoms such as tense muscles, unfocused anxiety, dizziness
and rapid heartbeats. We all encounter various stressors (causes of stress) in everyday
life, which can accumulate, if not released. Subsequently, it compels the mind and body
to be in an almost constant alarm-state in preparation to fight or flee. This state of
accumulated stress can increase the risk of both acute and chronic psychosomatic
illnesses and weaken the immune system of the human body. (Pareck, 2002).

Stress as Part of Life

It would be a dull life if there were no challenges in it. Indeed there is some
evidence that having no challenges at work is more ‘stressful’ than the presence of
challenges that stretch us to a degree. The idea that we ‘need stress’ in our lives is
obviously capable of exploitation. A balance between stimulation and rest is required
and common experience suggests that our ability to respond to challenges is limited. We
can be overstretched and lose function or we can operate within our tolerances and
function effectively. This means that two keys to considering whether stressors are
‘good’ or ‘bad’ is to ask if people are working within their tolerance and if they have
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adequate ‘recovery’ time. This approach tells us that prolonged and/or profound stress
can be unhealthy for a person and, by implication, the organization he or she works for.
One indication of a negative (as opposed to a challenging) situation is when many
employees report stress or where a work group becomes dysfunctional.

Stress Defined -VE VS +VE

Stress was defined according to its negative effects to one’s body such as S-
strain and pressure, T-tension, R-ranting and raving, E-easily irritated, S-sadness, and
S-saddled by our own fear.
However, stress was also defined positively in which S- for smiling and laughing,
T- for t alking softly, R- for relaxation, E- enjoy yourself, S-smelling of flowers and S-
slowing down.
Everyone responds differently to stress. It depends, to some degree, on one’s
conditioning and on the adaptive energy one is born with. Pressure is inevitable. We
cannot go through life without experiencing pressure and attempting to avoid pressure is
not realistic. Pressure needs to be actively managed. It’s a neutral force, which can
produce both positive and negative outcomes depending on an individual’s adaptability
and coping skills. It can also be the stimulus to enjoy our lives and learn new skills,
experience excitement and get things done. On the other hand, it can be the force that
causes depression and anxiety, makes one fail to complete tasks, miss deadlines, break
up relationships and become serious ill. In other words, pressure can either help to raise
performance or it can cause stress. Therefore, the way we react to pressure, combined
with our adaptability, governs the outcome of the stress process. (Kobus, 2000)

Stress Can Be Positive

The words 'positive' and 'stress' may not often go together but according to
Psychologists some 'stress' situations can actually boost our inner potential and can be
creatively helpful and that stress, in moderate doses, are necessary in our life. Stress
responses are one of our body's best defense systems against outer and inner dangers.
In a risky situation (in case of accidents or a sudden attack on life et al), body releases
stress hormones that instantly make us more alert and our senses become more
focused. The body is also prepared to act with increased strength and speed in a
pressure situation. It is supposed to keep us sharp and ready for action.
Research suggests that stress can actually increase our performance. Instead of
wilting under stress, one can use it as an impetus to achieve success. Stress can
stimulate one's faculties to delve deep into and discover one's true potential. Under
stress the brain is emotionally and biochemical stimulated to sharpen its performance.
Stress is, perhaps, necessary to occasionally clear cobwebs from our thinking. If
approached positively, stress can help us evolve as a person by letting go of unwanted
thoughts and principle in our life. Very often, at various crossroads of life, stress may
remind us of the transitory nature of our experiences, and may prod us to look for the
true happiness of life. (Flach, 2003).
According to Feldman (2004), there is no single level of stress that is optimal for
all people. Individual differ with unique requirements. As such, what is distressing to one
may be a joy to another. And even when we agree that a particular event is distressing,
we are likely to differ in our physiological and psychological responses to it.
The person who loves to arbitrate disputes and moves from job site to job site
would be stressed in a job which was stable and routine, whereas the person who
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thrives under stable conditions would very likely be stressed on a job where duties were
highly varied.
Also, our personal stress requirements and the amount which we can tolerate
before we become distressed changes with our ages. It has been found that most illness
is related to unrelieved stress. If one is experiencing stress symptoms, he is said to have
gone beyond his optimal stress level; and therefore he need to reduce the stress in his
life and/or improve his ability to manage it.
Research has proven that experiences that we have encountered over the years
are likely to cause diseases, which would not manifest until later on in life. The death of
a spouse or a truly loved one causes the highest level of stress, followed by divorce and
a marital separation. The conflicts intertwined with relationships with people close to you
cause you the most stress (Flach,2003).

Signs and Symptoms of Stress

To get a handle on stress, you first need to learn how to recognize it in yourself.
Stress affects the mind, body, and behavior in many ways— all directly tied to the
physiological changes of the fight-or-flight response. The specific signs and symptoms of
stress vary widely from person to person.
Some people primarily experience physical symptoms, such as low back pain,
stomach problems, and skin outbreaks. In others, the stress pattern centers on
emotional symptoms, such as crying jags or hypersensitivity. For still others, a change in
the way they think or behave predominates. (Kaufman, 2004)
Kaufman, gave the cognitive warning signs and symptoms of stress such as
memory problems, indecisiveness, inability to concentrate, trouble thinking clearly, poor
judgment, seeing only the negative, anxious or racing thoughts, constant worrying, loss
of objectivity and fearful anticipation.
He also cited the emotional symptoms of stress such as moodiness, agitation,
restlessness, short temper, irritability and impatience, inability to relax, feeling tense and
“on edge”, feeling overwhelmed, sense of loneliness and isolation, depression or general
unhappiness.
Headaches or backaches, muscle tension and stiffness, diarrhea or constipation,
nausea and dizziness, insomnia, chest pain and rapid heart beat, weight gain or loss,
skin breakouts (like hives and eczema), loss of sex drive and frequent colds are some of
the physical symptoms of stress.
However, eating too much or less, sleeping too much or too little, isolating self
from others, procrastination and neglecting responsibilities, using alcohol, cigarettes or
drugs to relax, nervous habits like nail biting and pacing, teeth grinding or jaw clenching,
overdoing activities like exercising and shopping, overreacting to unexpected problems
and picking fights with others are some of behavioral symptoms of stress.
According to Sheu, et.al (2002), the signs of stress vary from person to person,
depending on the particular situation, how long the individual has been subjected to the
stressors, and the intensity of the stress itself. Typical symptoms of stress can be:
apathy, negativism/cynicism, low morale, boredom, anxiety, frustration, fatigue,
depression, alienation, anger/irritability, physical problems like headaches and stomach
problems.

Variables that Lead to Workplace Stress

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There are some variables that can lead to a stressful workplace. These are the
demographic factors, the design of tasks, the management style, interpersonal
relationship p, the environmental conditions, the role of ambiguity and lack of
participation in deci sion making.
Marital status, aging, and gender are some of the demographic factors. Aging is
a natural and gradual process, except when exposed to extreme circumstances of grief.
Stressors actually occur before a child takes his first breath, and it grows as one grows
up. Gender where in females face higher degree of stress because of the work life
balance they have to maintain at home and work.
The design of tasks into heavy workload, infrequent rest breaks, long working
hours doesn’t utilize workers skills and provide little sense of control.
The lack of participation by workers in decision making, poor communication in
the organization are some of the management styles while interpersonal relationship like
poor social environment and lack of support or help from co-workers and supervisors,
conflict with other employees lead to stressful workplace.
Unpleasant or dangerous physical environmental conditions such as crowding,
noise, air, pollution etc., and the role of ambiguity or uncertainty about duties and
responsibilities as well as lack of participation in decision making are also variables that
contribute to a workplace stress. (Sheu, et.al, 2002)

Causes of Stress

Stress is one cause of general adaptation syndrome. The results of unrelieved

stress can manifest as fatigue, irritability, difficulty concentrating, and difficulty sleeping.
Persons may also experience other symptoms that are signs of stress. Persons
experiencing unusual symptoms, such as hair loss, without another medical explanation
might consider stress as the cause.
The general adaptation syndrome is also influenced by such universal human
variables as overall health and nutritional status, sex, age, ethnic or racial background,
level of education, socioeconomic status (SES), genetic makeup, etc. Some of these
variables are biologically based and difficult or impossible to change. For example,
recent research indicates that men and women respond somewhat differently to stress,
with women being more likely to use what is called the "tend and befriend" response
rather than the classical "fight or flight" pattern. These researchers note that most of the
early studies of the effects of stress on the body were conducted with only male
subjects.
Selye's observation that people vary in their perceptions of stressors was
reflected in his belief that the stressors themselves are less dangerous to health than
people's maladaptive responses to them. He categorized certain diseases, ranging from
cardiovascular disorders to inflammatory diseases and mental disorders as "diseases of
adaptation," regarding them as "largely due to errors in our adaptive response to stress"
rather than the direct result of such outside factors as germs, toxic substances, etc.
(Malik, 2008).
The potential causes of stress are numerous and highly individual. What you
consider stressful depends on many factors, including your personality, general outlook
on life, problem-solving abilities, and social support system. Something that's stressful to
you may not faze someone else, or they may even enjoy it. For example, your morning
commute may make you anxious and tense because you worry that traffic will make you
late. Others, however, may find the trip relaxing because they allow more than enough
time and enjoy listening to music while they drive.
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The pressures and demands that cause stress are known as stressors. We
usually think of stressors as being negative, such as an exhausting work schedule or a
rocky relationship. However, anything that forces us to adjust can be a stressor. This
includes positive events such as getting married or receiving a promotion. Regardless of
whether an event is good or bad, if the adjustment it requires strains our coping skills
and adaptive resources, the end result is stress.
Causes of stress include: Environmental stressors – Your physical surroundings
can set off the stress response. Examples of environmental stressors include an unsafe
neighborhood, pollution, noise (sirens keeping you up at night, a barking dog next door),
and uncomfortable living conditions. For people living in crime-ridden areas or wartorn
regions, the stress may be unrelenting. Family and relationship stressors – Problems
with friends, romantic partners, and family members are common daily stressors. Marital
disagreements, dysfunctional relationships, rebellious teens, or caring for a chronically-ill
family member or a child with special needs can all send stress levels skyrocketing.
Work stressors – In our career-driven society, work can be an ever-present source of
stress. Work stress is caused by things such as job dissatisfaction, an exhausting
workload, insufficient pay, office politics, and conflicts with your boss or co-workers.
Social stressors – Your social situation can cause stress. For example, poverty, financial
pressures, racial and sexual discrimination or harassment, unemployment, isolation, and
a lack of social support all take a toll on daily quality of life.

Internal Causes of Stress

Not all stress is caused by external pressures and demands. Your stress can
also be self-generated. Internal causes of stress include: uncertainty or worries,
pessimistic attitude, self-criticism, unrealistic expectations or belief, perfectionism, low
self-esteem, excessive or unexpressed anger, and lack of assertiveness.

Stress and Heredity

The effects of human activity on natural ecosystems have increased the risk of
extinction for many animal and plant populations. Human activities have caused an
increase in stochastic fluctuations in population sizes, changed the interactions between
predators and their prey and led to changes in the genetic structure within and between
populations.
These factors could potentially result in inbreeding and/or out breeding
depression and loss of genetic variation. For these and other reasons, a fitness decline
has accelerated during the last decades in many populations and this process is likely to
continue in the future. To set conservation priorities, it is important to assess the relative
threats posed by the different factors causing fitness declines.
Conservation biologists need rapid and reliable techniques for detecting
reductions in fitness inflicted by demographic and environmental insults. From a genetic
point of view, acquiring more knowledge about how to detect inbreeding and out
breeding depression and loss of genetic variability under natural conditions at an early
stage and to evaluate its consequences are the main priorities. Recognizing the
presence of genetic and environmental stresses before their effects become deleterious
is one of the most important but at the same time difficult tasks. (Frankham, 2005)

The Consequences of Stress

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Stress has been the consequence for 50-80% of diseases. Insomnia or the
inability to fall asleep, aging, and hypertension or high blood pressure, which would lead
to lethal complications are some of the consequences of stress. Research has proven
that people age faster when they experience more stress. (Baker, 2004)
Modern living is stressful. According to figures from New York's American
Institute of Stress, 90 percent of all American adults experience high stress levels one or
two times a week and a fourth of all American adults are subject to crushing levels of
stress nearly every day. "Stress" is a term that often is used in a negative sense. The
same stressors that are stimulating or challenging in a positive sense also may be
debilitating if they accumulate too rapidly. It is believed that setting unrealistic goals
generates much of the negative stress people feel. These goals may include the need for
a particular standard of income or technical perfection. Although setting lofty goals and
high standards is a noble theory, how people do this can create a load that often
becomes unbearable.
During the first year of college, students are faced with numerous educational
and personal stressors which can negatively impact their psychological and physical
health. How much stress a person can tolerate comfortably varies not only with the
accumulative effect of the stressors, but also with such factors as personal health,
amount of energy or fatigue, family situation and age. Stress tolerance usually decreases
when a person is ill or has not had an adequate amount of rest. During major life
changes (birth of a child, serious accident to family member or oneself, divorce, death,
geographic relocation), people’s ability to tolerate stress also is reduced. Past experience
enhances people’s ability to manage stress and develop coping skills. After several
similar experiences, people normally learn a standard way to cope with a particular
stressor. Our stress tolerance often will vary according to the people who surround us;
being surrounded by significant and supportive others can help people resist the effects
of stress. Dentists and dental auxiliaries who like each other and work well together can
reinforce one another and help raise one another’s tolerance of stress.
The National Center for Health Statistics (NCHS) in 1990 conducted the National
Health Interview that included several questions regarding stress. Data were published
in a report entitled "Health Promotion and Disease Prevention" (United States, 1990).
The report said that more than half (57 percent) of adults experienced a moderate
amount of stress. Persons with higher education and income were more likely to feel
stress than persons with lower education and income. Four in ten adults (41 percent)
reported that stress had at least some effect on their health, with women (47%) more
likely than men (34%) to have reported this. The survey also noted that only 13 percent
of adults had sought help to reduce their stress from either a professional or
nonprofessional. (Hall, 2006)
Society is changing rapidly causing changes in values, life styles, career
patterns, family expectations and so on. Over the past few years, popular and
professional books, magazines and journals have focused increasingly on stress and its
impact on people. In any bookstore one can find books on stress and how to escape
from it. Professional publications in the behavioral sciences are dealing with the same
issue. Many different disciplines are trying to discover more about how people cope with
the pressures of daily living. While reviewing the vast amounts of literature, it became
quite clear that stress is a very complex problem in our day. Most likely, it is a problem
that will not soon leave us if our lifestyles continue in the hectic paces we have chosen.
Given that no two people are alike in the way they handle tension, pressure and pain,
clearly there is no particular way to deal with stress that works the best for each person.
Fortunately, as this review of literature will point out, there are things that people can do
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to actively reduce the amounts of stress they are feeling and by that, handle life in a
more healthy and happy way. (Polychronopoulou, 2005).
Lazarus and Folkman defined stress as a "relationship between the person and
the environment that is appraised by the person as taxing or exceeding his or her
resources and endangering his or her well-being" ( Pelletier 1992). This definition
suggests that not only the stressor but the person's perception of her ability to adapt to
the stressor are important in the perception of stress.
Benson and Stuart (1992) refer to stress as the negative effects of life's
pressures and events. Their reference in this context was to distress, as when the body
becomes unable to adapt and cope with ongoing pressures.
Asterita (1995) defined stressors as "any stimuli which an organism perceives as
a threat". She explained that these stressors may be physical, psychological, or
psychosocial in nature.
A physical stressor may include such conditions as environmental pollutants or
other environmental pressures such as an extreme change in temperature or an
electrical shock. Other physiological stressors may include a decrease in oxygen supply,
prolonged exercise, hypoglycemia, injuries, and other trauma to the body.
Psychological stress results from reactivity within oneself to one's own thoughts
or feelings about perceived threats, real or imagined. Psychosocial stress may result
from intense social interactions, or their lack, or other variables associated with
relationships.
According to Kobasa (1999), stress hardy individuals show high levels of three
psychological characteristics: control, commitment, and challenge. People who are high
in control have a strong belief that they can exert an influence on their surroundings, that
they can make things happen. They believe that they can influence events instead of
becoming a victim. This is the opposite of feelings of helplessness. Psychologists define
control as "a belief that one has at one's disposal a response that can influence the
aversiveness of an event.”
People who are high in commitment tend to feel fully engaged in what they are
doing from day to day and are committed to giving these activities their best effort. They
have an attitude of curiosity and involvement in what is happening around them. People
who are high in challenge see change as a natural part of life that affords at least some
chance for further development. They believe that change brings a chance for growth
instead of fear that change is threatening. When potentially stressful experiences
happen in the lives of people with the hardy psychological pattern they are physically
more resistant to disease and illness. (Malik, 2006).
Naidu (2002) describe the differences in internal activity between the two who go
on the roller coaster ride. When the thrill seeker goes on the ride and experiences it as a
wonderfully exciting time, she produces certain chemicals, interleukins and interferons,
which are very powerful anti-cancer drugs. The person who abhors roller coaster rides,
although it is the same experience, secretes chemicals such as cholesterol, triglycerides,
norepinephrine, ACTH (adrenocorticotrophic hormone) and insulin. The body needs high
levels of adrenaline, and these other chemicals when it is physically threatened and it
must physically fight or flee. However, when we chronically invoke reactions that
produce these chemical responses, the excesses can turn against us. Again, it is the
perception, the interpretation of the situation that determines the internal activity.
Our physiological reactions are related to how much of a threat we perceive
ourselves to be in and how much control we believe we have over the situation. When
we perceive our trouble as more threatening than challenging, or our capacity to cope as
more hopeless than promising, the physiological changes that result may lead to illness.
Our bodies still react in the same manner to threats we come upon, be they real
 11

or imagined. Usually, the stressor, however, does not require us to fight or flee. Harvard
Cardiologist Herbert Benson remarked, "The fight-or-flight emergency response is
inappropriate to today's social stresses" (Benson, 1994).

General Adaptation Syndrome

When a stressor is perceived, the body goes through a process that Selye has
termed the general adaptation syndrome (GAS). A summary of this syndrome follows:1)
Alarm reaction. In the first stage, or the alarm reaction, the body immediately responds
to the stress. Various physiological changes occur that enable the body to combat
stress. A change that occurs almost immediately during the alarm reaction is depression
of the immune system; normal resistance is lowered, and the victim becomes more
susceptible to infection and disease. If the stress is brief, the body's response is limited
to that of the alarm reaction. When the stress ends, so does the reaction. 2) Resistance.
In stage two, resistance, the body makes physiological changes that enable it to adapt to
long-term stress. Coping with the stressor becomes the specific job of the particular
systems best suited to the task. During this second stage, resistance to the stressor is
usually high, but because resources are diverted away from other areas, general
resistance to disease may be low. 3) Exhaustion. The body eventually loses the ability to
keep up with the demands that stress puts on it, and it enters the third stage, exhaustion.
The organ systems or processes handling the stressor becomes worn out and breaks
down.
This whole process functions to maximize the body's ability to resist stressors.
Even after the exhaustion phase has occurred in one area, the burden may be shifted to
another system equally capable of dealing with the situation (Pelletier, 1992).

College Students’ Measures of Perceived Stress

Existing research provides limited information on stress among college students.

A study in a northern California community (Schafer & King, 1990) found that 37% of
college students of this community reported feelings of great stress more than once or
twice a week. Twenty-nine percent of non-students of this community reported great
stress more than once or twice a week.
Another study (Robinson, 2001) compared levels of perceived stress among
residents, medical students, and graduate students at a major medical university in
Calgary, Canada. They found stress levels were similar for all three groups and were
described as "elevated," although the graduate level (MSc/PhD) students showed
slightly higher levels of stress than the other two groups. Women reported higher levels
of stress than men. The three groups had similar stressors, as well, including preparing
for and taking examinations and evaluations, quantity of work required, time available,
and self-expectations.
Frazier, & Schauben wrote that in assessing stress among female college
students, many of those surveyed had experienced major stress in their lives. The
primary sources of stress for these students were test pressure, financial problems,
being rejected by someone, relationship breakups, and failing a test. They also found
that Asian American female college students reported a greater number of stressors and
a higher degree of stress than European American female college students, while a
needs assessment at the University of Maryland (Downey, 2003) found that stress and
tension was the second greatest health concern of college students following fitness.
For the past hundred years, the pedagogical focus of health professions training
has encouraged the development of clinical behaviors expressing impersonal objectivity
 12

in managing patients. In recent decades, however, course workload requirements and

the teaching of clinical decorum have slowly taken a more humanistic approach. Despite
these curricular changes, the evidence of stress studies in the health professions
education literature suggests that the education of medical and dental students has taken
a toll on their physical and psychological health.
The Garbee et al.(2008) survey recognized six categories of potential stressors
for dental students. For the purpose of our comparison study of allied medical and dental
students, the six categories will be consolidated into five: academic performance, faculty
relations, patient and clinic responsibilities, personal life issues, and professional identity.

Academic Performance As a Potential Stressor

In the dental literature, several factors have been linked to stress experienced as
a response to students’ efforts to meet academic performance requirements in dental
school. The two most frequently cited are grade competition and heavy workload.
Competition to receive good grades for freshman and sophomore students is generally
focused on the completion of preclinical laboratory projects in addition to successful
performance in demanding basic science courses. Junior and senior students, on the
other hand, generally experience stress related to difficulties in meeting procedural
clinical requirements. Long hours and heavy workload were also noted in several studies
as contributing to a stressful learning environment. Heavy workload pressures result in a
fear of failure due to concerns about falling behind in course requirements. Sanders and
Lushington found that students with higher levels of stress related to their relationships
with faculty members tended to have lower grades in tests of clinical competence and
basic understanding.
Studies of allied medical students have reported competitive pressures to
achieve good grades in didactic examinations and clinical practice evaluations. Other
studies noted heavy workload and long hours during professional training as highly
stressful experiences.

Student Relationships with Faculty As a Potential Stressor

Dental students reported high levels of stress due to inconsistent feedback from
faculty and perceptions of receiving unjustified criticism on preclinical and clinical
exercises. They found few faculty members who were willing to serve as mentors.
Faculty members appeared to be generally unaware of the high levels of stress their
students were facing and did not recognize signs of student burnout. Hayes et al.
suggested that allied medical schools promote a culture of intimidation for students who
do not comply with expected behavioral norms. Holm and Aspergen (1999), reported
that students who utilized both scientific and humanistic techniques were often criticized
as not being as professionally competent as their colleagues who relied exclusively on
an impersonal, scientific approach to managing patients.

Patient and Clinical Responsibilities As a Potential Stressor

Pau and Croucher (2003) conducted a study of British dental students that
measured their emotional intelligence quotient. Students with low emotional intelligence
scores perceived more stress when dealing with patients in their training clinics.
Incidental to the primary focus of their research on emotional intelligence, these
researchers found that third- and fourth-year students had higher levels of stress than
 13

preclinical students in their first or second year of training.

The effects of chronic stress in medical school training have been reported as
contributing to a feeling of depersonalization in dental students’ relationships with their
patients. Students complain about their inability to empathize with their patients’ anxiety
in coping with their illnesses. Spencer concluded that the often-reported decline in dental
empathy among dental students is due to transient social relationships, hurried and
fragmented relationships with patients, and avoidance of intimacy during medical
training.

Personal Life Issues As a Potential Stressor

Researchers in both dental and medical education have reported student

frustration with the lack of social support from their schools or an inadequate amount of
time for rest and relaxation. Acharaya (2003), reported that Indian dental students were
often stressed by the fear of facing their parents after failing academically. Mounting
financial responsibilities were also found to be a significant source of stress for both
student groups. Stewart et al. noted that the loss of opportunities for social and
recreational activities contributed to higher stress levels, less overall academic success,
and more symptoms of depression in second-year dental students.
Questions in the DES (Dental Education Stressor) have measured the effects of
stress in dental school education on peer relationships, but none of the studies to this
point have reported that dental education has a deleterious effect on peer interactions.
Hayes et al. reported that medical school training does have a negative effect on the
ability of some class members to fit in with their colleagues.

Professional Identity As a Potential Stressor

Students appear to face challenges during their professional training in

developing and maintaining a sense of confidence in their ability to be effective
clinicians. Very often, these challenges have been found to be affected by gender and
are also linked to an imperative for students to exhibit perfection in all aspects of their
behavior and clinical skills.
In three dental school studies, female dental students had significantly higher
stress levels than males. Burk and Bender found that dental students reported their
stress was related to personal disappointments over their academic performance. To
cope with stress caused by their perceptions of inadequate performance, students
sought support from upperclassmen, their peers, and faculty members in their preclinical
and clinical courses. Female dental students were reported to be more likely to
experience emotional problems related to stress. Polychronopoulou and Divaris, (2005),
also reported that females felt much more stressed about the difficulty of their
coursework and their fear of failing. Westerman et al. found stress scores to be generally
higher among females than males in several measurement categories of the DES.
Both dental and medical students also suffered stress due to a perceived lack of
competence in being able to treat patients. Upperclassmen in dental school
demonstrated stress related to insecurity about professional failure. Henning et al.
(2004), suggested that medical and dental students’ pursuit of perfection led them to feel
like imposters if they had difficulties adjusting to the rigors of professional life. Dahlin et
al. (2005), reported that third- and sixth-year students in Swedish medical schools
suffered significant stress from a lack of confidence in their personal ability to endure
long hours and perform clinical duties competently. Several stress factors were
 14

associated with depression. The incidence of depression symptoms reported by medical

students was felt to be greater than that found in the general population.
This study also found that female medical students reported higher levels of
stress than males and that the types of stressors having the greatest impact on students’
well-being changed as they progressed from preclinical to clinical training. Radcliffe and
Lester (2003) reported that developing a professional demeanor was felt by medical
students to be one of the most demanding aspects of their training. These investigators
reported that transition periods, such as graduating from preclinical to clinical training,
were considered the most stressful times in their professional education.
Rosenfield and Jones (2004) suggested that too much emphasis is placed on
scientific objectivity and detachment in medical training. Knowing when to talk, act, listen,
or tolerate a patient’s distress is part of the art form of medicine. An unfortunate side
effect of medical training noted by these authors is that it produces physicians who
believe that self-denial is valuable and necessary and that living under stress is normal.
Research also found that the faculty affects a student’s sense of self-efficacy
through social influence and group normative behaviors. Wilkes and Raven define social
influence as "a change in the attitude, belief, or behavior of a target resulting from the
actions of another person or group of persons”. Student trainees are often considered
the lowest members of the power hierarchy, which makes them more susceptible to
social influences. Because students are uncertain of their competence, afraid of a poor
evaluation, or want to please a superior, these feelings may have a profound effect on
their ability to learn and to adopt a professional demeanor.
Wilkes and Raven (2002), also argue that allied medical students’ professional
identity stressors are caused by poor relationships with faculty members, who may not
always set a good example for professional behavior. Lack of proper professional
demeanor includes behaviors such as cynicism, disrespect, and disdain for patients and
support staff. Some medical students wishing to establish a favorable relationship with
their faculty preceptors may emulate these behaviors. A faculty member’s professional
style may be reflective of his or her own sense of security and confidence in his or her
own competence. Teaching styles that either nurture or mentally abuse trainees may be
reflective of a faculty member’s own psychosocial needs. In addition to the effect of
faculty, Wilkes and Raven (2002) found that such factors as call schedules, sleep
deprivation, mood changes, lack of proper nutrition, lack of "quality" time with family and
friends, and worry over managing financial debt may also contribute to dental student
stress.

Preventive Management

Stress management is the way we respond and react to the everyday pressures
and demands of life. Developing effective stress management skills are crucial. It is the
field of management developed to deal with individual as well as workplace stress. It is
an intervention designed to reduce the impact of stressors in the workplace.
These can have an individual focus, aimed at increasing an individual’s ability to
cope with stressors. Stress-management programs can also have an organizational
focus and attempt to remove the stressors in a role. For example, improving
communication may reduce uncertainty. It basically deals with the measures taken by
the organization to help individuals overcome work related stress.
Pressures and stress are part of these jobs, and while you may be able to
eliminate some pressures, others will always remain. Major contributors to job stress are
lack of information, poor environments, lack of control over work and the pace of work,
frequent distraction and upset, and frustration of goals. People can also find that the
 15

demands of their jobs conflict with their values, beliefs or goals. This can cause intense
stress.
According to one theory, differences in individual characteristics, such as
personality and coping style, are best at predicting what will stress one person but not
another. The focus then becomes on developing prevention strategies that help workers
find ways to cope with demanding job conditions.
The other theory proposes that certain working conditions are inherently stress-
inducing, such as fear of job loss, excessive workload demands, lack of control or clear
direction, poor or dangerous physical working conditions, inflexible work hours, and
conflicting job expectations. The focus then becomes on eliminating or reducing those
work environments as the way to reducing job stress. (Parekh, 2002).
The German Freudian psychoanalyst Karen Horney (2006) defined four so-called
coping strategies to define interpersonal relations, one describing psychologically
healthy individuals and the others describing neurotic states.1. Moving With. These are
the strategies in which psychologically healthy people develop relationships. It involves
compromise. In order to move with, there must be communication, agreement,
disagreement, compromise, and decisions. Karen Horney (2006), describes the other
strategies as a neurotic. This means that they are unhealthy strategies people utilize in
order to protect themselves. 2. Moving Toward. The individual moves towards those
perceived as a threat to avoid retribution and getting hurt. The argument is, “If I give in, I
won’t get hurt.” This means that if I give everyone I see as a potential threat what ever
they want, I won’t be injured (physically or emotionally). 3. Moving Against. The
individual threatens those perceived as a threat to avoid getting hurt. 4. Moving Away.
The individual distances themselves from anyone perceived as a threat to avoid getting
hurt. The argument is, “If I do not let anyone close to me, I won’t get hurt.” A neurotic,
according to Horney desires to be distant because of being abused. If they can be the
extreme introvert, no one will ever develop a relationship with them. If there is no one
around, nobody can hurt them. These Moving Away people fight personality, so they
often come across as cold or shallow. This is their strategy. They emotionally remove
themselves from society.
Relaxation is the direct negative of nervous excitement. It is the absence of
nerve-muscle impulse. The word "relax" comes from the Latin word laxus which means
to be loose. To relax simply means to regain a natural feeling of looseness and ease. In
its physiological sense relaxation is the lengthening of muscle fibers, whereas tension is
the contraction of muscle fibers.
It became evident that there are many methods that people use to relax, to
reduce their perceived levels of stress. There is no final word about which single method
achieves the relaxation or stress reduction that people are seeking. However, some
methods of increasing relaxation have been more scientifically examined than others.
One thing that is clear is that people deal with stress in a wide variety of ways.( Malik.
2006).
Stress is often a frame of mind, result from being attached to the results of our
labor, the feeling that we need to be in control. When we are not in control, it causes
stress. Moreover, it is caused by one's ego. The ego causes us to take offense, to be
attached to the fruits of our actions, to need security, attention, to have the "what about
me" taken care of. It is a mental condition in which the mind/ego is out of sync with the
rest of our mind.
Often times an unhealthy physical stress reaction results from a mental reaction
to conditions at hand. Obvious examples are anxiety attacks and phobias. These major
maladies are frequently amenable to treatment by hypnosis.
Perhaps many societally induced stress reactions are merely subtle or less acute
 16

forms of the above problems. (Exclude stress caused physical phenomenon, e.g. a
nearly avoided accident on the freeway. (Though such events could trigger stress
reactions in later unrelated circumstances!)) Possibly, people that exhibit unhealthy
stress responses have mild underlying mental triggers, perhaps a complex array of
them. (Ron de Kloet, 2005)
Feldenkrais Method, is a very useful medium for retraining the nervous system.
This method works by accessing unconscious habitual contractive patterns and teaching
the client to make them conscious and then have the ability to choose what is more
comfortable or efficient.
The Feldenkrais Method is based on principles of physics, biomechanics and an
empirical understanding of learning and human development. By expanding the self-
image through movement sequences that bring attention to the parts of the self that are
out of awareness, the Method enables people to include more of themselves in their
functioning movements. Students become more aware of their habitual neuromuscular
patterns and rigidities and expand options for new ways of moving. By increasing
sensitivity the Feldenkrais Method assists people to live their lives more fully, efficiently
and comfortably.
The improvement of physical functioning is not necessarily an end in itself. Such
improvement is based on developing a broader functional awareness which is often a
gateway to more generalized enhancement of physical functioning in the context of one's
environment and life. (Shaikha, 2004)
Davis, Eshelman, and McKay, (1998), called The Relaxation & Stress
Management Workbook. Chapter by chapter it focuses on the following methods for
increasing levels of relaxation: body awareness; progressive relaxation; self-hypnosis;
meditation; autogenics; refuting irrational ideas; nutrition; breathing; visualization;
thought stopping; coping skills; assertiveness training; time management; job stress
management; biofeedback; and exercise.
Seaward (1994), divided the means for managing stress into two sections:
Coping strategies and relaxation techniques. The coping strategies include the following:
dealing with toxic thoughts; acceptance; cognitive restructuring; behavior modification;
assertiveness; journal writing; art therapy; humor (comic relief); creativity;
communication skills; time management; social-support groups; hobbies; forgiveness;
dream therapy; prayer.
The relaxation techniques in this text included the following: several breathing
techniques; concentration; visualization; transcendental meditation; the Benson method
of relaxation; Zen and other types of meditation; hatha yoga; conscious breathing;
mental imagery; color therapy; music therapy; visualization with music; massage therapy
including shiatsu, Swedish massage, rolfing, sports massage, and other touch therapies;
t'ai chi ch'uan; progressive muscular relaxation; autogenic training; clinical biofeedback;
physical exercise; nutrition.
Rice (1992) outlined a number of ways for increasing levels of relaxation and
reducing stress. This included the following: coping skills such as social support,
increasing self-efficacy, cognitive restructuring such as positive self-talk, problem solving
techniques, and increasing communication skills; positive diversions such as hobbies,
music, exercise; self-disclosure; seeking information; monitor levels of stress; avoidance;
denial; and addictions. He outlines ways to physically reduce stress and tension by:
progressive muscle relaxation; using a mantra; guided imagery; autogenics; systematic
desensitization; cognitive restructuring; stress inoculation; transcendental meditation;
yoga meditation; the Benson method of meditation; biofeedback; time management;
nutrition; and exercise.
Another text (Shaikha,2004) described the following as methods of reducing
 17

stress: increasing personal control over situations; set up a social network of support;
hypnosis; progressive relaxation; biofeedback; behavior modification; cognitive therapy;
and stress inoculation.
A final manual found in this review was written by Schafer (1992). In it are listed
a variety of methods designed to reduce stress levels. The sections are broken into
three parts. The first is titled Coping Options and considers the following methods:
exercise; situational self-talk skills; positive beliefs such as a sense of coherence,
hardiness, and optimism; problem-solving skills; communication skills; social support;
material resources; community services; and sleep. The second section considers ways
of coping considered by the author as "maladaptive reactions to stress." These include
the following: alcohol abuse; smoking; drugs; overeating; escapism; spending sprees;
physical and verbal abuse; blaming others; overworking; denial; magnification (making a
mountain out of a molehill); and martyrdom. Next, he reviews "adaptive reactions" to
stress: medications; solitude; music; play; prayer; intimacy; massage; professional
assistance; hobbies; hydrotherapy; humor; exercise; nutrition; sleep; deep relaxation;
health pleasures such as feeding animals, enjoying pets, conversations with family,
sitting in a recliner chair, reading the newspaper, taking a hot tub under the stars,
kayaking down a river.
An entire chapter of Shafers’ manual is devoted to how we talk to ourselves and
the beliefs that we carry around that motivate that internal dialogue. Techniques for
turning that negative self-talk into positive are discussed. Another chapter is devoted to
relaxation techniques such as breathing techniques; standing relaxation techniques;
mental techniques such as thought stopping, mental diversion, positive affirmations, and
desensitization; meditation; biofeedback; autogenic relaxation; hypnosis and self-
hypnosis; and visualization.
 18

Method

Research Design

The study used the descriptive research design with the combination of content
analysis of documents and related materials.

Participants

The participants of the study were paramedical students of Lyceum of the

Philippines University during the school year 2010-2011. Using the Slovins formula with
7% margin of error, respondent’s profile of the study is shown in Table 1.

Table 1
Percentage Distribution of the Respondents Profile
N = 188
Profile Variables Frequency Percentage (%)
Age
15 – 18 years old 124 66.00
19 – 22 years old 47 25.00
23 – 26 years old 12 6.40
27 – 30 years old 5 2.70
Year Level
1st year 60 31.90
2nd year 71 37.80
3rd year 51 27.10
4th year 6 3.20
Course
Dentistry 7 3.70
Med Tech 17 9.00
Rad Tech 9 4.80

PT 5 2.70
Nursing 150 79.80
Gender
Male 24 12.80
Female 164 87.20
Civil Status
Single 178 94.70
Married 10 5.30

Instruments
 19

The researcher utilized the following instruments and data gathering techniques
in conducting the study, particularly in collecting the data. A survey research design was
selected for this study. According to Isaac and Michael (1990): Surveys are the most
widely used technique in education and the behavioral sciences for the collection of
data. They are a means of gathering information that describes the nature and extent of
a specified set of data ranging from physical counts and frequencies to attitudes and
opinions. This information, in turn, can be used to answer questions that have been
raised, to solve problems that have been posed or observed, to assess needs and set
goals, to determine whether or not specific objectives have been met, to establish
baselines against which future comparisons can be made, to analyze trends across time,
and generally, to describe what exists, in what amount, and in what context.
A modified version of the Dental Environmental Stress questionnaire, compiled
by Westerman et al. (2003), was used as the original template for the survey.
Westerman et al. had made revisions to Garbee et al.’s original (1980) format to make
the survey suitable to their investigative design. For the research design of this study, the
questions were revised to apply to the clinical and didactic aspects of school training. To
accomplish this task, questions that pertain to dental training were changed to reflect a
neutral health care setting. The essential purpose of the question remained intact. The
questions were then jointly reviewed by dental administrators to establish their face
validity as predictors of professional school stress.
Survey data was collected from paramedical students of Lyceum of the
Philippines University. Prior to administering the survey, the survey questions and
research methodology were reviewed and approved by the Research Center of the
university.
The first part of the survey questions dealt with questions regarding the students’
perceived major sources of stress. The evaluation of this questionnaire used the five-
point Likert Scale presented as:

Descriptive Data Numerical Data

Strongly Agree 5
Agree 4
Undecided 3
Disagree 2
Strongly Disagree 1

The thirty-four Westerman et al. questions, which will ask respondents to indicate
the level of stress associated with each item, will be presented in a multiple-choice
format with responses as follows:

0=not pertinent
1=not stressful
2=slightly stressful
3=moderately stressful and
4=very stressful.

The Relaxation Frequency Inventory

This section asks respondents in a college setting on how they cope with stress.
It describes fourteen possible responses for methods they use to cope with stress. The
researcher created an inventory that will consider all the possible ways that college
 20

students perceive that they are dealing with their individual stress. It gathers information
about the extent that respondents are presently participating in ways to cope, ways to
unwind, methods of relaxing, or ways of managing stress.

Respondents are asked, "Thinking back on the past few weeks, on average, list
all the things you do regularly to cope with stress, relax, unwind or otherwise manage
stress in your life and how much time you spend doing them." Respondents listed all
methods that they employ to manage stress. Next to each response, the respondents
answer how frequent they participated in each activity. Responses range from:

Descriptive Data Numerical Data

Always 5

Frequently 4

Occasionally 3

Seldom 2

Never 1

Finally, an open-ended question, which could be responded to using an

additional blank piece of paper will be worded in the following manner:
There may be other activities that you do to help you relax, cope, unwind, or deal
with stress that do not fit into any of the categories listed above. We are very interested
in knowing anything else you regularly do and for what amount of time you do them,
during a typical week. Please use the accompanying blank sheet of paper to list these
activities. Also, write the approximate amount of time that you participate in each activity
that you list. There are no right or wrong answers.

Validation

In determining the instrument’s validity, the researcher presented the instrument

to her colleagues and dean for improvement. Pilot-testing was also done among 20
paramedical students. Necessary revisions were made for exactness and acceptability
of the instrument.

Statistical Analysis

The research questions, methods, and appropriate statistical design for this study
were: Pearson's r correlation and descriptive statistics.
Pearson’s r correlation was used to know if there was a relationship between the
major sources of stress and the levels of perceived stress among college students. On
the other hand, descriptive Statistics included means, standard deviation, ranges and
percentage. These were used to determine the major sources of stress the college
students perceived and the methods they actively participate in to reduce stress.
 21

Results and Discussion

This presents an analysis of the data collected according to the methods and
procedures described in the methodology. This analysis includes a reiteration of the
purpose of the study and the results of the demographic data collected on the sample of
paramedical students of Lyceum of the Philippines University who responded to the
survey.
As seen from the table 2.1, lack of time for relaxation, amount of assigned
coursework, difficulty of coursework were the top three items which obtained a rating of
strongly agree with weighted mean values of 4.68, 4.53 and 4.52 respectively.
Competition to receive good grades for freshman and sophomore students is
generally focused on the completion of preclinical laboratory projects in addition to
successful performance in demanding basic science courses. Junior and senior
students, on the other hand, generally experience stress related to difficulties in meeting
procedural clinical requirements. Long hours and heavy workload were also noted in
several studies as contributing to a stressful learning environment. (Garbee et al. 2008)
Necessity to postpone marriage, necessity to postpone children, and
dependencies to drugs, alcohol, and etc. were found to be not a source of stress maybe
because students were focused on their studies.
According to Schafer (19920, drugs and alcohol dependencies are “maladaptive
reactions to stress." Students knew that these will not help them to cope with stress. As
viewed from the table 2.2, it found out that the level of stress was slightly stressful given
by the composite mean of 2.40.
The level of stress varies mainly on slight to moderate level and among the
situation / activities enumerated, examinations, fear of failing course or year, difficulty of
coursework, concerns about treatment grades awarded and differences in opinion
between clinical staff concerning treatments obtained a rating of 3.27, 3.16, and 2.83
respectively. All were concerned on school matters and were interpreted as moderately
stressful.
Studies of allied medical students have reported competitive pressures to
achieve good grades in didactic examinations and clinical practice evaluations. Other
studies noted heavy workload and long hours during professional training as highly
stressful experiences. (Garbee et a. 2008)
Most of the items mentioned were interpreted as slightly stressful, but theeast
were necessity to postpone marriage (1.80), necessity to postpone children (1.55) and
making friends (1.53).
Problems with friends, romantic partners, and family members are common daily
stressors. Marital disagreements, dysfunctional relationships, rebellious teens, or caring
for a chronically-ill family member or a child with special needs can all send stress levels
skyrocketing. (Frankham, 2005).
Based from the table 3, the respondents occasionally manage stress in their daily
living as revealed by the obtained composite mean of 3.37. Among theitems mentioned,
talking with family, friends or other supportive people got the highest weighted mean of
3.94 and rated frequently. The idea of social support has been described as the
knowledge of a person to believe that he or she "is cared for and loved, to believe that
he or she belongs to a network of communication and mutual obligations.
Rice (1992) outlined a number of ways for increasing levels of relaxation and
 22

reducing stress. This included the following: coping skills such as social support,
increasing self-efficacy, cognitive restructuring such as positive self-talk, problem solving
techniques, and increasing communication skills; positive diversions such as hobbies,
music, exercise; self-disclosure; and seeking information. He outlines ways to physically
reduce stress and tension by: progressive muscle relaxation.

Table 2.1
Sources of Stress among Paramedical Students
N = 188
Weighted
Items Verbal Interpretation Rank
Mean
1. Moving away from home. 3.36 Undecided 27
2. Environment in which to study 3.96 Agree 7
3. Lack of home atmosphere. 3.91 Agree 10
4. Other problems with accommodation. 3.80 Agree 14
5. Making friends. 2.73 Undecided 36
6. Financial Responsibilities. 3.94 Agree 8
7. Personal physical health. 3.84 Agree 13
8. Relationship between members of opposite
2.93 Undecided 32
sex.
9. Necessity to postpone marriage. 2.38 Disagree 39
10. Necessity to postpone children. 2.42 Disagree 38
11. Having multiple roles. 3.93 Agree 9
12. Conflict with spouse/mate over career
2.98 Undecided 31
development.
13. Lack of time for relaxation. 4.68 Strongly Agree 1
14. Having children in the home. 2.78 Undecided 35
15. Having reduced holidays compared with
3.65 Agree 19
other students.
16. Fear of going out due to crime. 2.99 Undecided 30
17. Dependencies (drugs, alcohol, etc.) 2.47 Disagree 37
18. Expectation versus reality in school. 3.88 Agree 12
19. Approachability of staff. 3.21 Undecided 28
20. Criticism about academic or clinical work. 3.59 Agree 24
21. Rules and regulations of the school. 3.14 Undecided 29
22. Discrimination due to race, nationality,
2.88 Undecided 33
gender, or social class.
23. Amount of assigned coursework. 4.53 Strongly Agree 2
24. Difficulty of coursework. 4.52 Strongly Agree 3
25. Fear of being able to catch up if falling
4.09 Agree 6
behind.
26. Competition for grades. 3.66 Agree 18
27. Fear of failing course or year. 4.31 Agree 5
28. Uncertainty about career. 2.85 Undecided 34
29. Examinations. 4.49 Agree 4
30. Lack of input in decision making process in
3.91 Agree 11
school.
31. Concerns about manual dexterity. 3.48 Undecided 25
32. Transition to clinical course. 3.68 Agree 17
33. Learning precision manual skills. 3.61 Agree 23
34. Completing clinical requirements. 3.64 Agree 21
35. Concerns about treatment grades awarded. 3.75 Agree 15
36. Differences in opinion between clinical staff
3.63 Agree 22
concerning treatments.
37. Shortage of allocated clinical time. 3.69 Agree 16
38. Patient management 3.64 Agree 20
39. Confidence in all clinical decision making. 3.44 Undecided 26
Composite Mean 3.55 Agree
 23

Table 2.2
Level of Stress
N = 188
Weighted Verbal
Items Rank
Mean Interpretation
1. Moving away from home. 2.13 Slightly Stressful 32
2. Environment in which to study 2.47 Slightly Stressful 17
3. Lack of home atmosphere. 2.62 Moderately Stressful 13
4. Other problems with accommodation. 2.55 Moderately Stressful 14
5. Making friends. 1.53 Slightly Stressful 39
6. Financial Responsibilities. 2.65 Moderately Stressful 10
7. Personal physical health. 2.40 Slightly Stressful 20
8. Relationship between members of opposite
sex.
2.13 Slightly Stressful 35
9. Necessity to postpone marriage. 1.80 Slightly Stressful 37
10. Necessity to postpone children. 1.55 Slightly Stressful 38
11. Having multiple roles. 2.39 Slightly Stressful 21
12. Conflict with spouse/mate over career
development.
2.07 Slightly Stressful 33
13. Lack of time for relaxation. 2.45 Slightly Stressful 19
14. Having children in the home. 2.34 Slightly Stressful 25
15. Having reduced holidays compared with
other students.
2.36 Slightly Stressful 24
16. Fear of going out due to crime. 2.24 Slightly Stressful 28
17. Dependencies (drugs, alcohol, etc.) 2.01 Slightly Stressful 35
18. Expectation versus reality in school. 2.39 Slightly Stressful 22
19. Approachability of staff. 2.17 Slightly Stressful 30
20. Criticism about academic or clinical work. 2.32 Slightly Stressful 26
21. Rules and regulations of the school. 2.20 Slightly Stressful 29
22. Discrimination due to race, nationality,
gender, or social class.
1.99 Slightly Stressful 36
23. Amount of assigned coursework. 2.51 Moderately Stressful 15
24. Difficulty of coursework. 2.83 Moderately Stressful 3
25. Fear of being able to catch up if falling
behind.
2.64 Moderately Stressful 11
26. Competition for grades. 2.47 Slightly Stressful 18
27. Fear of failing course or year. 3.16 Moderately Stressful 2
28. Uncertainty about career. 2.01 Slightly Stressful 34
29. Examinations. 3.27 Moderately Stressful 1
30. Lack of input in decision making process in
school.
2.69 Moderately Stressful 8
31. Concerns about manual dexterity. 2.71 Moderately Stressful 6
32. Transition to clinical course. 2.63 Moderately Stressful 12
33. Learning precision manual skills. 2.70 Moderately Stressful 7
34. Completing clinical requirements. 2.68 Moderately Stressful 9
35. Concerns about treatment grades awarded. 2.82 Moderately Stressful 4
36. Differences in opinion between clinical staff
2.78 Moderately Stressful 5
concerning treatments.
37. Shortage of allocated clinical time. 2.47 Slightly Stressful 16
 24

38. Patient management 2.29 Slightly Stressful 27

39. Confidence in all clinical decision making. 2.39 Slightly Stressful 23
Composite Mean 2.40 Slightly Stressful

Table 3
Stress Management Activities as Practiced by Respondents
N = 188
Weighted Verbal
Items Rank
Mean Interpretation
1. Biofeedback 2.61 Occasionally 17
2. Body Relaxation exercises
2.1. Lying down or sitting in chairs with eyes
3.70 Frequently 4
closed.
2.2. Briefly tensing and then releasing each
portion of the body successively from head to 3.74 Frequently 3
foot.
2.3. Briefly putting your passive attention on
each part of the body in succession from feet to 3.36 Occasionally 10
head.
3. Drinking 3.03 Occasionally 15
4. Eating 3.77 Frequently 2
5. Exercise (running, jogging, bicycling, hiking,
walking, roller blading, swimming, yoga, 3.28 Occasionally 12
stretching, weight lifting, volleyball, basketball)
6. Hobbies or leisure activities (drawing,
painting, listening to music, fishing, playing 3.51 Frequently 5.5
computer games, etc.)
7. Massage, acupressure or Shiatsu (using
hands to rub, stroke, press or touch portions of 3.05 Occasionally 14
your body for therapeutic/relaxing purposes)
8. Meditation (breathing exercise, consciously
3.01 Occasionally 16
focusing on the present moment)
9. Mental Activities (visualizing, relaxing
images, colors or scenarios in your 3.42 Occasionally 8
imagination)
10. Naps 3.39 Occasionally 9
11. Sex (Using sexual intercourse,
2.07 Seldom 20
masturbation)
12. Shopping/spending money 2.51 Occasionally 18
13. Smoking 1.87 Seldom 21
14. Social activities ( spending time with friends
away from stressful environment including 3.23 Occasionally 13
parties, dates, eating out with friends, etc.)
15. Spiritual or religious development 3.48 Occasionally 7
16. Talking with family, friends or other
3.94 Frequently 1
supportive people.
17. Time management activities ( planning
ahead, scheduling future activities, taking time
3.51 Frequently 5.5
to evaluate personal effectiveness or control
over your life.)
18. Watching television 3.30 Occasionally 11
19. Over-the-counter prescription Drugs
(tramadol, paracetamol, mefenamic acid, 2.36 Seldom 19
ibuprofen)
20. Recreational Drugs (solvents such as 1.25 Never 22
 25

solvent glue, aerosols, nail varnish, gas lighter

fuel and petrol; opium; barbiturates (valium &
ativan) ecstacy; cocaine.
Composite Mean 3.37 Occasionally

There are some activities that seldom practiced in managing stress like smoking,
with a weighted mean of 1.87, and sex (using sexual intercourse, masturbation, with a
weighted mean of 2.07.
Recreational Drugs (solvents such as solvent glue, aerosols, nail varnish, gas
lighter fuel and petrol; opium; barbiturates (valium & ativan) ecstacy; cocaine was never
observe as way out to manage stress since it obtained the least value of 1.25.
According to Schafer (1992), drugs and alcohol dependencies are "maladaptive
reactions to stress."

Table 4
Relationship Between Level of Stress and Stress Management Activities of the
Respondents
α = 0.05

r-value p-value Decision Interpretation

Level of Stress and
Stress Management 0.056 0.443 Accept Not Significant
Activities
** Correlation is significant at the 0.01 level (2-tailed)

As seen from the table 4, the resulted r value shows positive negligible
correlation and the p-value is greater than 0.05 level of significance, therefore the
null hypothesis of no significant relationship between the level of stress and stress
management is accepted.
This means that there is no relationship exists between the treated variables. It
implies that the stress management practiced by the respondents does not depend on
the degree or level of stress they experienced.

Findings

1. Perceived major source(s) and levels of stress among paramedical students.

1.1. The weighted mean distribution of the perceived major source(s) stress among
paramedical students showed that lack of time for relaxation, amount of assigned
coursework, difficulty of coursework were the top three items which obtained a rating of
strongly agree with weighted mean values of 4.68, 4.53 and 4.52 respectively.
It was followed by uncertainty about career (4.49), fear of failing course or year
(4.31), fear of being able to catch up if falling behind (4.09), environment in which to
study (3.96) and financial responsibilities (3.94). All items mentioned were verbally
interpreted as agree which means a source of the respondents stress.
Other items were rated undecided by the respondents such as moving away from
home (3.36), making friends (2.73), relationship between members of opposite sex
(2.93), conflict with spouse/mate over career development, having children in the home
(2.98), fear of going out due to crime (2.99), approachability of staff (3.21), rules and
regulations of the school (3.14), discrimination due to race, nationality, gender, or social
class (2.88), uncertainty about career (2.85), concerns about manual dexterity (3.48) and
confidence in all clinical decision (3.44).
 26

Overall, the perceived major source(s) of stress among paramedical students got a
weighted mean of 3.55 with the verbal interpretation of “Agree”.

1.2 The perceived level of stress among paramedical students found out that the
level of stress was slightly stressful given by the composite mean of 2.40. All were
concerned on school matters and were interpreted as moderately stressful such as lack
of home atmosphere (2.62), other problems with accommodation (2.55), financial
responsibilities (2.65), amount of assigned coursework (2.51), difficulty of coursework
(2.83), fear of being able to catch up if falling behind (2.64), . Fear of failing course or
year (3.16), examinations (3.27), lack of input in decision making process in school
(2.69), concerns about manual dexterity (2.71), transition to clinical course (2.63),
learning precision manual skills (2.70), completing clinical requirements (2.68), concerns
about treatment grades awarded (2.82), and differences in opinion between clinical staff
concerning treatments (2.78).
Most of the items mentioned were interpreted as slightly stressful. These are
moving away from home (2.13), environment in which to study (2.47), making friends
(1.53), personal physical health (2.40), relationship between members of opposite sex
(2.13), necessity to postpone marriage (1.80), necessity to postpone children (1.55),
having multiple roles (2.39), conflict with spouse/mate over career development (2.07),
lack of time for relaxation (2.45), having children in the home (2.34), having reduced
holidays compared with other students (2.36), fear of going out due to crime (2.24),
dependencies (drugs, alcohol, etc.) (2.01), expectation versus reality in school (2.39),
approachability of staff (2.17), criticism about academic or clinical work (2.32), rules and
regulations of the school (2.20), and discrimination due to race, nationality, gender, or
social class (1.99).

2. Stress management activities as practiced by respondents.

The respondents occasionally manage stress in their daily living as revealed by the
obtained composite mean of 3.37. Among the items mentioned, talking with family,
friends or other supportive people got the highest weighted mean of 3.94 and rated
frequently. It was followed by eating (3.77), briefly tensing and then releasing each
portion of the body successively from head to foot (3.74), lying down or sitting in chairs
with eyes closed (3.70), time management activities ( planning ahead, scheduling future
activities, taking time to evaluate personal effectiveness or control over your life.) and
hobbies or leisure activities (drawing, painting, listening to music, fishing, playing
computer games, etc.) with a mean of (3.51).
Spiritual or religious development (3.48), mental Activities (visualizing, relaxing
images, colors or scenarios in your imagination) (3.42), naps (3.39), briefly putting your
passive attention on each part of the body in succession from feet to head (3.36),
watching television (3.30), exercise (running, jogging, bicycling, hiking, walking, roller
blading, swimming, yoga, stretching, weight lifting, volleyball, basketball) (3.28), social
activities ( spending time with friends away from stressful environment including parties,
dates, eating out with friends, etc.) (3.23), massage, acupressure or Shiatsu (using
hands to rub, stroke, press or touch portions of your body for therapeutic/relaxing
purposes) (3.05), drinking (3.03), meditation (breathing exercise, consciously focusing
on the present moment) (3.01), biofeedback (2.61), and shopping/spending money
(2.51) were rated “Occasionally” by the respondents .
Other items were rated “Seldom” by the respondents. Some of these were over-
the-counter prescription drugs (tramadol, paracetamol, mefenamic acid, ibuprofen), sex
(using sexual intercourse, masturbation) and smoking with a mean of 2.36, 2.07, and
1.87 respectively.
 27

Paramedical students never use recreational drugs (solvents such as solvent glue,
aerosols, nail varnish, gas lighter fuel and petrol; opium; barbiturates (valium & ativan)
ecstacy; cocaine in managing stress.

3. Relationship between the levels of stress and stress management activities of the
respondents.
The resulted r value showed almost positive negligible correlation and the p-
value is greater than 0.05 level of significance, therefore the null hypothesis of no
significant relationship between the level of stress and stress management is accepted.
This means that there is no relationship exists between the treated variables. It also
implies that the stress management practiced by the respondents does not depend on
the degree or level of stress they experienced.
 28

Table 5
Proposed Program to Enhance Stress Management

Area of Objectives Activities Person/s Expected

Concern Involved Outcome

1.Emotional To measure Role playing Faculty members Students will

Intelligence( the Workshops Deans be able to
EI) student’s Open forum/sharing Department conceptualize
Assessment ability to of experiences Heads d
Program perceive counselling Guidance perceptions,
emotions in Counsellor appraisal and
self and Paramedical expression of
others as Students emotions,
well in employing
handling emotional
relationship knowledge
s. and regulate
emotions.

2. Stress To know and Seminar and Lecturer/Resourc Paramedical

managemen understand Workshops e Speaker students will
t Course the different Aerobic exercises Faculty be
stress meditation Paramedical responsible in
management Students managing
and stress
relaxation properly.
techniques.

3. Cognitive- To help the Workshop Deans Students will

Behavioral students Role playing Department be able to
Skill modify the Lecture Heads determine
Training appraisal Guidance whether the
processes Counsellor stimulus is
that to Paramedical harmful and
specific Students be able to
stimulus. develop
behavioral
skills for
managing the
stressor.

4. Time and 1. To Lecture Resource The students

Life provide Seminars/workshop Speaker will be able to
Managemen courses and s Faculty Member set goals,
t Course seminars that Paramedical identify their
 29

will train the Students roles and

students to priorities, and
manage time be good in
and life not decision-
limit making.

Table 6
Proposed Program to Enhance Stress Management

Area of Objectives Activities Person/s Expected

Concern Involved Outcome

not limited
only to
academic
setting.
2. To involve
students in
decision making.

5. College To help Counselling Workshops Colleges will

Counselling or students to Interview anticipate
Health Services manage stress. student’s
Program stress and
provide more
workshops on
coping skills.
 30

Conclusions

Based on the data analyses the following conclusions were drawn:

1. Sources of stress, or hassles that cause the most concern for students are
those that correspond to academic factors, decision making, and time issues. The
frequency and intensity of academic demands are perceived to be high among
respondents of the survey.
Study showed that paramedical students agreed that too much assigned work
and lack of time for relaxation made them easily stressed. This implied that majority of
paramedical students in LPU don’t know how to manage time properly.

2. As the frequency and intensity of hassles or stressors increase, levels of

perceived individual stress also increase.
Based on the revealed data, paramedical student’s level of stress was slightly
stressful. It varies depending on the situation and activities the respondents were dealing
with.

3. The respondents occasionally managed stress in their daily living. In a

stressful condition, talking with family, friends and with God through prayer made the
respondents feel relaxed and comforted.
Recreational activities contributed much in reducing stress and increases the
level of the respondent’s relaxation.

4. No significant relationship exists, between the subgroups of the demographic

variables for the stress they feel, the things that cause them to feel stressed and how
they attempt to manage the stress they experienced.
Paramedical students were given the opportunities to cope and use a wide
variety of measures to maximize stress and overcoming those problems which create
stress.

Recommendations

Based from the findings and conclusions of this study, the following
recommendations were suggested:

1. Faculty members and clinical instructors should help the students to identify
their priorities by encouraging them to make a time table or to set goals each semester
to avoid delays in their subject requirements.

2. Students must ultimately take greater responsibility for the stress they
experience and take active steps to reduce stress that does not support them in their
individual pursuits. Students should know the different stress management techniques
so that stress would not really affect them physically, emotionally and intellectually.

3. Increase collaboration between the wellness center and the student recreation
center to make use of the facilities available to support stress management programs
sponsored by the wellness center.
 31

4. For professionals involved in Health Education and Health Promotion, the

researcher suggests a more concerted effort to involve ourselves in the discipline of
stress management and relaxation techniques. As promoters of health and wellness, we
must become aware of the many useful and practical methods presently known to
reduce stress.

5. For future researchers, further research in this area should also continue to
study unconventional methods of reducing stress that to this point are mostly anecdotal
in their validity. Additionally, studies that look on the frequency and type of stress
management activities using the theory of reasoned action or the health belief model
may provide insights into the reasons that some people choose some activities over
others. Furthermore, an interesting qualitative study would include an analysis of
philosophies of life and their relationship to stress following the response given by the
student who said that she felt relatively little stress because of her strong faith in Jesus
Christ.

6. The proposed program must be adopted and implemented.

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